Tennis Elbow
What is Tennis Elbow?
Tennis elbow, otherwise known as "lateral epicondylopathy" is a painful irritation of the attachment of the wrist extensor muscle group which is near the outer elbow. Lateral epicondylopathy (LE) is the most common cause of elbow pain. The condition is related to repetitive wrist extension and is commonly referred to as "tennis elbow", although the majority of those affected do not play tennis.
Nearly all forces associated with wrist extension are funneled through one, small tendon which attaches to the lateral/outer aspect of the elbow. Due to the demand on this small tendon, it is susceptible to overuse. Overuse tends to include repetitive wrist extension causing micro-tearing of the tendon, ultimately leading to a failed healing response and degeneration over time. While acute inflammation may accompany the earliest phase of tendon disease, it is unlikely to last more than a few days. In chronic cases, inflammatory cells are absent. Researchers now recognize that repetitive microtrauma does not cause inflammation but rather a failure of the natural healing process, resulting in a disorganized pathological degeneration of the tendon called angioblastic degeneration. Since LE is primarily a degenerative condition rather than a chronic inflammatory process as once hypothesized, the term "tendinitis" has been replaced with "tendonosis" or "tendinopathy". A degenerated tendon may be predisposed to partial or full-thickness tears as a result of ongoing strain, particularly rapid, heavy overload.
LE affects between 1 and 3% of the general population each year. The condition occurs predominantly in the fourth or fifth decade. Females are affected slightly more frequently. LE strikes the dominant arm in 75% of cases. LE results in an average of 12 weeks disability in up to 30% of those workers affected.
LE is a byproduct of excessive force or repetitive movement, combined with improper biomechanics and/or posture. The primary risk factors for LE include repeated wrist extension and forearm rotation. Certain occupations and activities are predisposed, including carpenters, bricklayers, seamstresses, tailors, pianists, drummers, and those who perform prolonged keyboard or mouse work. Only 5% of LE patients participate in racquet sports, but among tennis players, 50-60% will be affected at some point in their career. LE injuries related to tennis are thought to develop as a result of improper mechanics during backhands or serves. Additional racquet-related risk factors include: using a new, heavy, or tightly strung racquet, excessive grip size, and hitting wet or heavy tennis balls. High cholesterol and smoking are risk factors for LE; which should not be surprising considering the degenerative hypovascular etiology of this condition.
What Will Tennis Elbow Look and Feel Like?
Symptoms often begin insidiously following overuse-type activity, without a history of specific trauma. The classic clinical presentation includes pain over the bony, outside aspect of the elbow. Symptoms are typically provoked by activities that involve gripping and/or wrist extension. Pain may vary from mild to sharp severe pain that limits the simplest activities- like picking up a coffee cup. Rest may provide relief.
Pain is generally localized, but can occasionally radiate down the forearm, which may indicate nerve involvement. Radial tunnel syndrome is entrapment of the radial nerve as it passes through the top of the forearm. Research suggests that up to 10% of patients with tennis elbow have co-existent radial tunnel syndrome. The similarities of tennis elbow and radial tunnel syndrome can make differentiation of the two conditions challenging. The pain of radial tunnel syndrome should be more acute lower in the arm. Pain at night is more common in radial tunnel patients than those with lateral epicondylitis.
How Do We Treat Tennis Elbow?
The natural course of tennis elbow can be exasperating. Twenty percent of untreated patients demonstrate no improvement after one year. Even those patients undergoing optimal management may require three to four months for full recovery. Evidence supports the use of traditional conservative measures, including: manipulation, mobilization, exercise, friction massage, bracing, and modalities.
Initially, patients may require selective rest and avoidance of activities involving repetitive wrist extension, or rotation. Counter-irritant creams may provide palliative relief. Ice or home ice massage may be helpful for acute “tendinitis” patients, but do little to alter the long-term course of chronic tendinopathy. Tennis players should look for ways to improve mechanics, including not leading with their elbow and switching to a 2-hand back stroke that limits rotation. The use of a counter-force strap, applied firmly approximately 10 cm below the elbow joint has been shown to decrease pain and improve grip strength in some cases. Counter-force braces may be more effective in younger patients, i.e., less than 45-years old. Counter-force braces should not be used in cases of concurrent radial tunnel syndrome, as the additional pressure will likely exacerbate compressive neuropathy symptoms.
Practitioner-directed therapy is more effective than bracing alone. There is moderate evidence supporting the use of mobilization/manipulation of the elbow, spine, and wrist for the treatment of tennis elbow. Mobilization/manipulation of the elbow demonstrates an immediate decrease in pain and a substantial increase in pain-free grip. Manipulation of the cervical and upper thoracic spine regions have been shown to decrease pain and disability in tennis elbow patients.
Any tendinosis is associated with excessive, disorganized collagen formation, scarring, and contracture of peritendinous tissue. Instrument assisted soft tissue mobilization (IASTM) is thought to help mobilize scar tissue and increase pliability by re-initiating an inflammatory process through controlled microtrauma. The use of IASTM has demonstrated “significantly better” outcomes than exercise alone – with 57% resolution of complaints after one month of care, and 78% resolution after two months. Deep friction massage is another valuable tool for tennis elbow. Dry needling may also be a useful alternative for certain cases. Myofascial release is an effective treatment for tennis elbow. Soft tissue mobilization (STM) and stretching exercises should be directed at the muscles on the back of the forearm and in the forearm in order to reduce tension at the tendon.
“The evidence supports a slowly progressive loading program, rather than complete rest.” The goal of tendinopathy rehab is to carefully balance stimulating a controlled musculotendinous inflammatory response without causing greater injury or exacerbating symptoms. Rehab should begin with moderate effort and low repetitions. Response to tensile loading may be assessed by the patient’s change in night pain. Increases in night pain indicate the current rehab load is excessive. Progression advances when the patient tolerates a given level of tensile load.
Modalities may be used initially as adjuncts for pain relief. Some clinicians advocate the use of low-level laser, ultrasound, phonopheresis, iontopheresis, elastic therapeutic tape, dry needling and acupuncture for the treatment of tennis elbow. More recent concepts for the management of tennis elbow include the application of a glycerol trinitrate patch, which has been shown to decrease pain and enhance healing while stimulating collagen synthesis. Shockwave therapy has shown to significantly reduce the pain that accompanies tendinopathies. Acupuncture and functional dry needling has been shown to improve pain and function in tennis elbow patients. Favorable outcomes have been demonstrated via 4-6 conservative treatments spaced over 12 weeks (consisting of education, stretches, activity modification, and pain management techniques).
Medical management includes the use of oral or topical NSAIDs. Autologous or platelet-enriched-plasma (PRP) injections have been advocated for the treatment of tennis elbow, however, some data questions their effectiveness. While corticoid steroid injections may provide some short-term relief, these injections can be detrimental to long-term recovery. One study demonstrated that corticosteroid injections significantly reduce pain, with 78% success at six weeks (versus 65% improvement for standard physical therapy.) Unfortunately, the same study demonstrated that at one year, those patients treated by injection were “significantly worse” compared to those managed conventionally or those who underwent no treatment.
If you have been struggling with elbow pain or tennis elbow, call us to make an appointment to see how the doctors can help.