The trouble with tennis elbow!
Tennis elbow, often clinically known as lateral epicondylitis, epicondylosis or epicondylalgia can be a confusing condition for patients. Particularly if they have been nowhere near a tennis court!
How do you know if you have it??
There are some fairly consistent signs and symptoms which lead to the ‘umbrella’ diagnosis of tennis elbow
- Pain is felt often like a dull ache on the outside (lateral aspect) of the elbow and may extend down to the forearm.
- Pain is usually worse on gripping and twisting objects-such as opening a jar lid, turning a door handle or shaking hands.
- There is usually an acute tender spot on the outside of the elbow itself when pressed.
How can we confirm it?
The main tendons affected in tennis elbow are your wrist extensor tendons. These arise from the lateral epicondyle, which is the bony bit on the outside of your elbow. Therefore your physiotherapist will often perform some quick resisted tests of these muscles if a diagnosis of tennis elbow is suspected.
- With your arm extended and your wrist and fingers in line, resisting a downward pressure to the middle finger reproduces pain on the affected side.
- If your physiotherapist has a dynamometer to measure your grip strength, you may find it is reduced on the affected side, relative to normative values for your dominant/non dominant arm.
But….I haven’t been playing tennis???
This is the important question to answer for most patients especially where they can think of no specific trigger for the pain. Whilst repeated backhand strokes with poor technique may be the history for a small number of tennis playing clients, lots of others may have reproduced this overstrain of the wrist extensors with a variety of repetitive tasks.
Common triggers include:
- DIY tasks-such as painting, drilling, sanding and screwing
- Cutting up cooking ingredients, especially meat.
- Computer work-particularly using the mouse too far in front of you with the elbow and wrist more extended.
How do I get it better?
The tricky thing about treatment for this condition is that it is really important to understand the cause of the problem in the first place in order to avoid further irritating the elbow tendons whilst undergoing treatment. I’ll come back to this…
It is now widely accepted that the condition is not inflammatory. Therefore whilst NSAIDS such as ibuprofen might have a short term pain relieving affect they have not been found to improve the long term prognosis for this condition. In some cases they could make things worse if you continue to overuse the arm whilst you feel the analgesic affects.
Likewise, steroid injections, which were used more commonly in the past are now considered outdated as they have been shown to have only a short lasting effect on pain and may again lead to further tendon damage if overuse continues.
In the past conventional physiotherapy may have involved local ultrasound for this condition but again, in line with evidence based practice, this is no longer considered the most effective treatment. Instead you may find the following treatments form part of your management plan in the clinic.
There is some good evidence that the use of the traditional Chinese acupuncture points themselves is more effective for pain relief than random needle placement. However some clinicians find a dry needling technique called periosteal pecking where a needle is inserted very superficially repeatedly by the epicondyle itself has good results for reducing pain.
The most common brace is a strap worn around the tendon just below the elbow joint. It provides pressure and a binding force over the origin of the wrist extensor tendon, helping to reduce the elongation of the musculotendinous fibres at the common extensor origin.
Braces like this can be pretty effective in reducing pain for gripping and twisting activities. They might be recommended if you are in the middle of a DIY renovation that you absolutely have to finish. However it is worth noting that you will still be putting strain on the already worn tendon and so the brace will not heal the problem if you carry on overusing your arm. You would need to combine it with some form of strengthening and where possible modify your activity levels to rest the tendon and avoid overuse.
- Eccentric Exercise
This is possibly the most important part of your rehab! In the last 20 years lots of research has found that ‘eccentric’ exercise –where the muscle and tendon are lengthening under load is particularly useful for the rehabilitation of tendons. In the last 5 years this has been specifically related to the common extensor tendon, implicated in tennis elbow. A study has found excellent results carrying out 3 sets of 15 ‘Tyler twists’ (an eccentric exercise for the wrist extensors) a day, using a flexible rubber bar (FlexBar). The link provides a detailed description of the exercise with pictures and link to a video demonstration.
- Manage the cause of the symptoms
It is important for your therapist to discover the underlying causes of your ‘tennis elbow’. Often this means they need to examine other joints in order to establish their contribution, particularly if you have not been doing anything major to overexert the wrist extensors. Weaknesses of the shoulder blade or shoulder muscles themselves could lead to an overload on the elbow tendons with repetitive tasks. This is often the case in ‘computer elbow’ where a poorly stabilised shoulder blade is linked to overextension of the elbow and wrist.
Your physiotherapist may suggest Pilates style exercises which focus on strengthening the muscles around your shoulder blade in order to reduce the load on your elbow joint.
An examination of your neck may be carried out. Tennis elbow is often associated with dysfunction in the cervical spine and pain can refer to the elbow area from some of the nerves in the lower neck. Often patients who have elbow pain with no history of injury or change in activity present with a hinge like neck posture. This can lead to gradual compression of the nerve roots in this region with resulting referred pain over time.
In this case your physiotherapist will highlight the importance of good posture in managing the problem and will likely include postural strengthening for your neck muscles alongside strengthening of the overloaded elbow tendons.
Tennis elbow can be a complicated problem which may have very little to do with tennis. Thanks to recent research our treatment approaches have changed to make us more successful at treating this once tricky condition.
By Nikki Richards MPHTY(Sports)BSC(Hons)Physio MCSP
Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients With Unilateral Lateral Epicondylalgia: A Randomized Controlled Trial. JAMA. February 6, 2013;309(5):461-9.