How to treat Tennis Elbow

by | Sep 27, 2024 | Elbow, Tennis Elbow

What is Tennis Elbow?

Tennis elbow is defined as a cause of pain and tenderness in the outer part of the elbow (lateral epicondyle) where the tendons of the forearm muscles attach. It is an overuse injury from repetitive or forceful/explosive movements involving eccentric motion and/or in which the wrist frequently deviates from a neutral position. This can be from training errors, inadequate equipment or poor environmental conditions.
 

Who can get Tennis Elbow?

Tennis elbow can affect anyone, it is common in people between 30 and 60 years of age. It appears to be more severe and of longer duration in females. And the most commonly affected arm is the dominant arm.
 

What is the presentation of Tennis Elbow?

Tenderness over the elbow bone (lateral and medial epicondyles)
Pain on gripping
Pain on resisted wrist extension
Extreme cases may lead to nerve involvement – nerve pain and neck range of motion restrictions
 

Do I need an Xray or MRI?

A diagnosis can be made based on the history of the condition and a physical examination. X-rays may be used to help rule out other causes of elbow pain, such as arthritis. An ultrasound or magnetic resonance imaging (MRI) scan will show the degenerative changes in the tendon, but is rarely required.
 

How do you treat Tennis Elbow?

Evidence tells us that exercise is the most effective way of treating tennis elbow, with adjuncts of manual therapy (L.Bisset et al 2015)
 

3 Best exercises of Tennis Elbow:

1. Isometric Wrist Extension

– Arm straight, wrist pointing downwards
– Hold weight and sustain neutral wrist position for as long as possible (e.g. 10 sec)
– Repeat 5 times (e.g. 10sec x 5 reps), perform the exercise once a day
– There should be NO pain during these exercises (reduce the reps and/or wrist extension hold until you have found a comfortable level)
 

2. Eccentric Wrist Extension

– Arm straight, wrist pointing downwards
– Hold weight, slowly lower weight down towards the ground.
– Use your opposite hand to assist with returning the weight back to wrist extension (the starting position)
– Repeat 8-10 reps, perform the exercise once a day
– There should be NO pain during these exercises (reduce the reps until you have found a comfortable level)
 

3. Stick roll ups

– Both arm’s straight, wrist’s pointing downwards
– Hold stick and roll the stick all the way forwards and all the way backwards against the resistance band
– Repeat 4-6 roll ups/downs or until onset of fatigue
– There should be NO pain during these exercises (reduce the reps until you have found a comfortable level)
 

Treatment includes:

1. Load management:
– Stopping the aggravating activity
– Progressive loading
2. Ergonomic advice (for example, the amount of time spent out of neutral wrist position is strongly associated with tennis elbow)
3. Self-management
– Analgesic drugs, electrotherapies such as heat and cold
4. Correction of biomechanics – later for return to sport
 

Tips & Tricks:

– Avoid the aggravating activities or positions that bring on your pain
– Carry things with your palm up
– Carry things close to the body
– Load the tendon with exercises, but reduce manual labor
– There should be no pain when performing exercises
 

Do Corticosteroid Injections work?

Corticosteroid injections are NOT recommended, in the study Vicenzino et al 2006, 198 participants got assigned to three groups (physiotherapy interventions, corticosteroid injections and ‘the wait and see approach’). The corticosteroid group had most reported recurrences at 72%, and physiotherapy had a superior benefit to the wait and see approach.
 
Patients can also be reassured that most cases will improve without intervention and just information regarding modification of aggravating activities, ergonomic advice and reassurance that their condition will eventually settle.
 

What else is there?

– Manual therapy – there is a superior benefit to pain free grip strength and pressure pain thresholds (Vicenzino et al., 2001; Paungmali et al., 2003)
– Bracing/taping – there is conflicting evidence for the effectiveness of bracing/taping compared with placebo or no treatment
– Acupuncture/dry needling – conflicting evidence, but may be more effective than placebo and ultrasound at relieving pain and improving self-assessed treatment benefit in the short term
– Laser therapy – may be beneficial in short term compared with placebo, likely no difference between laser and other active interventions in the short or long term
– Ultrasound – no more effective than placebo for pain relief or self-perceived global improvement in short term
– Shock wave therapy – little or no benefit in reducing pain or improving function
– Platelet rich plasma injections – not effective therapy
 

References:

•Physiotherapy management of lateral epicondylalgia – Bisset, Vicenzino (2015)
•Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia – Paungmali, O’Leary, Souvlis, Vicenzino (2003)
•Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia – Vicenzino, Paungmali, Buratowski, Wright (2001)
•Manipulation of the wrist for management of lateral epicondylitis: A randomized pilot study – Struijs, Damen, Bakker, Blankevoort, Assendelft, Van Dijk (2003)
•Incorporation of Manual Therapy Directed at the Cervicothoracic Spine in Patients with Lateral Epicondylalgia: A Pilot Clinical Trial – Cleland, Flynn, Palmer (2013)
•A randomized controlled trial of eccentric vs. concentric graded exercise in chronic tennis elbow (lateral elbow tendinopathy) – Peterson, Butler, Eriksson, Svardsudd (2014)
•Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial – Bisset, Beller, Jull, Brooks, Darnell, Vicenzino (2006)
•Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: A prospective randomized trial – Tyler, Thomas, Nicholas, Malachy, McHugh (2010)
•Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy – Cook & Purdam (2009)
Ankle dorsiflexion knee to wall measure for squat

How to Treat and Manage Stiff Ankles

If your ankle mobility isn’t up to par, the next steps depend on the source of the restriction. Generally, if the limitation is felt at the front of the ankle, it may be due to joint-related issues.

  • Banded Ankle Mobilizations: This technique involves using a resistance band tied to a stable surface while performing ankle flexing exercises on a step. Check out this quick helpful video for guidance.

Conversely, if the tightness is located in the back of your ankle around the Achilles tendon region, consider:

  • Contract/Relax Stretches: A simple exercise like the bent-knee calf raise can effectively relieve restrictions in this region.

Lastly, for an immediate solution, consider using a wedge or support under your heels during a squat. Two papers from The Journal of Strength and Conditioning Research have shown that wedges can enhance squat depth without negatively impacting biomechanics. While some may see this as a “cheat,” the science supports it. If you struggle to achieve that 12 cm in the knee-to-wall test and find it challenging to squat low, use that wedge!

Hip Range of Motion

How Much Flexibility Do I Need and How Do I Test It?

For effective squatting, studies have determined that achieving 125 degrees of hip flexion is necessary—this is 35 degrees beyond a right angle. To test your hip mobility, you can use an inclinometer available on your iPhone. Simply follow these steps:

  1. Lie down on your back with your legs extended.
  2. Place the inclinometer length-ways on your thigh,
  3. Gently lift your knee towards your chest to measure the maximum angle, without moving the opposite leg.

     

    measuring hip flexion

    How to Treat and Manage Stiff Hips

    The hip joint is mostly passive during a squat, so if you’re experiencing limitations, it’s most likely due to an issue with the hip joint itself. There is up to 20% of the population that may be limited by the shape of their hip joint and the way it developed during childhood and adolescence. If that is the case, it makes if very difficult to improve the range of motion. Things like acetabular retroversion or a lower femoral head/neck offset ratio cannot be changed.

    For the rest of the population, here are some effective strategies for improving hip mobility:

    • Banded Hip Mobilisations: These exercises can help increase the range of motion in your hips by stretching and mobilizing the joint. Look for a demonstration in this video.
    • Inner Range Hip Flexor Strengthening: Strengthening your hip flexors can counteract tightness and enhance your ability to squat lower.
    • Like with ankle mobility, adding a heel wedge can help. By elevating your heels, you may experience a reduction in trunk forward bend, minimizing the hip flexion required and facilitating a more comfortable squat position.

    Conclusion

    Mastering a deep squat requires more than just strength; it hinges on sufficient ankle and hip range of motion. The studies from 2015 and 2022 have made it clear: flexibility in these joints is paramount for optimal performance.

    By regularly assessing your mobility and implementing these targeted exercises and techniques, you can improve your squat depth, enhance your overall strength training, and reduce the risk of injury. Remember, every body is unique, so listen to yours and adjust your approach accordingly. Happy squatting!