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)
