Symptoms of Tennis Elbow
Due to the complex structure of the elbow, it is one joint that is most susceptible to injury. Repetitive movement of the joint and overload of the muscle causes micro-damage and results in degenerative changes.
Tennis elbow (TE) is characterized by pain and tenderness over the elbow, specifically the lateral epicondyle of the humerus where the wrist extensor muscles originate. Extensor Carpi Radialis Brevis is the muscle most commonly affected. The tendons of these muscles become inflamed and pain is elicited in gripping, and on resisted extension of the wrist, the middle finger, or both.
Tennis Elbow Risk Factors
Those at higher risk of developing TE are in professions that involve repetitive rotational movements or where lifting and pushing are involved. These include plumbers, painters, decorators, builders, gardeners, and anyone working full time at a keyboard. For the same reasons TE is also a common injury among the CrossFit population.
TE is an overuse syndrome that is most prevalent in your 30’s and 75% of the time it is the dominant arm that is affected. It may seem like a rather benign diagnosis, but 30% of people report missing work due to TE.
TE occurs in 1-3% of the total population, but this number jumps to 15% in manual professions with repetitive movements. This population accounts account for 35-64% of all TE cases. They are also more resistant to treatment and have a poorer prognosis. The same is true for anyone who delays starting treatment and has higher pain and disability before doing so.
Despite the name of the condition, tennis is a direct cause of TE in only 5% of cases. This is largely because tennis racquets have become lighter and tennis coaches have started teaching the double handed backhand.
- Avoid lifting heavy weights.
- Lift objects close to the body with the elbow bent and palms facing upward.
- Avoid repetitive gripping and twisting activities.
- Avoid all tasks that aggravate the condition and seek light duty at work if possible.
Tennis Elbow Recovery
80-90% of people will recover spontaneously, without treatment, but this may take up to 2 years and during this span considerable time off work can be expected.
10-30% of TE cases require an average leave of absence of 12 weeks, this has a significant economical impact on worker’s compensation cases and even early retirement. Those who participate in an appropriate exercise program report fewer absences from work due to TE.
As symptoms improve, progress should be measured by pain free grip strength, it is more sensitive to change than maximal grip strength. Treatment should include eccentric exercise, as it has been shown to be more effective at reducing pain than friction massage or ultrasound. This form of exercise provides the right load to the tendon to encourage healing. Overloading and under loading are both bad for tendons. It is important to load the tendon as close to its limit without exceeding it. The partial loading provided in eccentric exercises helps to repair degenerative tendon tissue and prepare it for future loads. Athletes or workers who play and work through the pain are overloading the tendon and inflicting further damage to the tissue.
Tennis Elbow Treatment Options
As with any injury there may be temptation to seek passive forms of treatment to recover faster and not have to put in the work. Corticosteroid injections may decrease pain, but patients are strongly cautioned against returning to activity during the pain-free “honeymoon period” due to risk of further injury. Due to premature return to activity, the recurrence rate of TE in patients who received corticosteroid injections is up to 72%. Risk of re-injury increases even more if more than 1 injection is given.
Cryotherapy (the application of cold temperatures to the involved area) has been shown to decrease pain in 64.7 to 76.5% of patients with an increase in joint mobility, as well as an increase in motor activity. Cryotherapy should not be applied for greater than 20 minute increments and should always have sufficient layers between the skin and cold pack to prevent contact burns.
Topical non-steroidal anti-inflammatory drugs (NSAIDs) have been found to improve pain in the short term.
Bracing and Taping
No definitive conclusions can be drawn regarding the effectiveness of bracing or kinesiotaping in treating TE. The current evidence available is conflicting.
The evidence for acupuncture and dry needling to treat TE is also conflicting, but it might be more effective that ultrasound at relieving pain in the short term.
Mobilization with Movement
Mobilization with movement (MWM) can decrease the recurrence of injury by 90 percent. Just 8 sessions of MWM can yield a significant reduction in symptoms and improved pain-free grip strength that was maintained at 6 weeks and 12 months.
Wait and See
A wait and see approach can be taken and has good outcomes after 1 year. With most injuries a wait and see approach is unadvisable, this also holds true for TE in the short term. The immediate outcomes of physical therapy are far better than that of a wait and see approach, but at 1 year there is not a significant difference…it just depends if you can wait that long for it to go away on its own. If you had a recent temporary change in activity that brought on TE this may be reasonable. But if your condition was caused by your work environment or competitive athletics, a wait and see approach isn’t going to be a reasonable option.
Deep Friction Massage
Deep friction massage produces a numbing effect at the site of injury, resulting in an immediate decrease in pain with an increase in mobility and strength.
Physical therapy has been shown to be more effective in treating TE than rest and anti-inflammatory medication, just 9 sessions of an appropriate exercise program has been shown to yield at least 50% improvement in pain. Despite a great response to treatment, physical therapy is not considered to be cost-effective and only 30% of patients seen in primary care are referred to physical therapy. An exercise program performed at home has been able to effectively treat TE and improve pain over the short and long-term. Such a program includes therapeutic exercise to decrease symptoms and restore function.
Exercise promotes hypertrophy of the muscular-tendon unit and neural reorganization. Stretching of the tendon increases proliferation of stem cells inside the tendon. Rest, on the other hand, induces muscle atrophy, decreases neuromuscular capacity, and decreases bone mineralization.
Here are a couple exercises used to treat Tennis Elbow, you can find the complete program here!
Straighten elbow, pronate forearm (palm faces floor), and with the opposite hand flex the wrist. Deviate the hand laterally while flexing, if tolerated. Hold 30 sec, 3 reps.
Deep Friction Massage
Sit with elbow at 90 degrees, full supination (hand faces up). Index and middle finger of opposite hand are placed at site of pain, with moderate pressure through fingers and move the skin back and forth over the tendon for 2 minutes, then stop 2 minutes, repeat up to 15 minutes total.
Click here for the complete Tennis Elbow Recovery Program!
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