What is Tennis elbow?
“Pain over the outer (lateral) aspect of the elbow that is aggravated by movements of the wrist, painful with direct pressure over the lateral epicondyle (outer side of the elbow) and pain during contraction of the extensor muscles of the wrist” (Struijs et al, 2003).
“Pain to direct pressure over the lateral epicondyle (outer side of the elbow) with pain and weakness during gripping ” (Vicenzino, 2003).
Why has Tennis elbow got so many names?
Tennis elbow is the generic name that most people will of heard. The lateral epicondyle is the name of the part of the bone that the tendon affected attaches to. Like lots tendon injuries the terminology has changed over the years from “itis” to other descriptive terms. This is because “itis” means inflammation of something, but this is hotly debated, hence the newer term of “algia”, which means pain. Schwarzman (2017) describes tennis elbow as epicondylopathy, which means ‘pathology of’ the epicondyle. It generally affects the origin of Extensor Carpi Radialis Brevis (ECRB) tendon & is not an inflammatory process despite initial thinking.
How common is Tennis elbow?
Vicenzino, (2003) states that Tennis elbow affects between 1-3% of the general population, so it is not really common but it obviously has a higher incidence in certain occupations.
Men and women tend to get it to equal levels but it seems to be more severe and lasts longer in women (Vicenzino & Wright 1996).
It can be quite debilitating, so much so that 5% of adults had to take time off work because if it (Walker-Bone et al 2012).
What are the causes of Tennis elbow?
Like most injuries they are caused by an overload to the structure involved. This can come as a one-off overload or a cumulative overload. Tennis elbow is more of a cumulative overload. This comes down to doing too much too soon or something that the body isn’t really designed for regularly. Examples of this could be excessive gripping and typing work.
Age related reasons:
Like most things, age is a factor, degenerative changes in the tendon occur simply because of age. This degeneration causes Fibroblasts to proliferate (multiply), Vascular hyperplasia occurs, which is the development on more blood vessels, The collagen becomes disorganised, which basically weakens the tendon and can cause pain and restriction (Khan et al, 2000).
Basically overall, tendons lose resilience & strength with age but it isn’t all doom and gloom, this is where loading (strength training) is even more important than ever to compensate for the loss of this resilience and strength (Narici et al 2005).
Postural and movement issues:
If a person has sustained poor postures and have problems with the whole upper limb kinetic chain, which means poor or abnormal movement then this can pre-dispose you to tennis elbow. An example is weakness in the wrist flexors way cause a compensation in the wrist extensors or poor shoulder position may cause stability issues for the whole upper limb creating abnormal forces in the elbow.
Some people can have Cervical spine involvement, because neck problems can radiate to the elbow and this can create inhibition of the muscles locally at the elbow and even more likely there may be a nerve root compression (Trapped nerve) in the neck and this nerve may supply the wrist extensors again causing weakness. (Gunn and Milbrandt,1976).
Just like muscles, nerves can get tight too, so some people can have upper limb neural involvement, where the nerve itself has shortened or tethered, which can cause nerve pain (Yaxley and Jull, 1993).
What are the signs and symptoms of Tennis elbow?
Pain over Lateral epicondyle (outer side of elbow)
Pain on gripping activities.
Grip strength weakness.
It is not inflammatory and it has been found that there is a lack of inflammatory markers on a blood testing.
Secondary hyperalgesia (hypersensitive pain). The longer the Tennis elbow lasts, the more likely the body goes into more fight or flight, chronically, and the area can become very over sensitive making it much harder to rehab and get rid of.
What are the treatments for tennis elbow?
Treatment can sometimes be easy, but usually it takes time and is multi-faceted and complex. It has been said that Tennis elbow is the 3rd most complex Musculoskeletal disorder to treat after Frozen Shoulder and Plantar Fasciitis!
Some reasons why Tennis elbow is complicated to treat are:
Basically, whenever you assess somebody, you need to have a thorough list of potential diagnoses for what they may have, and these are called differential diagnoses. If you have not thought of what else it could be and not ruled certain things out then you can simply be barking up the wrong tree and you will get nowhere. The symptoms have so much cross over. Only this week, I treated somebody that was diagnosed with Tennis elbow and they had already tried failed Physiotherapy treatment then had a Platelet-rich plasma (PRP) injection with no effect and it was their neck all along. Once we treated this, it responded!
Sometimes it can be very difficult addressing all contributing lifestyle factors. If your working environment is a main factor causing it in the first place, then it may be impossible to correct these factors making it very challenging to get to the root cause.
Waiting too long before addressing or treating it:
It is often seen in the chronic stages in a lot of patients because Tennis elbow often creeps up slowly and people don’t take early action until it gets worse. This means that there can be lots of changes such as central nervous system sensitisation, causing chronic pain and hypersensitivity.
This means the interaction of biological (structural injury), Psychological (emotions, thoughts and feeling) and social (the effect on work, hobbies and life). For example, stress of losing your job because the effect of the condition will actually make pain increase, affect sleep and therefore recovery and this can create a vicious cycle (Poltawski, Watson & Byrne 2008).
So how do you treat Tennis elbow?
Basically, reducing the overload to the area is a must to make a good recovery. Essentially if you continue to overload the structure then you can keep the injury symptomatic indefinitely. Absolute rest is not advised so the best option is to modify your activities to a level that doesn’t cause pain levels to increase. If you do an activity that is painful either during, after or the next day then this means that you are probably doing too much, and you need to modify the activity so that it is tolerated (Buchanan et al 2019)
Acupuncture has been shown to help in the short term with Tennis elbow so can be a viable option for treatment (Trinh et al 2004).
Epi clasps, which is basically a strap that goes around your forearm, can give some relief and help with gripping activities. Rothschild (2013) found it to be effective in reducing stress to the common extensor tendon in tennis elbow.
Steroid injection also known as Corticosteroids are mainly used to reduce inflammation and suppress the immune system. So, at best for this type of condition they would be barking up the wrong tree and ineffective due to the fact that Tennis elbow is non inflammatory!
Coombes et al (2013) found that physio with placebo injection was better than steroid injections alone. Even worse, they found that Corticosteroid injection resulted in worse clinical outcomes after 1 year with Tennis elbow.
In fact Olaussen et al (2013) found that although there was a short term benefit there was a negative effect in the intermediate term, never mind the long term.
What are the negative side effects of the steroid?
Well there are many, but the British National Formulary states that it weakens muscle, bone and tendon and leads to ruptured (snapped) tendons.
If you are interested here is the full list of side effects:
Side effects of corticosteroids
Promotes repair activity through injecting growth factors directly to the site of injury (Coombes 2010).
However, the quality of evidence here is poor when compared to usual care (Rabago et al 2009).
The same idea as Autologous blood injections again to introduce growth factors (Coombes 2010).
Again, there is insufficient evidence to support the use of Platelet Rich Therapies for musculoskeletal soft tissue injuries (Moraes et al 2014).
Injected to inhibit collagenase, which would otherwise break down collagen. This is a problem in Tennis elbow so males sense (Coombes 2010).
Injected to prevent tendon degeneration and facilitate repair through inhibiting metalloproteinase enzyme activity (Coombes 2010).
Also known as botox. This is Injected to decrease tensile stress through the tendon and inhibit substance P, which is increased in tennis elbow (Coombes 2010).
Injected locally to absorb mechanical stress and provide a protective buffer for tissues (Coombes 2010).
Targeted disruption of new vasculature by administration of a scelerosant to cause blood vessel fibrosis (Coombes 2010).
Hypertonic glucose injected locally to initiate repair activity by causing local tissue trauma (Coombes 2010).
NSAID’s (Non-Steroidal Anti-inflammatory Drugs):
NSAID’s such as Ibuprofen inhibit tendon cell growth, therefore has a negative effect on tendon healing (Tsai et al 2004).
Extracorporeal shock wave therapy:
The National Institute for Health and Care Excellence (NICE) states that shockwave therapy is safe, although it can cause minor side effects, including bruising and reddening of skin in the area being treated.
Research shows that shockwave therapy can help improve the pain of tennis elbow in some cases. However, it may not work in all cases, and further research is needed. This a considered a viable option for chronic cases and has been found as effective as a steroid injection but obviously without the detrimental effect of the steroid itself (Lee et al 2012)
Exercise therapy: The main focus!
All the experts in tendons firmly agree that progressive loading of tendons is the key to recovery of function and symptom resolution. The evidence also supports expert opinion and has found that strength training decreases symptoms (Hoogvliet et al 2013).
Mechanical loading of the tendon works on the basis of that loading a tendon creates an upregulation of insulin-like growth factor (IGF-I) & this stimulates healing (Khan & Scott 2009).
Deep Transverse Frictional Massage:
No evidence supporting this according to Loew et al (2014) but there is excellent anecdotal evidence that fits the current understanding of tendinopathy.
Mobilisation With Movement (MWM’s):
A systematic review by Herd et al (2008) found that Mulligan mobilisation, which are mobilisations with movement worked very well in both the short and long term in Tennis elbow.
Cervical mobilisation/ manipulation techniques:
Again the same systematic review by Herd et al (2008) found that neck manipulative treatment was effective in tennis elbow but only in the short term.
It does improve wrist extension, grip strength, overall function and pain levels but we don’t know fully the reasons how this occurs (Hamneshin Behbahani et al 2014).
Surgery: Last resort
If after 6 to 12 months of conservative management, then surgery may be an option. However, surgical intervention is increasing despite a lack of supportive research evidence. Current evidence suggests that surgery for tennis elbow is no more effective than nonsurgical treatment. (Bateman 2019).
Tennis elbow is complicated, the first issue is to get the right diagnosis. Next you need to look at why it has occurred and improve or eradicate these causes, where possible. Conservative non operative treatment is the best way to go and it must involve progressive loading and strength work. Other treatments can be done alongside this but the main thing to remember is that it takes time, so be patient and trust the process!
The content in this blog article is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation.