Did you know that you don't have to play tennis in order to get tennis elbow?
What is it?
Lateral epicondylopathy or formally known as lateral epicondylitis, is a painful irritation of the wrist extensor muscles which originates on the lateral epicondyle of the elbow--(the outside of the elbow bone). Lateral epicondylopathy (LE) is the most common cause of elbow pain. This occurs when the wrist is repeatedly put into extension and the forearm is twisting from supination (palm up) to pronation (palm down). LE is a byproduct of excessive force or repetitive movement, combined with improper biomechanics and/or posture. LE is commonly referred to as “tennis elbow”.
The most common wrist extensor (the muscle that puts the wrist into extension) is called the extensor carpi radialis brevis, which is hypovascular (lacking blood flow), creating an increased likelihood of injury. It is also hypoxic which increases the probability of degeneration in the muscle or tendon.
LE occurs when the wrist is in repetitive extension causing micro-tearing of the common extensor tendon, ultimately leading to a failure in the healing process and causing degeneration. A degeneration of the tendon may lead to a full tear due to the ongoing stress to the tendon, especially if you were to rapidly overload the tendon.
While acute inflammation may occur in the early stages of tendon disease, it usually does not last past a few days. In chronic cases, inflammation (swelling) is absent.
Certain occupations and activities put you more at risk which include carpenters, bricklayers, seamstresses, tailors, pianists, drummers, those who shake hands a lot, and those who perform prolonged keyboard or mouse work. LE results in an average of 12 weeks disability in up to 30 percent of those workers affected.
Those who have hypercholesterolemia or someone who smokes are at risk for lateral epicondylopathy because these conditions will help with the degeneration process because of lack of blood flow.
Even though only 5 percent of those with LE are racquet sport participants, among tennis players 50-60 percent of them will be affected at some point in their careers. Tennis players that are using new, heavy, or tightly strung racquets, excessive grip size, and hitting wet or heavy tennis balls are more at risk. Also, players with poor mechanics during a back swing or serve are exposing themselves to LE.
Symptoms
Symptoms usually begin slowly following an overuse-type activity, without any specific trauma. Pain is located over the lateral (outside) side of the elbow. Symptoms typically arise by activities that involve gripping and/or wrist extension. Pain can range from mild to severe and sharp which will limit simple activities such as picking up a cup. Rest in early stages may provide some relief.
The classic clinical findings of lateral epicondylopathy include pain when touching the lateral side of the elbow, pain with resisted (pushing against something pushing the opposite way) wrist extension, and pain with resisted middle finger extension. Those affected will also begin to have issues with wrist flexion and shoulder internal rotation as well. Grip strength may diminish, particularly with the elbow straight versus bent.
Diagnosis
A trial of conservative care is recommended! Radiography is of little use when diagnosing soft tissue disorders, so in this case they would not be helpful. Tendinopathy is usually diagnosed through clinical findings, and imaging should only be sought out for special circumstances. An MRI may show some tendinosis as well as bony or soft tissue pathology that is associated with LE.
Management
Twenty percent of untreated patients demonstrate no improvement after one year. Patients that are undergoing optimal management may require three to four months until full recovery. Evidence is pointing towards traditional conservative measures including manipulation, mobilization, exercise, friction massage, some bracing, and modalities.
In early stages patients may require selective rest and avoidance of activities that put their wrist into extension, pronation, or supination. Tennis players should focus on good mechanics, especially making sure not to lead with their elbow and possibly consider switching to a two handed backstroke to limit pronation of the forearm.
Counterforce Brace Strap: The use of a counterforce brace strap, when applied distal (just below the elbow) to the elbow joint, has been shown to decrease pain and improve grip strength. Do not use counterforce braces if the patient is experiencing numbness or tingling because the additional pressure will exacerbate compressive neuropathy symptoms. However, clinician based therapy is considered more effective than bracing alone.
Chiropractic Adjustments: Research supports the use of mobilization and manipulation of the elbow, cervical spine, thoracic spine, and wrist for the treatment of LE. Mobilization and manipulation has proved to diminish pain and helps with pain-free grip. Manipulation of the cervical and upper thoracic spine have shown to be effective when trying to decrease pain and disability using the arm. Addressing scapular stability deficits has improved outcomes for LE patients.
Manual Therapy: IASTM (instrument assisted soft tissue mobilization) or Graston will help mobilize scar tissue and increase pliability (flexibility) by initiating the inflammatory response. This will promote healing to the area. Those that incorporate this technique coupled with exercise have shown 56 percent of their complaints resolved after a month, and 78 percent resolved after two months.
Friction Massage: A deep friction massage is another way to help alleviate symptoms of lateral epicondylopathy.
Kinesiotape: Elastic therapeutic taping (kinesiotape) may be helpful with this condition.
Dry Needling/Cupping: Dry Needling may be helpful with prolonged cases. Ice or a home ice massage may be helpful with acute (sudden onset or just happened) tendinitis, however will do little for those struggling with chronic (long-term) issues.
Acupuncture: Acupuncture could show benefits with the long-term cases or those who are experiencing numbness and/or tingling.
Exercises/Strength Training: Evidence suggests that a slow progressive loading program, rather than complete rest. Stretching and exercises should center around wrist extension and the supinator (those that make the hand go palm up) muscles. Rehabilitation will also start with moderate effort and low repetitions. Progressions will advance as the patient becomes more tolerable to more tensile load.
Resistance training begins with isometric (contracting muscle but not moving elbow) exercises then advances to eccentric (shortening the muscle) exercises.
Some medical management includes the use of oral or topical NSAIDs (non-steroidal anti-inflammatory drugs). While corticosteroid injections may provide some short-term relief, these injections can be detrimental to long-term recovery.
Less than 11 percent of patients will require surgical intervention. This should only be considered after six months of failed conservative care.
Favorable outcomes have been found to show favorable outcomes with 4-6 conservative treatments spaced over a 12 week span, if consistent with their exercises, stretches, activity modification, and pain management techniques. With these techniques about 85 percent of patients report pain relief after a month and 91 percent report good to excellent satisfaction after six months.
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