Tennis Elbow: Understanding, Treatment, and the Indispensable Role of Physiotherapy
▫️Written by John Keller
✅ Reviewed by Dr. Jenny Hynes on November 15, 2023
Tennis elbow, known medically as lateral epicondylitis or lateral epicondylalgia, significantly hampers elbow joint health and function, affecting daily activities for a wide range of individuals, not just athletes. This condition results in pain and tenderness around the elbow's common extensor origin on the outside of the elbow and is prevalent in 1-3% of the Australian adult population each year, with a higher incidence in the dominant arm (Cutts et al., 2019). Its impact extends to the general populations, especially those who engage in repetitive gripping or lifting, underlining the importance of understanding this condition beyond sports.
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The importance of seeking knowledgeable care cannot be overstated. Statistics indicate that up to half of all tennis players will experience symptoms, often due to poor technique or equipment misuse, but the condition also frequently impacts laborers using heavy tools or performing repetitive tasks (Cutts et al., 2019). Thus, tennis elbow emerges as a significant occupational and public health concern, necessitating a broader awareness and comprehensive therapeutic approaches.
Unmasking Tennis Elbow
Tennis elbow, known in medical terms as lateral epicondylitis or lateral epicondyalgia, is an overuse injury impacting the wrist extensor tendons that attach to the lateral or outer part of the elbow, specifically the extensor carpi radialis brevis (ECRB). The wrist extensors are a complex group of muscles that originate near the lateral epicondyle of the elbow and insert into the distal forearm and hand. Their anatomy is intricate because they span across both the elbow and wrist joints, playing a crucial role in movements at these sites.
In tennis elbow, these muscles, specifically the extensor carpi radialis brevis, are subject to stress from repetitive gripping and wrist extension, leading to pain and dysfunction that can impact various daily activities. Repetitive stress leads to abnormal fibroblast deposition, disorganized collagen, and increased vascularity within the tendon (Ikonen et al., 2022). The result is pain that often leads to underuse and further weakening of the affected arm. The affect on daily activities is marked, particularly those involving wrist and arm movements, emphasizing the need for timely intervention to prevent worsening of symptoms and to promote healing (Coombes et al., 2015).
Repetitive gripping and wrist motions, such as those in swinging a golf club, handling tools, or even consistently using a computer mouse, exert a strain on these tendons. The accumulation of this strain can lead to microtears within the tendon structure. These microtears, if perpetually aggravated, can culminate in symptoms characteristic of Golfer's Elbow: pain radiating from the inner elbow, tenderness to touch, and a weakening grip strength (Cook & Purdam, 2009).
The implications of such a condition extend beyond mere discomfort. For individuals who rely on hand and wrist activities for their professions – be it carpenters, chefs, or computer professionals – Golfer's Elbow can be severely problematic. A weakened grip or persistent pain can hinder tasks we often take for granted: turning a doorknob, lifting grocery bags, or even holding a coffee mug. Such disruptions underscore the profound influence of this condition on our daily lives.
Timely intervention becomes paramount. If left unchecked, the symptoms can progress from episodic flare-ups to persistent pain, potentially leading to long-term functional impairments. The evidence suggests that early recognition and appropriate management can not only alleviate symptoms but also significantly reduce the risk of recurrence (Bisset et al., 2015).
Understanding medial epicondylitis’ intricacies is the cornerstone to proactive management. This condition serves as a reminder that the rigors of our daily activities, even seemingly innocuous ones, can have profound effects on our health. Recognizing the signs and seeking timely care can make all the difference.
Causes and Risk Factors of Tennis Elbow
Tennis Elbow commonly arises from the overuse of forearm muscles, repetitive gripping, and activities involving forceful wrist extension. Occupations like manual labor and hobbies that stress the forearm like gardening and playing racket sports are major risk factors (Karjalainen et al., 2023). To minimize these risks, individuals can:
To minimize these risk factors, individuals can:
Modify activities to reduce force and repetition (Coombes et al., 2023).
Arrange workstations ergonomically to prevent awkward movements.
Choose tools and sports equipment that suit their body size, grip width and strength to lessen the strain on elbow tendons (Karjalainen et al., 2023).
Engage in exercises aimed at strengthening the forearm muscles and improving flexibility (Karjalainen et al., 2023).
Learn and apply proper techniques in both sports and occupational activities (Karjalainen et al., 2023).
Recognising the Signs of Tennis Elbow
Tennis Elbow is characterized by pain and tenderness on the outer elbow due to changes in the tendon at the extensor carpi radialis brevis muscle's origin. It is crucial to distinguish these symptoms from similar conditions that effect the elbow, which may present with symptoms that overlap but have distinct features from lateral epicondylalgia (Johns, N., & Shridhar, V., 2020).
These include:
Entrapment syndromes like radial tunnel syndrome can mimic Tennis Elbow but typically present with pain lower than the lateral epicondyle, coupled with the absence of tenderness on the lateral epicondyle itself.
Cervical radiculopathy may cause pain in the elbow region; however, it is usually associated with neck pain and neurological symptoms like numbness or tingling in the arm.
Bony pathology, such as arthritis, may lead to elbow pain but is distinguished by joint stiffness and changes visible on X-rays.
Inflammatory conditions, for example, rheumatoid arthritis, often involve multiple joints and are associated with systemic symptoms, unlike the localized pain in Tennis Elbow.
These conditions are distinguished from Tennis Elbow through a detailed clinical history, physical examination, and when necessary, imaging or electrodiagnostic studies (Shiri et al., 2006). Misdiagnosis can delay appropriate treatment, hence consulting a healthcare professional is essential for an accurate diagnosis and a tailored treatment plan (Karjalainen et al., 2023).
Prevention Strategies for Tennis Elbow
To prevent Tennis Elbow, incorporating evidence-based techniques and exercises into daily routines is essential. Karanasios et al. (2021), suggests the five best ways to prevent tennis elbow include:
Proper Technique: Employing correct techniques during activities that involve gripping and wrist movement can reduce the stress on the elbow's tendons. This includes ensuring the correct grip size and form when playing racquet sports or using ergonomic tools for manual tasks.
Adequate Rest and Recovery: Allowing time for rest and recovery is crucial in preventing overuse injuries. Interspersing periods of activity with rest can help prevent the tendon overloading that leads to Tennis Elbow.
Forearm and Upper Limb Strengthening Exercises: Specific exercises that strengthen the upper limb and forearm muscles can also be beneficial. Exercises aimed at strengthening the elbow, forearm, triceps, and biceps, as well as stretching routines for the wrist flexors and extensors, are recommended. These might include wrist curls, reverse wrist curls, and forearm pronation/supination exercises.
Stretching: Regular stretching of the forearm muscles can increase flexibility and reduce tension in the tendons. Stretching exercises such as wrist flexor and extensor stretches are often recommended.
Use of Supportive Equipment: For athletes, using the right equipment, such as racquets with shock-absorbing handles or the appropriate string tension, can minimize the risk.
These general principles are based on an understanding of the condition's pathology and the mechanics of injury, which need to be assessed by a health professional. Keilor Road Physiotherapy offers expert advice on the prevention of tennis elbow.
Treatment of Tennis Elbow
The treatment of lateral epicondylitis typically begins with a non-operative approach, including physiotherapy as the primary method. (Sayegh & Strauch, 2015). Manual therapy has been shown to play a vital role in the treatment of lateral epicondylitis. Hands on techniques including massage and trigger point release have been found to be effective in reducing pain associated with tennis elbow (Viswas et al., 2012) Elbow mobilisation has also been shown to reduce pain and improve function (Mulligan, 2010).
Tendon loading programs are a critical component in the conservative management of tennis elbow, aiming to improve the capacity of the tendon to manage load. Malliaris et al. (2015) provided a structured protocol that includes isometric loading, isotonic loading, and energy-storing loading. Their recommended protocol starts with isometric exercises (static holds), progresses to isotonic exercises (movement through range), and finally includes energy-storing exercises to replicate the demands of specific sports. This approach takes into consideration that tendons and muscles function as a unit, and rehabilitation should address the musculotendinous unit as a whole. The development of a rehabilitation plan should be individualized, taking into account the pathoanatomical diagnosis, the stage of tendinopathy, and functional assessment.
When conservative treatments fail, patients may consider other options which include corticosteroid injections and extracorporeal shock wave therapy (Barr, Cerisola, & Blanchard, 2009).
Corticosteroid injections have been widely used for the treatment of Tennis Elbow (lateral epicondylitis) and are known to be effective for short-term relief of symptoms. However, their long-term effectiveness is uncertain, and they may not have advantages over other treatments such as oral NSAIDs and physiotherapy in the intermediate and long term (Barr, Cerisola, & Blanchard, 2009). Some studies suggest that corticosteroid injections could lead to worse clinical outcomes after one year, with a potential for encouraging recurrences of the condition (Barr, Cerisola, & Blanchard, 2009). The current trend in expert opinion is shifting away from corticosteroid use for Tennis Elbow due to the growing body of evidence against their long-term efficacy
Despite these concerns, corticosteroid injections are still considered for short-term relief, especially in cases where pain is severe. However, healthcare providers are advised to discuss the potential for long-term relapses and adverse effects with patients. For chronic cases of Tennis Elbow that last more than 12 months, other interventions such as platelet-rich plasma (PRP), prolotherapy, or even surgery may be considered.
The use of extracorporeal shock wave therapy (ESWT) is increasing in the management of tennis elbow. Clinical evidence suggests that ESWT can effectively alleviate pain and functional impairments like loss of grip strength associated with tennis elbow, with a better safety profile than several other methods. In terms of specific improvements, one study indicated that the common extensor tendon (CET) thickness showed a more significant improvement in the group treated with shockwave therapy compared to a group that received drugs and traditional procedures.
The efficacy of other non-surgical interventions was reviewed by Sims et al., (2014), which looked at botulinum toxin A injections, prolotherapy, platelet-rich plasma (PRP), and autologous blood injections. Their findings suggest:
Botulinum toxin A and prolotherapy have been found to be superior to placebo; however, botulinum toxin A may cause extensor weakness.
PRP and autologous blood injections have shown mixed results, being both more and less effective than corticosteroids in different studies.
For those whose symptoms persist despite these treatments, surgical intervention may be considered (Coombes et al., 2015). The management of lateral epicondylalgia is multifaceted and should be tailored to the individual patient, considering the variety of available non-surgical treatments and the potential need for surgery if non-operative measures prove insufficient.
Physiotherapy's Role in Managing Tennis Elbow
The literature suggests physiotherapy plays an integral role in alleviating the symptoms of tennis elbow and it’s successful management. Interventions such as manual therapy, exercise, and education are beneficial in reducing pain and improving function (Bisset et al., 2005; Coombes et al., 2013).
Keilor Road Physiotherapy is one of the leaders in the management of Tennis Elbow. Our physiotherapists are experts in evaluating and diagnosing the specific contributing factors for each individual patient.
The tailored exercise programs designed by our physiotherapists aim to correct muscle imbalances that may be contributing to our patient’s condition. These exercises often focus on strengthening the forearm muscles, enhancing wrist extensor strength, and improving the endurance of these muscles to better support the elbow joint and reduce the load on the tendons.
Joint stability is another key focus of physiotherapy treatment. By using targeted exercises that may include proprioceptive training, physiotherapists help to stabilize the elbow joint, which can mitigate stress on the affected tendons and alleviate pain.
Optimizing functional movement is crucial in the treatment of Tennis Elbow. At Keilor Road Physiotherapy, we analyze our patient’s movement patterns, especially those involving the wrist and elbow, to identify and correct dysfunction. By educating patients on ergonomics and proper techniques in their daily activities or sports, physiotherapists ensure that healing is not only about symptom relief but also about preventing recurrence.
The approach to managing Tennis Elbow is collaborative, with physiotherapists working closely with patients to develop a management plan that includes education on activity modification, pain management strategies, and progressive loading exercises. This partnership is essential for ensuring adherence to the treatment plan and for making adjustments based on the patient's progress and feedback.
Restoring Functionality
In the journey to restore functionality for patients with Tennis Elbow, physiotherapy leverages a blend of therapeutic exercises, manual therapy, and neuromuscular re-education.
Therapeutic exercises are tailored to strengthen the muscles around the elbow and enhance flexibility. These exercises often include progressive tendon loading programs, leading into more specific resistance training and stretching, which have been shown to be effective in reducing symptoms and improving grip strength (Peterson et al., 2014).
Manual therapy techniques, such as soft tissue mobilization and joint mobilization, can help alleviate pain and improve joint movement. They work by reducing muscle tension and increasing blood flow to the affected area, promoting healing (Bisset et al., 2005).
Neuromuscular re-education is used to correct improper movement patterns that may have contributed to the development of Tennis Elbow. This approach focuses on the coordination of muscle activity to improve the stability and efficiency of the elbow and wrist movements.
Physiotherapy has been shown to be a key player in not only reducing pain but also in restoring optimal forearm and wrist function. This enhances patients' ability to perform daily activities, thereby improving their overall quality of life (Coombes et al., 2013).
Contemporary literature supports the effectiveness of these physiotherapy techniques in the treatment of Tennis Elbow, underlining that a combination of exercise, manual therapy, and neuromuscular re-education is beneficial for this condition (Bisset et al., 2005; Coombes et al., 2013).
Conclusion
Tennis elbow is a condition typically caused by overuse of the arm, forearm, and hand muscles that results in lateral elbow pain. Diagnosis is critical, and it should be performed by a healthcare professional like the experts here at Keilor Road Physiotherapy, to ensure an accurate understanding of the condition and to rule out other possible issues.
Treatment should start with physiotherapy, with a tailored treatment plan to the individual's needs. Conservative treatment should include manual therapy in the acute stage, complimented by a progressive tendon loading program for the best results. Advice around preventative Measures are also important and include proper technique in sports and ergonomic assessment in work environments to minimize stress on the elbow.
In the limited amount of cases that don’t respond initially, corticosteroid injections or extracorporeal shock wave therapy are options to aid the healing response. Other non-invasive measures need more research to assure their viability. For those that don’t respond to conservative treatment of tennis elbow, surgical intervention might be warranted.
While tennis elbow can be a painful and debilitating condition, it is manageable with the right approach. Seeking the expertise of healthcare professionals and physiotherapists can lead to a more effective and efficient recovery. With their support, individuals suffering from tennis elbow can take proactive steps towards managing their condition, regaining strength, and returning to their daily activities.
References
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Article by
John Keller
Clinical Director | Sports & Musculoskeletal Physiotherapist
John graduated as a Physiotherapist from the Auckland University of Technology with the John Morris memorial prize for outstanding clinical practise in 2003. John has since completed Post Graduate Diplomas in both Sports Medicine and Musculoskeletal Physiotherapy with distinction, also collecting the Searle Shield for excellence in Musculoskeletal Physiotherapy.
Reviewed by
Dr. Jenny Hynes FACP
Clinical Director | Specialist Musculoskeletal Physiotherapist
Jenny sat extensive examinations to be inducted as a fellow into the Australian College of Physiotherapy in 2009 and gain the title of Specialist Musculoskeletal Physiotherapist, one of only a few physiotherapists in the state to have done so.