AUTHOR: SAMANTHA PANOS, bounceREHAB Physiotherapist
CO-AUTHOR: MATTHEW CRAIG, bounceREHAB Principal Physiotherapist & Founding Director
WHAT IS TENNIS ELBOW?
Extensor tendinopathy (a.k.a. tennis elbow) is a common, painful condition of the elbow. It involves pain at, or just below, the lateral humeral epicondyle within the common extensor origin (i.e. around the bony knob on the outside of your elbow.. see the red dot in the diagram below).
The common extensor origin serves as the upper attachment point for the tendons of your forearm muscles. These muscles include the:
- Extensor carpi radialis longus and brevis
- Extensor digitorum
- Extensor digiti minimi
- Extensor carpi ulnaris
These muscles extend your wrist and fingers, which helps you to use your wrist and hand to grasp and turn things. The tendon of the extensor carpi radialis brevis (ECRB) muscle is the most common tendon affected in tennis elbow.
HOW DOES IT OCCUR?
The proper name for tennis elbow is “extensor tendinopathy”. A tendinopathy refers to the pain and pathological characteristics of disease that can occur in a tendon. Tendons are composed of highly organised connective tissue that join muscle to bone.
The fibro-elastic composition of tendons makes them strong enough to resist high tensile forces while transmitting forces from muscle to bone to allows movement to occur at your joints. The connective tissue that makes up tendons is dense and arranged in a regular pattern made up of collagen fibres, different types of cells, and ground substance. The tendon is surrounded by a sheath called the epitenon.
The collagen fibres of tendons run parallel to the long axis of the tendon. This helps it transmit large mechanical forces produced by the muscles to the bone to elicit movement, and absorb external forces during impact to prevent damage to the muscle.
When a healthy tendon is used to transmit or absorb forces (“loaded”), it’s fibres straighten out – becoming more linear and parallel. When the load is removed, the fibres are able to recoil back to their resting crimped position.
If the load on the tendon is increased and the fibres can’t straighten any further, microscopic tears can form. This stimulates a healing response in the tendon. If the tendon continues to be subject to too much load that it can handle, this healing response can become dysfunctional, causing a tendinopathy.
Tendinopathy occurs in a continuum involving 3 stages:
- Reactive Tendinopathy: when the tendon is suddenly overloaded or undergoes direct trauma. In response to this, the tendon starts to thicken, tendon proteins are produced and tendon cells are activated and proliferate.
- Tendon disrepair: if the tendon continues to be overloaded, collagen fibres become more disorganised from their parallel formation, scar tissue begins to form, and new blood vessels and nerves grow.
- Degenerative tendinopathy: if the load hasn’t been reduced, degenerative changes occur in the tendon, which can be very difficult to reverse. Large tears can occur in the tendon, which compromises its structural integrity and ability to function normally.
Pain can potentially originate from sensitive nerves, too much compression/tension on the tendon, or in later stages – the growth of new pain sensitive blood vessels and nerves.
It’s important for collagen fibres to grow parallel to the long axis of the tendon to optimise its ability to transmit large mechanical forces produced by muscles and absorb external forces to prevent damage to the muscle (e.g. when playing tennis, tendons in the upper limb will absorb some of the forces produced that go through the racquet when you return a serve, to protect the muscle from too much force). With tendinopathy such as tennis elbow, the fibres become disrupted and disorganised due to the failed healing response, which reduces the strength of the tendon and makes it mechanically less stable – this makes the tendon even more susceptible to damage.
There isn’t much evidence for inflammation in the tendon (tendinitis) except in the very early stages of the disease, which is why treatments like rest, non-steroidal anti-inflammatory medications (NSAIDs eg Asprin, Ibuprofen, Celebrex, Voltaren) and corticosteroid injections aren’t very effective for long term management of the issue (Andres & Murrell, 2008).
WHAT ARE THE SYMPTOMS OF TENNIS ELBOW?
- Pain over the outer elbow, which may increase with gripping, resisted wrist and finger movements
- Pain, pins and needles around the elbow and/or referring to the wrist
- Weak elbow muscle strength, and reduced grip strength when the elbow is straight
- Symptoms develop after completion of an aggravating activity e.g. gripping activities, extending the wrist. In later stages symptoms may occur with minimal activity such as brushing teeth, shaking hands
WHAT ARE THE RISK FACTORS FOR TENNIS ELBOW?
Tennis elbow affects 1-3% of the population, and 15% of workers in at risk occupations.
The following physical occupational factors can increase your risk of tennis elbow:
- Handling loads > 20kg (at least 10x/ day)
- Handling tools > 1 kg
- Repetitive arm movements > 2 hrs/day
- Arms lifted in front of the body, hands bent or twist, and precision movements during a part of the working day
Your risk also increases with:
- Obesity (includes diabetes)
- Age: 45-54 years
Clinically, tennis elbow is commonly seen in patients who participate sports and occupations requiring gripping (e.g. tennis players, carpenters, tailors, office workers, riding motorbikes/cycling). Pain commonly arises gradually, usually 24-72 hours after engaging in an unaccustomed activity where the tendon has been overused.
HOW CAN PHYSIOTHERAPY BE USED AS TREATMENT FOR TENNIS ELBOW?
Goals of physiotherapy treatment and patient education include:
- Reducing pain
- Reducing inflammation (in acute cases)
- Regain muscle strength and range of motion
- Return to normal daily functioning and occupational duties
As an overuse injury, modification and load management is important especially in the early stages to prevent tennis elbow from progressing. A physiotherapist will identify biomechanical factors and activities that need to be modified to help the healing process. In the laters stages of tendinopathy, it’s important that the tendon is loaded appropriately to strengthen it without overloading it again.
Research has shown that eccentric strengthening programs are an effective way to reduce pain intensity, improve strength, improve tendon structure and reduce disability that can occur with chronic tennis elbow (Croisier, Foidart-Dessalle, Tinant, Crielaard & Forthomme, 2007). An eccentric muscle contraction means that the muscle contracts as it lengthens – it has been hypothesised that strengthening the muscle as it lengthens encourages the collagen fibres to remodel along the long axis of the tendon so that it returns to the normal structure of a healthy tendon. Stretches, forearm coordination and grip strength training can also assist with recovery. Physiotherapists at bounceREHAB are trained to safely guide you through a comprehensive, specialised exercise program to facilitate tendon remodelling and healing, improve upper limb flexibility and strength, and help you gradually return to normal activities.
Physiotherapists can also provide ergonomic advice to help reduce strain on the tendon while it’s healing – this can include to avoid lifting objects with the palm turned down or with a straight elbow, and to instead lift with the palm turned up, with the elbow bent, and the object kept close to the body. If relevant, technique of sport participation may also be addressed and corrected if it is a contributing factor to the injury.
Manual phyiotherapies such as mobilisation/manipulation of upper limb, neck and thoracic spine joints, and soft tissue therapy can provide relief from symptoms, improve joint range of motion, improve function, and reduce compensatory movement patterns that may be contributing to excessive loading of the tendons.
Muscles are surrounded and divided by fibrous connective tissue called deep fascia. Myofascial release techniques (such as Instrument Assisted Soft Tissue Mobilization used by bounceREHAB physiotherapists) can help reduce fascial restrictions to reduce pressure on pain sensitive structures around the elbow. Dry needling techniques can elicit a local twitch response in trigger points in affected muscles and provide both mechanical and biochemical changes which can be helpful in reducing pain and improving muscle length and function. If all else fails shockwave therapy has been shown to show some promising benefit in reducing pain and improving function in a chronic tendinopathy state.
Tension on the radial nerve can also contribute to pain around the outside part of the elbow, and this is a common feature in patients who engage in activities that repetitively load the forearm such as working for prolonged periods of time at a computer with poor ergonomics.
Neural gliding techniques can reduce sensitivity and improve mobility of the nerve, which can provide relief from symptoms (Arumugam, Selvam, & MacDermid, 2014).
Strapping or braces applied just below where the ECRB originates at the elbow can provide a compressive force which unloads the area for symptom relief. KT taping techniques can also facilitate muscle function during the recovery process.
IS A CORTICOSTEROID INJECTION APPROPRIATE FOR TENNIS ELBOW?
A study by Bisset et al (2006), investigated the effects of different treatment modalities for tennis elbow.
Here are their findings:
- After the first 6 weeks, patients with tennis elbow who had the corticosteroid injection had the best outcomes (compared to a “wait and see” approach or drugs)
- BUT recurrence rates were higher, recovery delayed and poor overall performance in the mid to long term (12 months) after corticosteroid injection compared with physiotherapy or a wait and see approach. I.e. the significant short term benefits of an injection are reversed after six weeks, which implies that this treatment should be used with caution when managing tennis elbow.
- Physiotherapy (elbow manipulation and exercise) has a superior benefit to a “wait and see” approach in the first 6 weeks, and to corticosteroid injections in the long term, and may be recommended over corticosteroid injections
- Most cases of tennis elbow will improve when a patient is given information and ergonomic advice about their condition
- Patients who received physiotherapy sought significantly less other treatment
Overall, cortiscosteroid injections are only appropriate for short term decrease in pain in early stages of tennis elbow only. This is likely because the injection is meant to target inflammation, but the process of a tendinopathy does not involve inflammation except in the very initial stages of the injury.
HOW LONG DOES IT TAKE?
The oxygen consumption of tendons is 7.5x lower than that of skeletal muscles. This is because tendons need to carry loads and maintain tension for long periods of time, and are suited to having a lower metabolic rate with lower blood supply and demands for oxygen when generating energy. While this low metabolic rate is essential for their normal function, it also means that tendons have a slow healing time after injury.
WILL I NEED SURGERY FOR TENNIS ELBOW?
Surgery is considered the last resort option (after ~ 6 months of conservative therapy) to treat tendinopathies such as tennis elbow if all nonoperative treatment options have been attempted and have failed. Moderately good results have been reported with various surgical approaches such as open debridement, but this is supported by low quality research only.
HOW CAN bounceREHAB HELP YOU?
- Physiotherapy & Pilates: manual therapy (soft tissue/trigger point therapy, massage, mobilisation and manipulation), exercise therapy (stretching, strengthening/clinical Pilates, neural gliding techniques), taping/bracing, dry needling, cupping, shockwave therapy
- Nutritional medicine: dietary changes and supplements to assist tendon regeneration (proteins, collagen, vitamin C, zinc)
- Massage: myofascial release techniques and trigger point therapy