TENNIS ELBOW (Lateral Epicondylitis)

What is tennis elbow or lateral epicondylitis?

Tennis elbow or lateral epicondylitis is an extremely common injury that originally got its name as it appeared in a high proportion of tennis players. Nevertheless it commonly manifests in a vast proportion of people who do not play tennis at all. Tennis elbow occurs most commonly in the tendon of the extensor carpi brevis muscle at approximately 2cm below the outer edge of the elbow joint or lateral epicondyle of the humerus bone.

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Abnormalities of the tendon occur in that there appears to be an excess of fibroblasts and blood vessels in the area and actual deformity of the normal collagen that makes up a healthy tendon. Inflammation is rarely present and there is an increase in pain receptors in the area making the region extremely tender.

Causes of tennis elbow

Tennis elbow occurs as a result of repeated extension (bending back) of the wrist against resistance. This may be from activities such as tennis, badminton or squash but equally from activities such as brick laying, excessive use of a screwdriver and computer typing.

A poor backhand technique in racket sports can be a primary cause. This is commonly seen in athletes who arrive ‘late’ for a backhand meaning that they cannot get their body behind the ball. In doing so they are not using the added strength of the whole arm as well as the twisting movement of the trunk. This means that the wrist has to compensate and in doing so injuries are caused to muscles and tendons which provide this movement.

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In addition the wrist should be firm and not bent when the ball is struck so the forces can be spread over the arm, shoulder and the rest of the body. If you imagine a ball traveling at 70mph and over hitting the end of a long lever made up of your arm and the tennis racket then all that force is focused on the tiny insertion of the tendon of the lateral epicondyle causing tennis elbow symptoms. Another can be a grip that is too small.

A small grip will mean the muscles in the elbow must work a lot harder leading to structural changes in the tendon. The majority of people getting tennis joint pain in the elbow are between 40 and 50 yrs but it can affect athletes of any age. (Is this because 40 – 50 yr olds are the ones with more time to play?)

Two types of onset are commonly seen:

Sudden Onset: Sudden onset of tennis elbow occurs in a single instance of exertion such as a late back hand where the extensors of the wrist become strained. This is thought to correspond to micro-tearing of the tendon.

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Late Onset: This normally takes place within 24-72 hours after an intensive term of unaccustomed wrist extension. Examples may be a tennis player using a new racket or even a person who’s spent a weekend doing DIY.

Symptoms of tennis elbow / lateral epicondylitis

  • Pain about 1-2 cm down from bony area at the outside of the elbow (lateral epicondyle)
  • Weakness in the wrist with difficulty doing simple tasks such as opening a door handle or shaking hands with someone.
  • Pain on the outside of the elbow when the hand is bent back (extended) at the wrist against resistance.
  • Pain on the outside of the elbow when trying to straighten the fingers against resistance.
  • Pain when pressing (palpating) just below the lateral epicondyle on the outside of the elbow.

Other injuries and conditions with symptoms similar to tennis elbow

The symptoms for this injury are very similar to Entrapment of the radial nerve which we recommend you also have a look at. It is important to have the neck examined as well as elbow pain can be referred from problems in this region.

Tennis elbow treatment

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No single treatment has been shown to be totally effective, however a combination of the treatments below are known to resolve tennis elbow over time. Each individual will react differently to different treatments. Below are examples only- we always recommend seeing a qualified therapist before attempting any rehabilitation.

What can the athlete do?

  • Apply ice or cold therapy to the elbow (20 min’s on up to six times a day). This will help reduce pain and inflammation if present.
  • Rest – an extremely important component in the healing of this injury
  • Wear a brace or support to protect the tendon whilst healing and strengthening, particularly when returning to playing / equivalent. The brace should not be put on the painful area but rather approximately 10cm down the forearm.
  • As with all soft tissue injuries a comprehensive exercise program should be carried out. This is particularly the case with tennis elbow.

What can a sports injury specialist or doctor do?

Correctly diagnose the condition: This may be done by carrying out Mills’ test- resisted wrist extension with the palm facing the floor (pronated) and moving the hand sideways in the direction of the thumb. If pain is elicited then this is a positive sign for the test.

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  • Another test is to resist extension of the middle finger-pain is a strong indicator for tennis elbow.
  • Rule out neural involvement
  • Advice on pain control-such as NSAID’s like Ibuprofen.
  • Apply ultrasound or laser treatment to help reduce pain and inflammation as well as stimulate healing.
  • Use manual therapy treatments such as massage therapy, myofacial release and/or transverse friction techniques across the tendon
  • Acupuncture has been shown to be extremely effective for tennis elbow
  • Advise on rehabilitation to return the athlete to full fitness.
  • Provide advise on neural stretching exercises if nerve tissue involvement is suspected
  • Give a steroid injection to reduce inflammation if present
  • Identify and correct any predisposing factors which lead to the onset of tennis elbow. Your tennis coach should also be able to provide some advice with regards your backhand technique.
  • Operate – if the conservative treatments have failed for about a year then this may be considered.

REHABILITATION

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The following guidelines are for information purposes only. We recommend seeking professional advice before attempting any rehabilitation.

Aims of rehabilitation

  • Reduce pain and inflammation.
  • Identify possible causes of injury.
  • Stretching and strengthening.
  • Gradual return to activity.

A number of treatment methods are available in the rehabilitation of tennis elbow. In order to maximize the chance of a successful rehabilitation it is important to apply as many as you can. It is important throughout the rehabilitation process to maintain fitness in ways that do not stress the elbow such as cycling or running so long as it is not painful.

Reducing pain and inflammation

Rest from activity that causes pain. If you are a tennis player then stop playing. It is not just tennis that causes this injury or may aggravate it. Gripping anything tightly or for long periods may make it worse, even opening heavy doors.

Wear a brace, support or heat retainer. This will give support and help prevent further injury. Increasing heat after the initial acute stage will stimulate blood flow and aid healing.

Cold therapy should be applied in the early stages – first couple of days. This can ease the pain, reduce swelling, reduce bleeding (initially) and encourage blood flow (later). Do not apply ice directly to the skin as this may cause ice burns – wrap in a wet tea towel.

NSAID’s (Non Steroidal Anti-inflammatory Drugs) such as Ibuprofen can help reduce pain and inflammation, especially in the early stages. It is thought they are less helpful later in the rehabilitation process. Always check with a Doctor before taking medication. You should not take Ibuprofen if you have asthma.

This phase will usually take from 2 days to 2 weeks.

Identify possible causes

Overuse is the main cause of tennis elbow. Doing too much, too soon without allowing your body to recover. Keep a training diary. This will allow you to look back and identify if you have been over training. The chance of suffering over use injuries is greatly increased if you have faulty technique. For example in tennis incorrect backhand technique, having the wrong grip size or badly strung rackets can all increase the chance of suffering tennis elbow.

Sports massage therapy

Sports massage can play an important part in the rehabilitation process.

Massage should be applied after the acute stage – lightly at first, below pain levels.

Cross frictions at the site of injury can help stimulate healing and stripping techniques on the muscles will help relax tight and knotted muscles that may increase the strain at the elbow.

Apply cold therapy after massage treatment.

Stretching

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Stretching should begin as soon as possible, gently at first and continue throughout the rehabilitation process and after.

Hold stretches initially for 10 – 15 seconds – during the acute stage. Later stretches should be held for up to 40 seconds.

Repeat stretches 5 times and aim to stretch at least three times a day.

Click here for details of stretching exercises.

Strengthening

Strengthening exercises should begin as soon as pain allows. This will depend on how bad the injury is.

If it hurts during the exercise, after or makes it worse the next day then do not do strengthening exercises. Be patient.

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Start with static exercises. When these can be done comfortably move onto concentric and eccentric exercises.

It is important that strengthening exercises are done before trying to return to activity.

Apply cold therapy after strengthening exercises.

Return to activity

This should be done gradually and only when you can hit balls without pain.

When you can comfortably manage the strengthening exercises then it may be possible to return to activity. If you are a tennis player ensure you have the correct technique. Wearing a brace can help take the strain off the elbow during the return to full fitness.

Practice strokes without a ball to start with. Introduce a ball and gradually increase power in shots and number of practice shots played. For example session 1 – 20 strokes at 20% effort. Session 2 – 30 strokes at 40% effort and so on.

This gradual increase should take place over a six week period. If you find you have pain during, after or the next day then take a step back.

Throughout this phase it is essential that stretching and strengthening routines are maintained.

SPORTS MASSAGE

The following sports massage guide is intended for information purposes only. We recommend seeking professional advice before attempting any self help treatment.

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What equipment is required?

A lubricant is needed to allow the hands to glide smoothly. A number of massage oils are available to buy. A cheap but effective alternative is simple baby oil. Do not use too much oil. Enough to allow for smooth, controlled movement is required but too much will mean a lack of control. A firm, flat surface to lie on in order to apply pressure.

How can sports massage benefit the rehabilitation of this injury?

Sports massage has two aims. The first applied directly to the tendon attachment itself will help reduce adhesions (sticky bits) between the tendon and the tendon sheath and aid healing by stimulating the bodies’ natural healing mechanisms.

The second benefit is by applying massage to the surrounding muscles to improve the condition and flexibility of the muscles themselves and so taking some of the strain off the tendon.

Sports massage must not be performed during the acute stage of this injury – usually 48 hours after injury. For grade two and three strains, massage may not be suitable for over a week. This is because if the is still bleeding then heat and massage will increase bleeding, not stop it.

Cross frictions to the tendon.

If the injury is recent or it is the first time the athlete has suffered from tennis elbow then it may be wise to avoid massage to the tendon attachment itself. In more chronic cases where conservative treatment has not produced the desired results then friction massage may help.

Aim – to gradually apply firmer frictions to reduce adhesions and aid healing.

With a finger, apply frictions backwards and forwards across the tendon when it is in a stretched position.

Start gently and slightly away from the tendon attachment, gradually working towards the attachment and getting deeper as the athlete becomes accustomed to massage.

Apply frictions to the tendon for 5 to 10 minutes. Ice may be applied before and after to ease pain and reduce inflammation.

tennis-accu

Stripping the muscle and Circular frictions.

Aim – to apply sustained pressure to the muscle, ironing out any lumps, bumps and knots.

With the thumb of the left hand (for the left arm), apply deep sustained pressure along the full length of the muscle.

This technique should be slow and deliberate to ‘feel’ the muscle underneath.Repeat this 3 to 5 times in a row, alternating with petrissage for 5 to 10 minutes. If the therapist comes across and tight, tender knots in the muscle (usually at the point of strain or rupture), these can be worked out with deep circular frictions to the sore spot.

Massage should be deep but not so deep that the athlete tightens up with pain.

Trigger points

A trigger point is a highly sensitive localized point in the muscle. If the therapist finds any lumps and bumps or particularly sensitive spots then apply deep, sustained pressure to these points using the thumbs.

Increase the pressure on the spot until it ranks 7/10 on the pain scale (10 being painful). Hold this pressure until it eases off to 4/10 on the pain scale (usually about 5 seconds).Without easing off with the pressure, increase again until it reaches 7/10 on the pain scale once more. Hold until it eases, repeat once more.

This technique is very hard on the thumbs. It is important to keep the thumb slightly bent (flexed) when applying pressure to avoid damaging the joints.

Finishing off

yoga elbow

The therapist can finish off with more petrissage techniques and then finally effleurage again. The whole process should not last more than half an hour. Massage therapy can be applied every day if it is performed lightly however deeper techniques may result in a day’s recovery period to allow tissues to ‘recover’. For rehabilitation of muscle strains, sports massage is very important in softening / preventing scar tissue forming at the site of injury and re-aligning the new healing fibers in the direction of the muscle fibers.

This will help prevent re-injury.

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