To celebrate Andy Murray’s Olympic gold in the tennis, John Glover our Physiotherapist has wrote the following piece on a condition commonly called Tennis Elbow.
It’s ironic that the number of tennis players that suffer from tennis elbow are said to account for 5% of all cases (Peterson and Renström, 2001). In fact those most at risk of developing this condition are people in manual trades (carpenters, builders, electricians, painters etc) that involve repetitive wrist flexion and extension (imagine painting a wall) and also pro and supination (think of turning a screwdriver). I guess ‘Painter’s Elbow’ didn’t catch on but the terms you will commonly here used to describe this injury are: lateral elbow tendinosis, lateral epicondylitis and lateral epicondylalgia. Each of these is an attempt to describe the underlying pathological process, but what is actually going on inside that elbow of yours?
“What causes Tennis Elbow”
Ljung et al (1999) conducted biopsies on patients with tennis elbow and found no evidence of inflammatory markers while Nirschl et al (1989) and Regan et al (1992) discovered degenerative changes in the wrist common extensor tendon, synonymous with other chronic tendiopathies (achilles, and patella etc). There are still several hypotheses as to what the main cause of the pain is: raised glutamate levels (Alfredson et al, 2000); secondary hyperalgesia (Wright et al, 1992) or my favourite ‘angiofibroblastic hyperplasia’ (Brukner and Khan, 2000). This basically suggests that in response to the micro-damage to the tendon, the body deploys cells called fibroblasts that begin to lay down repair tissue (granulation tissue) which contain a lot of painful nerve endings (potentially accounting for the pain).
So what does all this mean and what’s important for you to know? Tennis elbow is essentially an overuse injury where the wrist extensor tendon (mainly extensor carpi radialis brevis) undergoes microscopic tears. The tendon has a poor blood supply leading to a continuous failed healing response as the tissue healing struggles to keep up with the demands placed upon it.
How do you know you have Tennis Elbow?
- Gradual onset of pain (24-72 hours after training or manual work)
- History of overuse or return to training after a prolonged break
- Pain over lateral aspect of elbow (+ or – radiating pain down forearm)
- Pain shaking hands or opening doors (turning door handle)
- Pain on resisted wrist extension (+ or – passive wrist flexion pain)
What else could Tennis Elbow be?”
Before commencing on any Physiotherapy ot treatment regime, it’s important to confirm that the injury is actually tennis elbow by ruling out other potential conditions first. Other causes of lateral elbow pain are:
- Referred pain from cervical or upper thoracic spine
- Radial nerve tension
- Radiohumeral bursitis
- Synovitis of the radiohumeral joint
- Posterior interosseous nerve entrapment
- Osteochondritis dissecans (flaking of the articular cartilage and subchondral bone) of the captiellum or radius
Brukner and Khan (2000)
“How can I avoid Tennis Elbow?”
If you’re a tennis player correcting/adapting technique will definitely play an important preventative role in reducing abnormal stresses placed on the wrist extensor muscles (e.g. adopting a double handed back hand rather than single arm), along with ensuring adequate recovery between training sessions This shuld be done in consultation with your coach and/or Physiotherapist. Other preventative measures include checking the grip width of your racket (should be equal to the distance from the middle of your palm to the top of your middle finger) and replacing tennis balls on a regular basis.
If you’re in a manual trade, factory worker or in any job that involves repetitive stress on the forearm muscles I’d advise taking breaks when able and to regularly alternate arms i.e. not relying purely on dominant side to do all your work.
“How do I get rid of Tennis Elbow?”
Once a diagnosis of tennis elbow (lateral epicondylitis) has been confirmed your physiotherapist can talk you through a range of treatment options available to you, offer advice and education as to what movements and activities to avoid and inform you when it’s safe to return to activity. Which ones are most appropriate will depend on the severity and stage of the injury. Treatment options include:
- Graduated therapeutic strengthening and stretching programme
- Mobilisations with movement (MWM)
- Sports taping / Counterforce bracing
- DTF (Deep Transverse Frictional Massage)
*While NSAIDS can be effective in controlling pain some evidence has shown that is can delay/impair the normal cycle of soft tissue healing (Greene, 1992).
**This is not a comprehensive treatment list but just used to give an idea of what’s involved in each stage of the rehabilitation process.
If your symptoms persist for more than 6-12 months and you’re unable to return to your activity/sport despite rehabilitation from a Physiotherapist then surgery may be indicated. The surgery is an arthroscopic debridement of the extensor carpi radialis brevis tendon that is generally uncomplicated and completed within 30 minutes. 80-85% of patients regain full strength and complete relief of pain although the surgery is always followed by a post-operative rehabilitation programme on week 3. Steroid injections are also another option prior to surgery if conservative measures fail to reduce pain.
- Brukner, P., Khan, K (2000) Clinical Sports Medicine, Australia, McGraw-Hill
- Greene, J (1992) Cost-conscious prescribing of nonsteroidal anti-inflammatory drugs for adults with arthritis, Archives of Internal Medicine, 152:1995-2002
- Peterson, L., Renström, P (2001) Sports Injuries: Their Prevention and Treatment (3rd Ed), United Kingdom, Taylor and Francis.
- Ljung, BO., Forsgren S., Friden, J., (1999) Substance P and calcitonin gene-related peptide expression at the extensor carpi radialis brevis muscle origin: implications for the etiology of tennis elbow, Journal of Orthopaedic Research, 17: 554-559.
- Nirschl, R (1989) Patterns of failed healing in tendon injury. In: Leadbetter W., Buckwalter, J, Gordon S (eds) Sports-induced Inflammation, American Academy of Orthopaedic Surgeons, Illinois, pp 577-585.
- Regan, W., Wold, LE., Coonrad, R., Morrey., BF (1992) Microscopic histopathology of chronic refractory lateral epicondylitis, American Journal of Sports Medicine, 20: 746-749.