Tennis elbow pain is a ‘self-limiting’ medical condition, meaning that it will eventually subside over time, even without treatment. The recovery period, though, is unpredictable and varies among individuals. In some cases, the symptoms and the pain may last for an average time period of 6-24 months, which can be quite distressing for patients. During the recovery period, it is important to avoid activities that may aggravate the pain and to seek appropriate treatment from a registered physician. Failure to do so may result in chronic tennis elbow pain. This is defined as persistence of the symptoms and pain beyond 6 weeks, and it tends to be resistant to treatment. At this stage, the quality of healing for the muscle and the tendon is poor, and the elbow may display signs of progressive damage. This can be very disabling for the patient and in situations where the damage is severe or irreversible, some form of surgery may be needed. Hence, it is crucial to seek treatment from a physician, particularly in the early stages of tennis elbow pain. Likely, assessment and appropriate intervention from the doctor can help to alleviate the pain and to prevent disease progression.
Understanding Tennis Elbow Pain
Tennis elbow is a condition that causes pain around the outside of the elbow. It’s clinically known as lateral epicondylitis. It often occurs after strenuous overuse of the muscles and tendons of the forearm, near the elbow joint. Tennis elbow is a condition that occurs by repetitive tearing of the wrist extensors which leads to degeneration and scarring of the common extensor origin, this is located on the lateral (outside) of the elbow. Due to the rupture of the wrist extensors, the pain can occur by lifting or gripping, especially with the forearm in the pronated position, as this movement causes a stretch to these muscles. Tennis elbow pain can make everyday routine such as lifting a kettle or opening a jar painful and difficult. The exact points of the pain felt with tennis elbow are due to stress at certain points of the common extensor origin, which causes inflammation and pain at the specific muscle that the extensor is responsible for. An irritation of the radial nerve can also occur and cause pain further down the forearm. It is important to note that there are similar clinical presentations such as arthritis of the elbow, radial tunnel syndrome and other inflammatory arthropathies. It’s essential for patients with pain on the outside of the elbow to seek a professional diagnosis, since treatment and duration of symptoms may differ. People in certain occupational groups are at a higher risk for developing tennis elbow. This is namely manual workers or people who have jobs that involve repeated forceful movements of the wrist and or movements of the forearm. This can range from lifting, using tools or simple computer work, especially if it’s coupled with poor ergonomics. It tends to affect people 40-60. Although unusual, tennis elbow can affect non-dominant arms and occasionally both arms.
Importance of Seeking Treatment
Seeking treatment for tennis elbow pain is important in order to speed up the recovery time and reduce the severity of symptoms. Tennis elbow has a natural history of about 12-18 months, but with treatment, the pain may resolve in as little as 6 weeks. Without treatment, the pain may become chronic. During the time that the symptoms are present, a person with tennis elbow may alter their activities of daily living to avoid movements that increase their pain. This may lead to muscle weakness and increased muscle tightness due to limited movement, and sometimes the development of pain in other areas. People with chronic tennis elbow have more often reported a decrease in overall health.
There are many treatment options for tennis elbow; these include both non-surgical and surgical methods. Non-surgical methods are always considered as the first line of management. This is because the natural history of tennis elbow often results in full recovery of the normal strength and function of the elbow, and symptoms may resolve spontaneously, regardless of the treatment used. Therefore, the aim of treating tennis elbow is to improve the symptoms in the short-term. This may then have carry-over effects into the long-term resolution of symptoms, as well as prevent the problem from returning. The decision on which form of treatment to use is based on the individual, their occupation and lifestyle, and the potential side effects from the various options. A patient with tennis elbow should always consult their bone specialist for advice on what treatment option to use. A good understanding of the potential benefits and risks of each treatment will lead to a better overall outcome. By researching the various methods of treatment for tennis elbow pain, this should enable the injury to be managed more effectively and thus lead to an improvement in the quality of life of the patients who suffer from this common condition.
Non-Surgical Treatment Approaches
The use of nonsteroidal anti-inflammatory drugs (NAIDs) and analgesics like Panadol are suggested to alleviate pain caused by mounting elbow. NAIDs are recommended as the main drug treatment method. If they are ineffective, weak opioid-based analgesic may be prescribed. Caution should be taken with this type of medication and professional medical advice should be sought. Long-term use of NAIDs can have negative effects and there can be adverse side effects from even the short-term use of opioids. The risks and benefits of medical treatment should be discussed with a GP or specialist.
Physical therapy and rehabilitation are the commonest ways in which to treat mounting elbow. They assist to promote healing, relieve pain, and prevent future symptoms or return of the condition. The type of therapy used can rely on individual circumstances, but will primarily work around the strengthening and stretching of the muscles of the forearm. If grip strength is poor, then strength training may also be used, typically in manual ways. This may be in the shape of small weights and thera-band exercises. Massage and electrical nerve and muscle stimulation can also be effective. Stretching techniques advised are eccentric exercise involving the contraction of muscle while it is being lengthened. High reps of low weight in the extensor exercises.
Physical Therapy and Rehabilitation
Deep friction massage is another proven means of promoting tissue repair and renewal. This is believed to stimulate a local inflammatory response and induce collagen formation. Finally, instrument-assisted soft tissue mobilization with tools like the Graston Technique has been shown to be an effective means of promoting soft tissue repair. It is believed to induce a local inflammatory response and facilitate cross-fiber realignment of repaired tissue.
Eccentric exercise has been shown to be the most effective means of restoring muscle function and addressing the issues at the common extensor tendon origin. In fact, recent studies have shown a 60-70% success rate in resolving symptoms and a 95% success rate in restoring muscle strength with eccentric exercise alone. This has been shown to be more effective when compared with concentric exercises, bracing, and corticosteroid injections.
Rehabilitation is a critical component of recovering from lateral epicondylitis. The goals of physical therapy are to improve muscle strength, correct faulty mechanics, and facilitate tissue repair. This is performed through a variety of modalities, including but not limited to eccentric exercise programs, deep friction massage, and instrument-assisted soft tissue mobilization (Graston Technique).
Medications for Pain Management
If the course of epicondylitis is associated with a significant degree of pain and functional deficit, it is perhaps not unrealistic to consider a short course of oral corticosteroid therapy. Corticosteroids, namely prednisone or prednisolone, are highly potent and effective anti-inflammatory agents. When taken orally or injected directly into the site of tendon insertion, they have been shown to provide rapid and significant pain relief. However, given the potential for serious side effects and complications (particularly in older patients), corticosteroids should be used with caution and it could be argued that the potential for aggravated tendon degeneration makes this form of therapy somewhat counterproductive in nature.
The most common medication of choice is a Non-Steroidal Anti-inflammatory Drug (NSAID). These medications function to promote pain relief and through reduced inflammation, in turn elevating pain threshold and decreasing muscle weakness. The effectiveness of NSAIDs in epicondylitis is somewhat anecdotal, with only a few clinical studies being done to support their usage. The consideration here is that NSAIDs considered in isolation only treat symptoms, not the cause of the symptoms. However, due to the low cost and minimal complications associated with their usage, NSAIDs are still a popular choice for many patients and practitioners.
It’s important to note that any pharmacological intervention in epicondylitis should be viewed with an automatic skepticism. The clinical effectiveness of any medication, in this case, ability to relieve pain and facilitate a return to normal levels of physical activity, must be weighed alongside the potential for complications and undesired effects. This cost/benefit ratio will not only differ from one medication to another, but will also fluctuate depending on the characteristics of the patient being treated. Generally, pharmacological intervention in epicondylitis should be considered a secondary treatment option, perhaps to be used in cases of chronic recalcitrant pain which have failed to respond to more conservative measures.
Orthotic Devices and Bracing
A well-designed brace should also be effective, but the cost-effectiveness of a custom-made brace is questionable. Shoestring budget patients may just be able to find a suitable prefabricated brace, but the array and quality of these braces is highly varied. Cacophony braces offer immobilization of the elbow at various points and still have their uses, particularly in severe cases where temporary immobilization may be necessary.
A well-made orthotic device will limit the amount of stress being transmitted through the tendon and should allow the area to heal. This is done by preventing the wrist from extending too far backwards (the position when the wrist and finger muscles are at their fullest stretch). It has been suggested that using a wrist cock-up splint is more beneficial than a forearm strap as it is better at preventing wrist movement. However, it can be uncomfortable and a lot of patients will not tolerate it.
Orthotic devices and bracing have been used for tennis elbow, but it is unclear whether the benefits outweigh the costs. Most of these treatment methods aim to apply pressure over the extensor muscles without it being too uncomfortable and involve a forearm strap or a counterforce brace. These can have positive effects in the short term by improving grip strength and reducing pain; however, the evidence is varied and it may not be a worthwhile investment.
Surgical Treatment Options
Arthroscopic surgery is a method of surgery performed through tiny incisions and with the use of a camera and very small instruments. The camera projects images onto a television screen, and the surgeon uses these images to guide miniature surgical instruments. Because the arthroscope and surgical instruments are so small, this procedure results in much less damage to the surrounding tissues than did open surgery. This translates into a faster recovery and less rehabilitation post-operatively. There are many advantages to arthroscopic surgery. It is considered an outpatient surgery and does not require an overnight stay at the hospital. Because the incisions are so small, the surgical wounds heal quickly and can be protected from water much sooner, decreasing the risk of infection. This procedure can be performed under local anesthetic, and the patient under light sedation, which decreases the risks associated with general anesthetic. High-resolution arthroscopy can result in an extremely accurate diagnosis compared to alternative imaging studies. Several conditions can be identified and treated with the use of the arthroscope that might otherwise necessitate a more invasive procedure. Arthroscopy has been very successful in treating tennis elbow with a rapid return to function for the patient. With very few reported complications, this is a safe and effective procedure.
Arthroscopic Surgery
One surgical option is arthroscopic surgery. This is a procedure in which an arthroscope (tiny camera) and small surgical instruments are inserted through small incisions. The camera transmits the internal view of the elbow to a video screen for the surgeon to view. This enables the surgeon to look within the joint. The direct visualization of the joint is an advantage over other methods. The surgeon can correctly identify the extent and location of the degenerative change in the tendon origin. This is important, as studies have shown that tennis elbow is often misdiagnosed. An anatomy study found that in 36 elbows, only 9 had pure lateral elbow pain, 17 had pain with other pathology, and 10 had no pain at all. This misdiagnosis could lead to incorrect application of treatment. Identifying the area of degeneration and local tenderness of the extensor origin on the lateral humeral epicondyle is important to distinguish tennis elbow from other conditions.
Tennis elbow is a condition that can cause lateral elbow pain due to degeneration of the elbow tendons. It occurs because of overuse of the elbow, which can cause microtears in the tendon, leading to unsuccessful healing of the tendon. Medical treatments, such as NSAIDs or corticosteroid injections, are often insufficient to alleviate the pain and reduce the inflammation. Sometimes, the pain continues and the function of the elbow is impaired by this condition. In such cases, surgery options may have to be considered.
Open Surgery
The surgeon makes an incision to remove a portion of the diseased tendon. Open surgery has the advantage of being able to take out a larger or more specific, diseased area of the tendon. It is possible to set the repair by formal suture of the ends of the tendon. This has theoretical advantages in healing the tendon back to itself at the repaired portion, hence decreasing the risk of recurrence. This is in contrast to letting the tendon heal by scarring (the natural resolution of a cut tendon), which does occur when a portion of the tendon is simply removed, rather than repaired back to itself. However, open surgery is more traumatic, the hospital stay longer, and the risks and complications are higher than arthroscopic surgery. For these reasons, open surgery is usually only recommended in very severe, chronic cases, after non-surgical methods have been exhausted. In my experience, this is quite rare, and the detailed discussion between patient and surgeon is likely to be based on “risk versus potential long-term benefit”.
Recovery and Rehabilitation
It is important to remember that both acute and reconstructive surgical procedures are a last resort and will usually only be considered if a full trial of conservative management has failed.
If the pain does not resolve with nonsurgical management, there is the option of surgical release. This involves cutting the damaged section of the ECRB and releasing it from its attachment on the lateral epicondyle. This is usually an acute procedure which can be done under local or regional anesthesia. An open technique is rarely needed. Another option is repair of the ECRB. This is not a common surgical procedure and is usually only used if the ECRB has been avulsed from its attachment on the lateral epicondyle. This is then followed by reattachment of the tendon to the bone. This procedure will require 2-3 weeks in a splint, and then the rehabilitation process can begin.
After surgery, a splint is usually used for a short time to minimize movement and stress on the affected area. This is usually for 10 days post-op for an acute release surgery or for 6 weeks following a reconstructed surgery. Next, the splint will be removed and normal daily hand activities will be resumed. Once the patient has full motion and is pain-free, strengthening exercises can be started. The progression of exercises should be gradual, and if any symptoms return, then it is a sign that the patient is trying to progress too quickly.
The next stage of treatment for tennis elbow is a recovery and rehabilitation process. In some cases, tennis elbow is a self-limiting condition that will usually get better in time, so simple management is all that is required. In more severe cases or cases which have not improved with time, the patient may require some form of intervention. This could be in the form of physiotherapy or, in more extreme cases, surgery. During the rehabilitation process, it is important that the patient does not rush things and allow the damaged tissue to repair over time. If the patient tries to lift too heavy weights or rush back to sport, it is highly likely that the problem will reoccur.
Post-Surgical Care
Although the use of ice has not been proven to be effective in musculoskeletal rehabilitation, there is strong evidence showing the utility of ice massage in the acute phase of injury and early postoperative soothing of tissue. Massage with ice increases contact area, decreases aromatic receptors’ sensitivity, reduces nerve conduction velocity, and limits edema, thus reducing pain from the injury. Following this, the transition from cryotherapy to thermal agents can be initiated to promote tissue healing. This can take the form of heat wraps or hot/warm packs and should be tested first to ensure that they do not produce any unwanted inflammation in the area. A recent study has suggested that hydrocollator moist heat may be more effective in increasing tissue temperature up to 1 cm in depth compared to microwave heat pads while being more convenient and maintaining a more constant temperature. The use of heat agents can promote healing through the production of various heat shock proteins that aid in cellular recovery and by increasing tissue pliability, thus increasing the effectiveness of stretching exercise programs.
Post-surgery for tennis elbow can be done to ease post-operative pain and swelling. Surgery for tennis elbow typically involves cryotherapy during the first 72 hours. Cryotherapy is used frequently (every 1-2 hours) to reduce blood flow and cell metabolism in the area. Tissue cooling using ice and water is more effective than chemical cold packs, which are more painful because of the pressure caused by the elastic wrap required to hold them in place.
Rehabilitation Exercises and Techniques
Cyriax physiotherapy is a common technique used today. Soft tissue friction has been shown to be beneficial in the treatment of chronic tendinopathies by stimulating the immune system and boosting the natural healing response (Kraushaar and Nirschl, 1999). Although there is limited evidence to suggest that it works, patients often experience pain relief. This part of the treatment aims to correct chronic changes in the tissue structure. This is followed by manipulation where the surgeon uses his fingers to stretch the tissue in the same direction as the muscle fibers. This aims at breaking down adhesions and realigning collagen fibers. Lastly, the patient performs isometric exercises with the wrist in flexion, extension, supination, and pronation. This is aimed at gaining strength and durability in the newly structured tissue.
Rehabilitation exercises are only started once the patient feels minimal or no pain during their daily activities. The extensor carpi radialis brevis tendon needs stress to repair itself, but this must be offset with the need to rest the forearm. Eccentric loading of the common wrist extensor group is the most proven method to achieve this. It has been shown to be the leading treatment for lateral elbow tendinopathy (Placzek et al., 1995). This exercise is performed with the wrist extended (palm down) in a supported position, using a weight (initially 0.5-1kg) held in the hand. The athlete then lifts the weight with the uninjured arm and then lowers it over a 3-5 second period using the injured arm. Heavy slow resistance training using isometric wrist extension in pronation has been compared to a wait and see program by Newcomer et al. (2005). After 8 weeks, subjects planning using the eccentric exercise reported significantly less pain than the wait and see group. They showed improvements in pain, strength, and functional ability. Step one of this protocol is performed isotonically with step two using the same method as eccentric wrist extension.
Preventive Measures for Future Injuries
Complete 3 sets of 15 on different days of the week, it’s that easy! Regularly strengthen these muscles will help prevent a future re-occurrences of this injury.
Technique:
– Sit on a stool
– Place your elbow on the thigh
– The forearm should be resting at the knee straight (should be inline with the shin)
– Only the wrist should be hanging over the knee
– Keep the forearm down on your leg throughout the entire exercise
– Slowly lower the dumbbell, curling the wrist inwards as far as possible
– Lift the dumbbell slowly and twist your hand as far as possible outwards
Wrist injuries are one of the most common injuries for tennis players, and research shows that it is due to weak wrist extensor muscles. The easiest way to strengthen these muscles is to use a standard dumbbell, beginners should initially start with a 0.5kg either moving up or down a weight depending on the person’s ability.
Strengthening the wrist
Session URL
Coursework 1: Level 4 Module 2
#819052
[Link]
Frequency: 20-40 minutes per day.
Safety: Because some of these can be quite physically strenuous, it is best to talk to a GP first. It also helps to find a class specifically for people with your condition.
This traditional Chinese meditative martial art is a study in balance, where one move flows naturally into the next. It improves flexibility and muscle strength, and the slow, focused movements can ease stress and pain – making it an excellent choice for a wide variety of people.
