In previous articles, we discussed some conditions that can affect the lower extremities but now lets touch on a topic that is very common amongst athletes and affects the upper extremities.
Medial and Lateral Epicondylalgia (Tennis Elbow)
This is the topic of elbow pain. Medial and Lateral Epicondylalgia to be specific, are two very plaguing issues that can occur at the elbow.
Remember we discussed Achilles tendinopathy? Well, the same type of problems can occur in all tendons, including those in the elbow.
It’s safe to say that a majority of athletes implement some form of weight or resistance training into their training regimen, which can vary from the use of weights, resistance bands or body weight methods.
This may be an important part of any athlete’s routine but with all training regimens, there is always a risk for injury.
Why Does Tennis Elbow Happen?
Non-traumatic elbow issues occur most commonly from pulling, carrying and gripping overload.
They are commonly seen in individuals who have grip intensive occupations such as manual labor workers but also are seen in upper extremity dominant athletes including golfers, tennis players, rock climbers, gymnasts, and weight lifters.
This is where the layman’s terms “Tennis elbow” and “Golfers elbow” originated.
How Does The Tissue Change WIth Epicondylalgia?
As discussed previously, tendinopathy occurs when there is disorientation of the fibers resulting in poor integrity of the tissue.
Studies have shown a change in the collagen wherein MRI results, the affected area lights up bright white. There also are changes in the neuronal tissue and nociceptive processes.
Nociception is your sensory input for pain and a problem with this input channel means that the pain can be perceived as worse than it really is.
The area can present as very sensitive to touch with excessive pain upon force production such as generating a tight fist.
MRI Image Results
Notice in the image on the right, the white area.
Ultrasound Image Results
Notice in the image to the right, the blackened region and small area lighting up white.
Grip strength has not been shown to be affected but is rather diminished due to the response of pain, meaning someone with a high pain tolerance can generate a strong grip force and fight through the pain if they wanted to.
More importantly than raw grip strength, studies have also shown that there is a delay in the contraction and reaction time on affected sides meaning the ability to generate force through the elbow such as gripping, is slower and not as smooth.
This is a result of the disorientation of the collagen fibers and poor vascularity or blood flow in the area.
This image shows a visual representation of the tendon fibers. Although inflammation is shown, it would most likely be during an acute flare-up episode. Generally, tendon issues result in pain from poor tissue integrity, not inflammation.
Diagnosis of tennis elbow is generally achieved clinically by the presentation of the following:
- Pain upon touch at either epicondyle. This area is very localized and the person will report that’s “spot on” when you hit it.
- Pain with resisted wrist flexion or extension.
- Pain with resisted supination and pronation (turning the wrist over as in rotation).
- Pain with resisted middle finger extension or ring finger flexion.
- Pain with gripping, grasping, activity such as “opening jars” or “doing pull-ups”
- Tenderness in the muscle belly of the wrist flexors or extensors.
Pull ups, chin ups, farmers carries, curling, Olympic lifts and holding weights during weighted leg exercises are just some examples of where the elbow is at risk for excessive strain.
A strong grip is important and has been correlated with a positive life expectancy but during training, the problem resides where there are deficits that cause the muscles of the forearms and wrist to overwork.
Studies have shown that clinical presentations of individuals with elbow pain due to tendinopathy reveal a weakness in scapula musculature and the rotator cuff.
Instability in the scapula can cause compensation at the elbows and wrists.
What Movements Cause Tennis Elbow?
The wrist flexors and extensors originate at the elbow. The flexors are on the inner side of the elbow and the extensors are on the outer side. They attach to a boney prominence called the epicondyle.
Think of this as an anchor, where on the other end are the tendons that flex and extend the wrist and fingers.
If the load to the anchor is excessive, the tissue experiences excessive stress as it attempts to work hard to support the wrist and elbow.
Common movements again are pulling such as during rowing movements, curling, carrying such as a farmers carry and fast wrist extension movements such as during a backhand swing,
Olympic lifting such a snatch or clean and catching a ball such as during med ball slams and tosses.
How To Treat And Rehab Tennis Elbow
Treating elbow tendinopathy is a constant challenge for therapists but as with anything, the earlier it can be addressed the better.
The sooner treatment and activity modification can be implemented, the better the prognosis for the individual.
Most individuals have an initial thought process of, “I need an injection” so they can receive some pain relief.
A cortisone injection or anti-inflammatory medications have usually bee administered to reduce the pain.
Recent research and clinical outcomes have proven this to actually be counterproductive as inflammation is the body’s way of bringing the proper nutrients to the area to heal and repair.
Anti-inflammatory medications are generally used to control excessive inflammation or if the person is in a lot of discomforts, limiting movement and exercise efficiency.
Ice also has been used in the past but the effects of ice cannot even permeate deep enough to the tendons to have an actual effect. The numbing effect may block pain but it will not have an effect on the tissue.
Do Braces And Taping Help Tennis Elbow?
Braces and taping methods are commonly used to help reduce strain onto the tissue by limiting force production in the muscle group. These are just band-aid techniques and can be implemented short term while the individual is working on the underlying mechanical deficits.
Percutaneous needling is one form of treatment that is very common practice administered by orthopedic specialists.
It is done under ultrasound where a needle is guided into the tendon and used to reorient the affected sections of fibers, cause inflammation and incite the healing process.
Following this procedure, a protocol of exercises is administered in therapy to restore proper tissue integrity and mechanics.
To start treatment, the primary focus is on the elbow.
Ensuring proper healing and restoration of normal tissue properties is important before initiating anything else such as shoulder stability exercises.
The beginning phase is very calculated and it is important patients are diligent and compliant with the protocol to ensure the best possible prognosis.
Massage And Exercises For Tennis Elbow
The following is an example of treatment administered in physical therapy. The exercises are for an example protocol for lateral epicondylalgia, “Tennis Elbow”
The dreaded transverse friction massage (TFM):
This is different than a normal soft tissue massage because its focus is different than moving blood and soft tissue around to stimulate a relaxation process.
TFM is implemented to basically dig at the tendon across the fiber orientation to aggravate it and cause inflammation.
At first, it seems counterproductive to cause more pain but this is important because it is followed up by a strict protocol of corrective exercises targeted to load and remodel the tissue while the proper nutrients to heal and repair are in the area.
Following the TFM, stretching is done immediately afterward:
Then isometrics are implemented to begin a controlled loading phase to the tissue:
Resisted wrist extension
Resisted middle finger extension
Isometric Grip Hold:
A weighted ball is often used
Eccentric Exercises For Tennis Elbow
The “lowering” phase of a movement which is where the tissue lengthens against gravity. Eccentrics are primarily used in tendinopathy treatments.
Eccentric Wrist Extension:
The patient starts with the wrist in the top position with weight and slowly lowers down. They then use their other hand to return the wrist to the start position to avoid the concentric (aggravating) movements.
The eccentrics are meant to be done slowly and with a good weight resistance where there is some discomfort and fatigue while ensuring the patient can still maintain good control of the weight.
Start:
Finish:
Eccentric Supination (Palm up):
Start:
Finish:
A hammer is often used for this exercise. The patient starts with holding the hammer and slowly lowers down with the same concept as done for wrist extension.
Once the patient can demonstrate less pain, less fatigue and improved control with higher repetitions and resistance, they are then progressed to more functional training involving gripping, pulling, carrying, and lifting and full body exercises.
Shoulder stability exercises are also implemented once the patient can tolerate gripping forms of resistance without pain. Implementing functional exercises too soon can cause regression and flare of symptoms.
This can also cause inefficient execution of the exercise, as the patient may tend to compensate due to pain.
The take home key points for elbow tendinopathy issues are:
- Recognizing and addressing the condition at the first signs of pain can prevent further damage and lead to a fast recovery.
- Elbow tendinopathy issues are usually a result of overworking wrist and forearm muscles.
- Deficiencies in shoulder stability with the scapula and rotator cuff muscles can contribute towards elbow issues.
- Poor form and execution of exercises involving heavy and sustained grip can also cause elbow issues.
- Braces and taping may be used as an adjunct to therapy and rehabs but aren’t a solution.
- Now that you have an understanding of the condition, hopefully you will be able to recognize signs and symptoms early on. Regardless, it is always best to consult a licensed professional when experiencing issues.
About The Author
Michael St. George, PT, DPT (@icore_stgeorge on Instagram) is a physical therapist who works for Excel Physical Therapy and Fitness which is a private practice that is based around the greater Philadelphia region and suburbs. He is FMS, SFMA, Y Balance and Motor Control Test Certified with 8 years of experience in outpatient orthopedics and sports medicine. His training consists of experience working with physicians and surgeons from the Rothman Institute and therapists in his field specializing in various manual techniques and advanced treatment procedures.
References:
- McShane, J., Shah, V., Nazarian, L. (2008) Sonographically Guided Percutaneous Needle Tenotomy for Treatment of Common Extensor Tendinosis in the Elbow.
- Chourasia, M., Buhr, K., Rabago, D., et al. (2013) Relationships Between Biomechanics, Tendon Pathology, and Function in Individuals With Lateral Epicondylosis. Journal of Orthopaedic and Sports Physical Therapy, Vol 43 (6), 368-378.
- Day, J., Bush, H., Nitz, A., Uhl, T. (2015) Scapular Muscle Performance in Individuals With Lateral Epicondyalgia. Journal of Orthopaedic and Sports Physical Therapy, Vol 45 (5), 414-424.
- Bisset, L., Collins, N., Offord, S. (2014) Immediate Effects of 2 Types of Braces on Pain and Grip Strength in People With Lateral Epicondylalgia: A Randomized Controlled Trial. Journal of Orthopaedic and Sports Physical Therapy, Vol 44 (2), 120-128.
