What is tennis elbow, how do I know if I have it and why do I have it?
Lateral epicondylitis, commonly known as “tennis elbow” is described as a condition that occurs from repetitive flexion and extension type movements of the wrist as well as pronation or supination of the forearm.
This can cause gradual pain over the lateral (outer) aspect of the elbow known as the lateral epicondyle. These repetitive type movements of the wrist and forearm can cause overuse of the surrounding soft tissue structures which can lead to collogen and angiofibroblastic degeneration and is not due to inflammation.
It must be remembered that tennis elbow can also result from direct trauma to the elbow and is not limited to an overuse injury. The common extensor tendon known as the extensor carpi radialis brevis tendon (ECRB) is the main tendon that is involved in tennis elbow. The reason for this is that it is prone to fatigue and injury as it can withstand up to 10 times a person’s body weight, but only receives up to 13% of oxygen and vascular supple. In other words, the volume of work the muscle is performing is not directly proportional to its vascular supply, making it susceptible to injury.
Patients with tennis elbow will report discomfort/pain on the outer aspect of the elbow, tenderness on direct touch of the lateral epicondyle as well as with palpation of the common extensor muscles of the forearm. Patients report pain and decrease in grip strength during activities like carrying objects or holding an object for prolonged periods. Tennis elbow is considered to be a self-limiting condition where 80% of individuals report it resolves within 1-2 years of consecutive conservative treatment. Ten – twenty percent of the population with tennis elbow requires surgical treatment.
Patients with tennis elbow will report discomfort/pain on the outer aspect of the elbow, tenderness on direct touch of the lateral epicondyle as well as with palpation of the common extensor muscles of the forearm. Patients report pain and decrease in grip strength during activities like carrying objects or holding an object for prolonged periods. Tennis elbow is considered to be a self-limiting condition where 80% of individuals report it resolves within 1-2 years of consecutive conservative treatment. Ten – twenty percent of the population with tennis elbow requires surgical treatment.
Tennis elbow is not only limited to tennis players
While tennis players do experience this condition, there is a high prevalence of tennis elbow also amongst golfers as well. Research shows that tennis elbow develops at the same rate as golfer’s elbow (medial epicondylitis). Furthermore, right-handed golfers are likely to develop tennis elbow in their left elbow due to the force exerted at their elbow and left elbow extension during the downward stroke and swing follow through.
Another sporting activity this condition is common amongst are weight lifters. This is largely due to the common extensor tendon acting as one of the main stabilizers for any gripping activities that is involved during pushing, pulling, wrist extension, flexion, pronation and supination exercises. All of which are involved in weight training. Again, the heavier the weight, the more pressure applied to the ECRB tendon.
Other activities such as gymnastics, knitting, sewing and other jobs that require usage of heavy machinery or lifting of any heavy objects are also prone to its development.
Poor posture has shown to also contribute to its development as it plays a role in changing the body’s biomechanics; leading to uneven loading and compensation.
Why choose chiropractic in the management of tennis elbow?
Active recovery and rest allow for the removal of repetitive loading of the muscles which commence the healing process and aid in prevention of further injury. For athletes, this can be difficult to achieve as rest may not be an option for you. Chiropractic care can therefore help with pain relief and modification of activities which will allow an athlete to still be functional without further injury.
A multi-modality approach is usually suggested for the best outcome and can include the following:
- Active release techniques (ART) are where the chiropractor applies a constant pressure to the tender spot and the patient actively moves the targeted tissue from a shortened to a lengthened position. Results are seen best when this is performed 5 times, per session for five sessions over 3 weeks duration.
- Dry needling technique over the tender areas of the extensor compartment of the forearm, show relief of elbow pain. A combination of ART and dry needling together shows major improvements of patient pain.
- Cross friction techniques have also shown to be beneficial. This technique promotes an increase in extensibility and mobility of the structure as well as increases inflammation at the site; allowing the inflammatory process to be complete and progress the injury to the later stages of healing.
- Shockwave therapy is a machine that is specifically indicated in the use of tendonitis’s and have shown to yield promising results. Usually a total of 7 sessions over a 4 week period is needed to show accurate results. It not only breaks down scar tissue and adhesions but helps start the healing process and desensitizes the pain receptors. The depth of penetration of the shockwaves all depends on the settings and the condition at hand.
- Elbow manipulation (Mills manipulation) of the elbow joint is effective as it stretches the common extensor tendon at the elbow and breaks down scar tissue.
- Instrumented assisted soft tissue mobilization (IASTM) has proven to be effective as the controlled microtrauma applied to the area induces healing. Evidence shows that combining this technique with eccentric strength training to be beneficial.
- Dynamic or kinesiology taping helps to offload the common extensor tendon, allowing it to rest and reduces pain levels.
- A local corticosteroid injection has temporary relief but is not permanently beneficial in the pathological and healing process of tennis elbow.
Importance of rehabilitation in the long-term treatment of tennis elbow
While the above conservative treatment will help in the pain management of tennis elbow, strength training is vital in the prevention of further injury or reoccurring injury in the future. The reason why rehabilitation is so beneficial in its treatment is that it restores flexibility, strength and endurance to the extensor muscles and common tendon, increasing its tolerance to forces that are placed on it. In addition, it also increases fibroblastic activity and collagen production which facilitates healing. It is important to remember that strength training must only commence when acute pain has subsided.
One exercise regime that yielded the best results was conducted over a period of 6-8 weeks and consisted of 3 sets of 10-12 reps twice daily. Another study suggested a strength training regime over a 5- week period. Typical exercises that are proven to be beneficial are isotonic eccentric wrist extension exercises, forearm pronation and supination exercises with a resistance band and forearm flexor and extensor stretches.
References
Bateman, M., Whitby, E., Kacha, S. and Salt, E., 2018. Current physiotherapy practice in the management of tennis elbow: a service evaluation. Musculoskeletal care, 16(2), pp.322-326.
Fedorczyk, J.M., 2011. Elbow tendinopathies: clinical presentation and therapist’s management of tennis elbow. Rehabilitation of the hand and upper extremity. 6th edn. St. Louis: CV Mosby, pp.1098-108.
Gliedt, J.A. and Daniels, C.J., 2014. Chiropractic management of elbow tendinopathy following a sports related trauma. The Journal of the Canadian Chiropractic Association, 58(1), p.52.
Gliedt, J.A. and Daniels, C.J., 2014. Chiropractic treatment of lateral epicondylitis: a case report utilizing active release techniques. Journal of Chiropractic Medicine, 13(2), pp.104-109.
Harneet, K.M. and Khatri, S.M., 2012. Efficacy of active release technique in tennis elbow–a randomized control trial. Indian Journal of Physiotherapy and Occupational Therapy, 6(3), p.132.
Lee, Y. and Lee, M., 2015. A Study on the Usage Experiences of Alternative Therapies for Tennis Elbow Patients in Korea. Proc. Advanced Science and Technology Letters, 116, pp.143-146.
Papa, J.A., 2012. Two cases of work-related lateral epicondylopathy treated with Graston Technique® and conservative rehabilitation. The Journal of the Canadian Chiropractic Association, 56(3), p.192.
Shaik, J., 2000. The relative effectiveness of cross friction and Mill’s manipulation as compared to cross friction alone in the treatment of lateral epicondylitis (tennis elbow) (Doctoral dissertation).
