Have you got pain in your elbow? Is it a classic case of what is commonly referred to as tennis elbow or otherwise known as lateral epicondylalgia or a common wrist extensor origin tendinopathy?As with all patients we discuss your history and then assess of your injury to then provide a diagnosis. The outside part of the elbow is also the sensation pattern for c5/6 referred pain from the neck - therefore if its important to determine is there accompanied neck/shoulder pain or is your elbow pain aggravated by movements of the neck, trunk or shoulder joint. Has there been any trauma directly to the elbow? Is there a mechanism of injury or what brought on your symptoms? All these factors need to be considered in diagnosing tennis elbow.
Tennis elbow or lateral epicondylalgia presents as pain directly over the lateral epicondyle of the humerus with occasional spreading of pain into the forearm when loading the wrist extensor (forearm) muscles. It affects 3% of the general population; 30% of repetitive hand workers and 40% of tennis players - hence the name tennis elbow. This tendinopathy is generally seen in 35-55 year olds whom would describe their symptoms as a gradual onset following and or aggravated by repeated gripping/twisting. Occasionally acute bouts following overload performing one lift or impact may result in tennis elbow [1-4]. Physical examination of patients may reproduce pain via palpation; resisted extension of wrist, middle and or index finger; as well as gripping or squeezing an object. Tennis elbow can cause decreased reaction times, increased sensitivity to pain/temperature, reduced wrist angle or range of motion with grip; widespread upper limb weakness of the wrist, fingers and shoulder [1-4]. Those whom present with concurrent neck and arm pain, perform high repetition manual work, have pain >3 months and patient-rated tennis elbow evaluation scores >54 tend to have poor prognosis [4].
There are 3 stages to making a full recovery from tennis elbow:
Phase 1: Re-education; mobility and strength
Load management, activity modification
Restore wrist extensor flexibility, wrist/elbow/shoulder range motion
Isometric/eccentric wrist extensor exercises
Dry needling
Correct upper limb biomechanics, thoracic mobility, alignment
Phase 2: tendon load storage capacity
Increasing load capacity, introduce supination/pronation exercises
Core/postural strengthening
Phase 3: Specificity/functional training
Increase upper-limb strength/power, endurance, load specific + plyometric tendinopathy progressions performed with correct movement patterns tailored to individual needs. E.g tennis, work, gardening
What exercises can you try at home?
No single exercise and dosage is going to suit all patients and the research doesn’t provide a definitive answer either. Therefore, it is ok to assess each patient and see if they response more favourably to eccentric (lengthening muscle) or concentric (shortening muscle) loads.
“For patients with reactive tendinopathy or irritable symptoms, gentle, pain free isometric contractions of 30 to 60 seconds in duration, performed daily, with the wrist in 20-30 degrees of extension and the elbow in 90 degrees of flexion, may be more appropriate” [4]. Concentric and eccentric exercises of the wrist extensors are advocated for patients that are in the degenerative stage of tendinopathy. With degenerative tennis elbow, pain 3/10 is acceptable during exercise, but not the following morning [4].
Wrist extension exercises can be done with the forearm resting on a table/bench and with the shoulder in a supported position. Each exercise should be performed slowly i.e. 6-10 seconds per a repetition.
Supination/pronation exercises can be done with an imbalanced object ie. hammer. The elbow is flexed to 90 degrees and stabilised beside the trunk. Repetitions are performed slowly over 6-10 seconds.
Posture is very important. No pain is recommended. Movements are slow. Dosage needs to be tolerated and adequate for strength gains. Allow for sufficient rest of 1-2 minutes between sets. Delayed onset muscle soreness is not a goal, if it hurts during, afterwards or next morning as a result of exercise/activity back it off.
“In summary, despite conflicting findings, there was evidence from several RCTs of sound methodological quality that exercise may be more effective at reducing pain and improving function that other interventions such as ultrasound, placebo ultrasound, and friction massage, but there may be no difference in effect between different types of exercise” [3]. This information reminds us that successful rehab requires clinical reasoning and your physio choosing a treatment that addresses the physical impairments found during the assessment of your injury.
Note, this is a guide and may not be suitable for all patients. Physiotherapy and exercise therapy should be tailored to the individual. For patient’s whom are struggling with ongoing elbow pain it is recommended to consult a physiotherapist to manage symptoms and guide the patient through their rehabilitation and return to activity appropriately. Contact Our Physio Central Coast (02) 4339 4475 for further information on how to manage your lateral elbow pain.
References
[1] Alizadehkhaiyat, O., Fisher, A. C., Kemp, G. J., & Frostick, S. P. (2008, July). P90 ASSESSMENT OF UPPER LIMB MUSCULAR STRENGTH IN TENNIS ELBOW. In Orthopaedic Proceedings (Vol. 90, No. SUPP_II, pp. 389-389). The British Editorial Society of Bone & Joint Surgery.
[2]Coombes, B. K., Bisset, L., & Vicenzino, B. (2009). A new integrative model of lateral epicondylalgia. British journal of sports medicine, 43(4), 252-258.
[3]Bisset, L. M., & Vicenzino, B. (2015). Physiotherapy management of lateral epicondylalgia. Journal of physiotherapy, 61(4), 174-181
[4]Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of lateral elbow tendinopathy: one size does not fit all. journal of orthopaedic & sports physical therapy, 45(11), 938-949.
Acknowledgements
Nick Kendrick - Clinical Edge
Sian Smale - Rayner and Smale
