With Wimbledon beginning this week today’s blog post will focus on an elbow condition known as ‘Tennis Elbow’ or Lateral Epicondylalgia. So what exactly is ‘Tennis Elbow’? It is a condition initially thought to be due to inflammation of the wrist extensors tendons which attach at the outer (or lateral) elbow. Now it has been shown that the cause relates to chronic degeneration caused by repetitive stretching of the extensor tendons (Jariwala et al., 2012). Therefore, the term lateral epicondylitis is now misleading. It can be caused by overuse, repetitive movements and muscle imbalance around the elbow joint. It actually has a low prevalence with 1-3% of the population being affected, more so on the dominant hand (Mallen, Chesterton and Hay, 2011). It is now less prevalent with tennis players due to better hitting techniques and lighter racquets being used (Jariwala et al., 2012). The symptoms of Tennis Elbow include, pain with gripping, pain with wrist extension, and tenderness over the outer aspect of the elbow. It has a gradual onset and is often worse during activity. In tennis the onset can be associated with a single handed backstroke, tighter strings, and heavier racquets (Jariwala et al., 2012). It is a self limiting condition, meaning eventually it will get better on it’s on but it can last from six months to two years. If you are experiencing these symptoms you should see a physiotherapist for a full assessment and advice on your personal management to rule out any other possible diagnosis.
Physiotherapy has been shown to be superior to a ‘wait and see’ approach in the initial six weeks for reduction of symptoms (Mallen, Chesterton and Hay, 2011). It can aid in treatment with the use of manual therapy such as soft tissue release of the extensor muscles and mobilisation of the elbow joint. Rehabilitation includes stretching the tight extensor muscles, which can be done with the elbow straight and bending the wrist with the palm facing downwards with slight pressure from the other hand (Image 1). This should be held for 30 seconds and repeated 3-4 times per day. Pain management can be assisted with anti-inflammatories and ice massage over the outer (or lateral) elbow.
Activity modification is another large aspect of minimising symptoms by decreasing loading on the tendon through: avoiding heavy lifting, avoiding repetitive gripping activities, taking breaks from lots of arm activities or pacing. Once your pain has settled your physiotherapist can guide you on when to begin strengthening the muscles and tendon. This should be done with eccentric exercises to load the tendon in a lengthened position to aid in increasing strength and pain relief (Image 3). This is may occur by stimulating muscle receptors which produce more collagen and in turn increase the strength of the injured tendon (Koch, Kamath and Chetri, 2015). Initially you should start with a low load (0.5 – 1kg) and build up as your pain allows and your body becomes stronger. Taping or force braces over the forearm can also be used to disperse forces across a wider area and decrease the load coming directly on to the tendon (Image 2). This in turn reduces your pain and allows you to return to activity more quickly. Acupuncture has also been shown to be effective against sham acupuncture in aiding pain, strength and disability in the short term (Fink, 2002). If you would like to learn more about acupuncture see my previous blog post here.
Picture 3: Eccentric wrist strengthening. 1) Resting your forearm on the edge of a table, use your unaffected hand to help lift the weight up. 2) Then slowly lower the weight. Repeat.
If pain is not improving with exercise and conservative management other treatment options can include; corticosteroid, platelet rich plasma (PRP) injection and low-level laser therapy. Corticosteroid has been shown to be effective in the short term but can increase the reoccurrence rate of symptoms in the long term (Mallen, Chesterton and Hay, 2011). Low level laser therapy may also be beneficial in the short term. Surgical approaches may be considered if symptoms persist longer than 12 months.
So if you have a niggling elbow pain that is not settling, make sure you come and see us about it! Pilates is also a great way to maintain strength and flexibility to keep you healthy and fit over the summer period. Have a look at our class timetable here. I hope all of you getting to see the live action enjoy Wimbledon and keep a watch out for any elbow braces and bright taping, maybe someone else is suffering the same nagging pain as you!
Anna Beldham. Physiotherapist and Pilates Instructor, APPI Hampstead.
Jariwala, A., Dorman, S., Bruce, D. and Rickhuss, P. (2012). Tennis elbow: diagnosis and treatment. Primary Health Care, 22(10), pp.16-21.
Mallen, C., Chesterton, L. and Hay, E. (2011). Management of tennis elbow. Open Access Journal of Sports Medicine, 2, p.53.
Fink, M. (2002). Acupuncture in chronic epicondylitis: a randomized controlled trial. Rheumatology, 41(2), pp.205-209.
Koch, M., Kamath, M. and Chetri, B. (2015). Efficacy of Cyrix Physiotherapy versus eccentric strengthening and stretching exercises in chronic lateral epicondylitis patients. International Journal of Physiotherapy, 2(5), pp.731-737.