Lateral epicondylosis, better known as tennis elbow, is the most common cause of overuse injury in the elbow that we see as Physiotherapists. It can also be one of the most frustrating conditions for people because it often occurs in their dominant arm and is quite resistant to old traditional treatment methods that are still often prescribed, despite being disproved by recent evidence.
There are several ways to treat tennis elbow. Some people prefer to rest their arms while others choose to exercise their arms. In this article, I will discuss the benefits of physiotherapy for tennis elbow and explain:
- What is tennis elbow?
- Why tennis elbow pain occurs
- How lateral epicondylosis (tennis elbow) is diagnosed
- Why you shouldn’t use cortisone injections for treatment
- How to relieve tennis elbow pain (lateral epicondylalgia) the right way
- What is involved in a long term treatment plan for tennis elbow
What is tennis elbow?
Tennis elbow was previously known as lateral epicondylitis, however, with new evidence emerging over the past decade, we now refer to it as lateral epicondylosis. Whilst no doubt seems like a small detail, the ramifications for the treatment of this overuse injury of the wrist extensors are quite dramatic. To explain the difference between lateral epicondylitis compared to lateral epicondylosis – the ‘itis’ means that it is an inflammatory condition and the ‘osis’ infers that it is a degenerative condition.
What this means for you and your treatment is that we need to avoid treating inflammation of the tendon and instead focus on treating degeneration of the common wrist extensor tendon at the elbow; and these treatments are vastly different!
Causes
The main cause of tennis elbow is overuse of your forearm muscles on the affected side due to strenuous exercise or repetitive movements, especially movements where force waves are resonating through the tendon. As with most tendon injuries, periods of overuse and strain on the tendon resulting in degeneration of the tendon occurring at a faster rate than the tendon can be repaired, resulting in lateral epicondylosis – or tennis elbow.
As we covered earlier, the evidence now shows that inflammation does not play a large role in this condition, rather it is the degeneration of the tendon of the forearm wrist extensor muscles. With this in mind, typically the most painful movements occur when holding an object whilst having your wrist extended – a common example being turning a door handle or using a set of keys. When we grip items, we naturally move our wrist into slight extension, and for this reason, one of the common symptoms of tennis elbow, besides pain in the forearm muscles, is weakened grip strength.
Tennis elbow pain injuries are frequently seen across a wide range of populations, from tennis players (not surprisingly!) to people who work at a desk all day, to people who do manual labour roles that involve repetitive movements. In fact, many people will face some aspect of tennis elbow pain at some point in their lives!
Steroid Injections for tennis elbow
The most common steroid injection that has been traditionally used to treat chronic tennis elbow pain is cortisone. Cortisone is a powerful anti-inflammatory drug that is injected into the painful site with the aim to reduce pain and inflammation, to help the injury to recover. However, as we have established earlier, we now understand that tennis elbow is not an inflammatory condition and is most likely the result of degenerative changes in the tendon of the forearm muscles and wrist extensors as they converge on the outside of the elbow, therefore cortisone is largely ineffective for this injury.
Important to note also is that steroid injections can actually weaken tendons when it is injected into or around the site. What this means clinically is that we need to avoid cortisone being injected into the painful degenerated tendon because it will have no measurable effect and can actually cause the degeneration of the tendon to progress further, aiding in worsening the elbow pain.
Tennis elbow pain relief techniques
Firstly, and most importantly, when dealing with tennis elbow we need to find a way to limit further aggravation and degeneration of the wrist extensor tendon. However, too often this results in people being told to simply stop doing the things that they need to or love doing.
What this should look like is limiting or modifying the aggravating activity; and this can occur in many forms including:
- Decreasing the amount of repetition of the activity that is aggravating the forearm muscles
- Decreasing the size of what is being held during the aggravating activity – in tennis we would decrease the size of the grip or the racquet in order to decrease the strain on the wrist extensors, therefore offsetting the load and decreasing the lateral epicondylalgia.
- Soft tissue release, better known simply as massage, can help to decrease pain in the forearm muscles, however it is important to note that this will only give short term pain relief and will not ‘fix’ the degeneration in the wrist extensor tendon.
- Heat or ice are common methods to decrease tennis elbow pain – both can be effective, however they are also short term solutions
Tennis elbow pain relief exercises
Eccentric strengthening exercises are the gold standard treatment to not only decrease pain in the elbow, but also reverse the degeneration within the tendon for a long-term solution. An eccentric exercise is one where the muscle is lengthening under tension, rather than shortening under the tension. There are various ways of achieving this, however, we will touch on the main ones that we would recommend:
- Flexbar Eccentric Exercise – The flexbar has been designed specifically for tennis elbow pain. The unique nature of the design allows you to load the wrist extensors through their natural movement, using your opposite hand as a counter lever, before slowly eccentrically loading the painful arm. When performing this exercise you would ideally have a very slow 6 second eccentric contraction. It is expected that there will be a tolerable level of pain and discomfort whilst performing this exercise, which is not harmful to the wrist extensor tendon.
- Eccentric Wrist Curl Exercise – Holding a small dumbbell with your palm facing the ground, begin in the fully extended wrist position before allowing a 6 second eccentric contraction as you lower the weight. It is also expected that there will be a tolerable level of pain and discomfort whilst performing this exercise, which is not harmful to the wrist extensor tendon.
Tips & Advice
Our number one tip is to find a Physiotherapist that understands tennis elbow treatment and can create a progressive eccentric loading protocol for you including the two exercises named above.
Tip number two is to not stop the aggravating activity completely with the expectation that rest will fix your tennis elbow. Tennis elbow is a degenerative tendon injury and it will not heal without appropriate load going through the tendon.
Our final tip is to not increase the load too fast when returning to normal activity. The most common mistake we see is that when people start to feel ‘pretty good’ again, they will go straight back to the level of activity that previously caused the lateral epicondylalgia and end up back where they started – in pain.
Frequently Asked Questions
How is tennis elbow diagnosed?
Tennis elbow is typically diagnosed by a Physiotherapist through a thorough medical history and musculoskeletal examination of the painful elbow and wrist extensors. The diagnosis is not required to be confirmed by an orthopaedic scan.
What does tennis elbow feel like?
Tennis elbow can begin by feeling like a dull ache on the outside of the elbow and, if untreated, it can progress to a sharp pain on the outside of the elbow that can radiate down the arm towards the thumb as the lateral epicondylitis progresses.
Why isn’t my tennis elbow pain getting better?
The medical terminology for tennis elbow is lateral epicondylosis, which means degeneration of the tendon on the outside of the arm at the elbow. Tendons have a poor blood supply and degenerated tendons will not heal without a progressively loaded treatment protocol designed by a Physiotherapist.
What are the early warning signs of an injury?
The early warning signs of tennis elbow are pain on the outside of the elbow at the start of an activity that seems to dissipate as you warm up. Due to this insidious onset, many people ignore the early warning signs and continue to aggravate the degeneration of the tendon, resulting in a chronic overuse injury.
When should you use a tennis elbow brace?
A tennis elbow brace can be used to help limit the continued overuse injury of the wrist extensors causing the elbow pain. It is important to note that these braces will only decrease pain in the short term by limiting movement, rather than aiding in the healing of the degenerated tendon.
