What is Tennis Elbow?
Tennis Elbow is a common ailment from repetitive activities, involving the wrist and elbow. The name came from the most common cause – tennis, but any activity that repetitively uses the wrist and forearm such as weightlifting, painting, welding, and house cleaning, can also be prone to this condition.
Pain from Tennis Elbow is located on the outside of the elbow, just below the bony ridge known as the lateral epicondyle. Any activity that requires gripping/turning of the wrist, such as: turning a doorknob, brushing your hair, or opening a jar, will be painful and weak.
“Lateral Epicondylitis” was traditionally the medical term for Tennis Elbow, with “itis” indicating an inflammatory component. Treatments were then focused around reducing inflammation, such as: ice, anti-inflammatories and steroid injections. But research about 10 years ago found this to be a misconception. The inflammatory stage only lasts a few days. Therefore, the pain after a few days, could not be attributed to inflammation.
It was then theorized that the tendon (where the muscle attaches to the bone) did not heal properly and continued use would cause micro-tears in a weakened tissue. – “Tendinosis”. Treatments were then focused on stretching and eccentric strengthening. Some found relief, but why did so many still go on to become chronic?
The focus had always been on the tendon, but new research has recently found that 85% of those with lateral elbow pain, have a “joint derangement” or mechanical disorder that interferes with the normal function of the small elbow joint. It sounds daunting but is usually easily treated!
Joints have cartilage protecting not only the outer layer of bone, but also an extra buffer between the bones. (Examples of buffers between bones: Meniscus in the knee; labrum in the hip/shoulder, disc in the spine.)
Repetitive motion puts a strain on the joint, especially if the motion is awkward or has poor mechanics. This strain can cause microscopic tears in the cartilage and even cause a microscopic piece of your cartilage to break off in the joint that is being overused. This is part of the natural wear and tear process, but excessive activity combined with poor mechanics will advance this breakdown, known as a “derangement”. Even though this piece is very small, it can cause pain and loss of motion if it interferes with the joint’s smooth mobility.
Treatment for Tennis Elbow:
Proper treatment must begin with a proper diagnosis. Unfortunately, those with elbow pain are often diagnosed as tendonitis or an inflammatory condition. Chemical or inflammatory pain must be constant, as inflammation does not come and go with activity. Examples of pain from inflammation are a toothache or hitting your thumb with a hammer, where the pain is constant and throbbing. When there is tissue damage from an injury or infection, the body releases chemicals to initiate the healing process to clean the area and increase blood flow to repair tissues.
Elbow pain that is brought on with activity such as turning a doorknob, brushing your hair, gripping, but not painful at rest cannot be from inflammation. Intermittent pain is from a mechanical source.
Most often lateral elbow pain is intermittent and brought on with activity. A mechanical exam with then determine if your pain is from a joint problem/derangement (85%) or from poor healing of the tendon – Tendinosis (15%)?
Most pain from Tennis Elbow is found to be the result of a problem within the joint, known as a derangement. Pain from a derangement is usually easily corrected. This mechanical problem within the joint, simply needs to be cleared. If you have a pebble in your shoe, it is painful to walk. If you simply shake your foot, so the pebble moves into your toe box, you can now walk without pain. The pebble is still there, you just moved it out of the way. Similarly, if you can move the small particle out of the joints arc of motion, you will no longer have pain.
The derangement can be anywhere within the joint, but most commonly there is a slight loss of the ability to fully straighten the elbow. This is then often the direction to clear the derangement out of the way. A way to test is to first find a baseline, or activity that causes pain. It could be squeezing something or resist as you extend your fingers. Perform that painful activity and assess your pain. Next, straighten your elbow and then relax by bending it slightly. Perform this 10 times, each time trying to go a bit further into extension or straightening your elbow. Retest your baseline activity. Do you have more, less or the same amount of pain performing?
If you have less…Great…you found your self-treatment!
If there is no change, then it could still be a derangement. You would just need further guidance to find the right direction to clear the derangement. Or you may have poor tissue healing – Tendinosis. A clinician specialized in Mechanical Assessment and Treatment could give you advice on what you need to abolish the pain. (Connect with a specialist virtually www.virtualphysicaltherapists.com )
- Maccio JR, Fink S, Yarznbowicz R, May S. J Man Manip Ther.2016 Jul;24(3):158-65. doi: 10.1080/10669817.2015.1110303 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4984815/
- Rio E, Moseley L, Purdam C, Samiric T, Kidgell D, Pearce AJ, et al. The pain of tendinopathy: physiological or pathophysiological. Sports Med. 2014. doi:10.1007/s40279-013-0096-z. (Ahead of Print).[PubMed][Cross Ref]
- Alfredson H, Ljung B, Thorsen K, Lorentzon R. In vivo investigation of ECRB tendons with microdialysis technique-no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop. 2000;71:475–9.10.1080/000164700317381162 [PubMed][Cross Ref]
- Khan K, Cook J, Kannus P, Maffulli N, Bonar S. Time to abandon the “tendinitis” myth. BMJ. 2002;324:626–7.10.1136/bmj.324.7338.626 [PMC free article][PubMed] [Cross Ref]
- Mercer S, Bogduk N. Intra-articular inclusions of the elbow joint complex. Clin Anat. 2007;20:668–76.10.1002/(ISSN)1098-2353 [PubMed][Cross Ref]
- Bisset L, Paungmali A, Vicenzino B, Beller E, Herbert R. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005;39:411–22.10.1136/bjsm.2004.016170 [PMC free article][PubMed] [Cross Ref]
- Cullinane F, Boocock M, Trevelyan F. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil. 2014;28:3–19.10.1177/0269215513491974 [PubMed][Cross Ref]
- Barr S, Cerisola F, Blanchard V. Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: a systematic review. Physiotherapy. 2009;95:251–65.10.1016/j.physio.2009.05.002 [PubMed][Cross Ref]
- Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333:939–43.10.1136/bmj.38961.584653.AE [PMC free article][PubMed] [Cross Ref]
- Kohia M, Brackle J, Byrd K, et al. Effectiveness of physical therapy treatments on lateral epicondylitis. J Sport Rehabil. 2008;17:119–36. [PubMed]
- Coombes B, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309:461–9.10.1001/jama.2013.129 [PubMed][Cross Ref]
- McKenzie R, May S. The human extremities: mechanical diagnosis and therapy, 2nd edn Wellington: Spinal Publications New Zealand Ltd; 2003.
- May S, Ross J. The McKenzie classification system in the extremities: a reliability study using Mckenzie assessment forms and experienced clinicians. J Manipulative Physiol Ther. 2009;32:556–63.10.1016/j.jmpt.2009.08.007 [PubMed][Cross Ref]