Tennis Elbow & Physiotherapy
Tennis Elbow, or Lateral Epicondylitis, is a common complaint associated with characteristics of pain and sensitivity in the lateral elbow region, especially over the bony prominence. This area is called the lateral epicondyle, and is the site of attachment for a group of muscles that pull the wrist backwards, or in other words, extend the wrist. This movement of wrist extension is the bread and butter of any tennis players’ skill set, and is commonly used in the backhand motion. As the name suggests, Tennis Elbow occurs in 40-50% of regular tennis players. In fact, the term has been dated back as far as 1873. This injury can also occur from isolated incidents in which there is damage to the fibers within the tendon tissue, such as sudden lifting, jerking or wrenching movements. It is therefore quite a common injury within the manual workforce.
Symptoms of Tennis Elbow:
The symptoms of tennis elbow include painand tenderness around the otter aspect of the elbow where the extensor muscle attaches. Pain may refer into the upper and lower arm along extensor muscles.
It may also cause pain when you:
Lift something and this may be a cup or a kettle.
Make a fist or grip an object
Turning the door knob or opening the door
Shaking hands
Typing or using the mouse
Treatment of Tennis Elbow?
The evidence around Tennis Elbow treatment protocol has been relatively hazy up until recent years. Studies in the early 00’s claimed that modalities such as Shockwave Therapy (ECST), TENS and laser therapy had a positive effect on Tennis Elbow symptoms. However larger studies have been carried out in following years that have shown that these modalities may only give short-term relief, and cannot be deemed as suitable protocol for treating Tennis Elbow.
The nature of the injury was believed for years to be inflammatory in nature, but researchers are moving away from this belief.
What causes Tennis Elbow is a disorder of tendon tissue due to incorrect loading. How do we fix the issue?
We improve the way that the tendon takes load and your physio creating a strength program for the wrist extensors that is at a level suitable for your tendon. The exercise that we prescribe can be categorized depending on how the fibers move when contracted, and is based on your pain response.
For very painful elbows, we start to apply load to the tendon very gently which can be achieved by isometric exercise. Isometric loading Involves actively contracting the muscle fibers without changing the length of the tissues and joint position. Think about pushing against an immoveable force, like a closed door. Long slow holds for up to 45 seconds are used to reduce pain and gently improve strength. This type of exercise is also used if there are any micro-tears to the tissue, which can be sustained from sudden injuries to the elbow.
Strength can be progressed to increase the amount of load put through muscle and tendon fibers. Eccentric loading is when fibers control the descent of a load, or lengthening under load. It is the opposite of concentric loading, which is the typical shortening of fibers we see when a muscle is contracted, for example, the biceps brachii muscle shortening during a biceps curl.
Tennis Elbow usually occurs from repetitive concentric contraction of the extensor muscle fibers. Controlled loading of the tendon is believed to re-train the tendon to tolerate forces and alter how it works when loaded. There is also evidence to show a degree of collagen-synthesis at the injury site (or a reproduction of the material that makes up tendons), during a program of this nature.
We use grip strength, or dynamometry as a way to measure changes in function in patients with Tennis Elbow. A 2018 study has proven that the addition of scapular stabilization and shoulder strength exercises to a program already consisting of wrist extensor loading can improve grip strength results in patients. This is particularly useful for clients who are in end-stage rehab and wish to return full-time to tennis or their occupation, which caused their symptoms to develop in the first place.
To return to these activities, a gradual increase in training must take place, and overlap with the strength program created for the wrist extensors. The way that the whole arm moves during tennis or other extensor-dominant exercises is going to play a huge part in whether or not the wrist extensors are over-used. De Smedt and colleagues have reported that up to 90% of patients will recover from Tennis Elbow within 1-2 years.
Poor adherence to interventions is definitely one of the challenges of implementing self-management treatment strategies in primary care. Perhaps the poor statistical data within studies to promote exercise strategies to treat Tennis Elbow is a result of poor adherence to exercise programs from patients. Due to the nature of the injury, the exercises promoted by physios are low-level loading and do not require gym membership. This can be seen as an advantage or a disadvantage as they are easy to do, but the likelihood of every client completing them daily is quite low. Education remains as the number one tool in the physio’s kit. Explaining the cause, the treatment and the lengthy rehab process to each patient with Tennis Elbow must be carried out to ensure maximum adherence to the process.
Reference
https://www.sciencedirect.com/science/article/pii/S0972978X1930248X?via%3Dihub
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3759476/
https://bjsm.bmj.com/content/39/7/411
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5909009/
https://www.ncbi.nlm.nih.gov/pubmed/25380079
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2465303/