Tennis elbow, otherwise known by its anatomical name – lateral epicondylitis (or epicondylalgia) – is a condition that affects the elbow joint. It is typically categorised as what we call an overuse injury and primarily involves the tendons that attach into the common extensor origin (Tosti et al., 2013). Namely, the muscles of the forearms that help extend the wrist.
Extensor (E.) Carpi radialis longusThe wrist extensor muscles
E. Carpi radialis brevis
E. Digitorum communis
E. Digiti minimi
E. Carpi ulnaris
Initially lateral epicondylitis was thought to be an inflammatory condition. However, the current consensus explains the process of “microtrauma” as the primary cause (Tosti et al., 2013). Despite the name “tennis elbow” denoting its sole cause from tennis, many individuals can develop tennis elbow through everyday activities and work.
Some examples include:
- Jobs that require specific repetitive movements
- Handling handheld tools for an extended period
- Regular heavy lifting at work
(Dingemanse et al., 2014)
The specific signs and symptoms for tennis elbow are quite easy to spot, and many individuals will have similar presentations for their tennis elbow. However, the difference generally lies within the length of time, the intensity and the demands of their work.
The Signs and Symptoms of Tennis Elbow
The signs of symptoms of tennis elbow can be different according to an individual’s specific circumstances. However, they do follow a general pattern (Tosti et al., 2013):
- Pain over the origin of the common extensor tendon
- Slow and insidious onset, and may coincide with recent increases in work or sport
- Discomfort with hand shaking, shaving, lifting luggage or groceries or raising a coffee mug.
- Weakness or pain with gripping and lifting objects
Other less common signs include jobs that require holding machinery that have a high amount of vibrations (e.g. using a jackhammer or chainsaw) or require constant opening and closing of hands (e.g. hairdresser).
Treatment: The Operative Route
Tennis elbow can be managed in various ways. The two primary categories of treatment are divided into operative and nonoperative management. Operative management options include:
- Percutaneous release
- Arthroscopic release
- Open release
In most cases, operative management is not required. However, there may be some cases of chronic pain, loss of range of motion, or failed conservative management that may necessitate a release of the common extensor tendon (Nazar et al., 2012; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3322435/).
Treatment: The Non-Operative Route
In terms of nonoperative management, we must consider the efficacy and evidence of treatment modalities. There are a plethora of treatment options that exist, which can be categorised as:
- Physical therapy and activity modification (e.g. manipulations and mobilisations, exercise training regimes or braces)
- Non-steroidal anti-inflammatory drugs
- Injections (e.g. corticosteroid injection, botulinum toxin – otherwise known as botox, platelet-rich plasma)
- Electrotherapy modalities (e.g. Ultrasound, Extracorporeal shock wave therapy, low laser therapy)
This list is by no means exhaustives, and many more recent methods have popped up including friction massage or using different types of elbow splints. However, these treatment methods generally have insufficient scientific evidence to back and support the claims against traditional treatments.
So what does the evidence say?
The evidence for lateral epicondylitis generally trends towards exercise as a primary treatment modality. There seems to be some evidence that other treatment modalities may be effective as an adjunct to exercise or as a stand-alone treatment method. As a summary, treatment options can be bulleted as such:
- Exercise for lateral epicondylitis is an effective treatment modality (Cullinane et al., 2013; Dingemanse et al., 2014).
- Exercise may provide greater effect for tennis elbow when compared to electrotherapy and placebo (dummy) treatments (Dingemanse et al., 2014).
- There may be some short term benefits with regards to ultrasound and corticosteroids, but no differences in long-term outcome (Dingemanse et al., 2014.
- Currently, there is a need for further research in the optimal use of biologic injectables, particularly with regards to timing, concentration and dosage (Tosti et al., 2013).
While these treatment methods may be beneficial for your tennis elbow, they require repeat visits and consultations with your physiotherapist. Unfortunately, this costs time and money that some individuals may not have… so what can we do instead?
Finally, the 3 steps to pain-free Tennis Elbow
Massage and relaxation of the extensor muscles of the elbow
Massaging your sore forearm muscles are a fantastic say of generating some short term pain relief, and there are a few guidelines we must follow when doing so:
Do not massage directly over the tendon and sore spot. Direct massage over the sore tendon can irritate the already sore tendon, and increase the amount of time needed for recovery.
Avoid stretching the sore muscles. Although stretching the affected sore muscles may feel good, but can cause stress and irritation of the tendon. Which, again, can increase the amount of time needed for recovery.
Massage of the forearm muscles can be done by hand, massage ball or foam roller
Strengthening of the forearm muscles
Isometric strengthening of the wrist extensors is extremely important. Stability of the wrist is often found to be lacking in the affected side of the person’s upper limbs. Some easy exercises include:
- Isometric wrist extension – different ROM
- General isometric grip strength work
Wrist position during everyday life
Excessive ulna deviation or pronation during lifting activities can irritate your extensor tendons. Being mindful of wrist positions even during working activities and lifting everyday objects is important,such as lifting a full and heavy kettle.
Wrist position is often overlooked when treatment of tennis elbow. Particularly when performing activities in the gym, wrist position is extremely important and we must be mindful of it when performing various activities. A few particular examples include:
- Wrist position during horizontal pushing movements and vertical pushing movements – avoiding excessive radial or ulnar deviation of the wrist.
- Wrist position during heavy dumbbell holds e.g. farmer carry – We want to ensure a neutral wrist position when we are carrying the weight. As we fatigue, the wrists will naturally drop, which is normal. However, we want to try to actively maintain a neutral wrist position for as long as possible.
Now that’s not to say that lifting heavy loads should be avoided entirely, but through strengthening and awareness of wrist positions we should be able to build tolerance of the extensor muscles and the wrist itself to be able to tolerate heavier loads.
Tennis elbow is a common condition that affects many people and often has its origins outside of playing tennis. Unfortunately, the current research on how to treat tennis elbow can lead into a rabbit hole of complex equipment or requiring a in-person physiotherapy consultation. However, as this isn’t financially viable for many people, this post highlights some easy ways to resolve your tennis elbow at home!
- Cullinane, F. L., Boocock, M. G., & Trevelyan, F. C. (2013). Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil, 28(1), 3 – 19.
- Dingemanse, R., Randsdorp, M., Koes, B. W., & Huisstede, B. M. A. (2014). Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: A systematic review. British Journal of Sports Medicine, 48(12), 957.
- Nazar, M. A., Lipscombe, S., Morapudi, S., Tuvo, G., Kebrle, R., Marlow, W., & Waseem, M. (2012). Percutaneous Tennis Elbow Release Under Local Anaesthesia. Open Orthop J, 6, 129 – 132.
- Tosti, R., Jennings, J., & Sewards, M. (2013). Lateral Epicondylitis of the Elbow. The American Journal of Medicine, 126(4), 357.e1 – 357e6