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Tennis Elbow - What is it?
How to Treat it?
Tennis elbow is known by various names — carpenter’s elbow, politician’s paw,
dentist’s elbow, potato picker’s plight and so on — and yet the basic cause
remains repetitive load being placed on the outer side of the elbow.
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Tennis players suffer this pain due to poor technique used while executing a back-hand stroke, the wrong grip size or high string tension which places load on the forearm. Tennis elbow sufferers are not only tennis players, golfers, swimmers, etc. In fact, 90 per cent of tennis elbow occurs in non-players. Any activity which puts repetitive stress and strain on the lateral part of the elbow joint like lifting heavy weights, squeezing clothes, using a screw driver, turning keys, etc. |
The symptoms are pain and stiffness at the elbow joint. There is
difficulty in holding, pinching and gripping objects. Tightness of
muscles of the forearms associated with insufficient functional strength
is common.
This is a preventable problem if proper treatment is started early.
It hurts where?
An epicondyle is a bony prominence located on either side of the elbow. You have
two of them, one on the inside of the elbow and one on the outside. Since
lateral means outside, the pain is usually right around the bony prominence on
the outside of the elbow. The pain often extends from the lateral epicondyle,
down into the forearm. It is often sensitive to touch directly over the lateral
epicondyle and the surrounding muscles and tendons.
How does it happen?
Lateral Epicondylitis is a repetitive overuse injury of the wrist extensor muscles. These are the muscles that pull your hand up (as if you were singing "stop in the name of love")…you get the idea. Anyway, this injury comes on gradually and is not the result of a single incident. The direct cause depends on the sport activities of the athlete. It is often attributed to the deceleration phase of throwing, as well as many variables in racquet sports. For instance…too tight of a grip, improper grip size, too much string tension, too heavy of a racquet and improper backhand technique. Needless to say the repetitive stresses eventually cause inflammation and microtears of the extensor tendons which attach to the lateral epicondyle, therefore causing pain on the outside of the elbow and forearm.
Injury Progression...
Initially the athlete will only complain of pain while participating in aggravating sport activities, this is considered stage 1. As the injury progresses, the athlete will begin to complain of pain when picking up a coffee cup or grabbing a gallon of milk out of the refrigerator (or similar), this is considered stage 2. If the injury progresses beyond this point the athlete will complain of elbow pain at all times…a constant discomfort, even at rest. The athlete will most likely demonstrate strength deficits of the upper extremity. This is considered stage 3, if the athlete gets here it's definitely time for a visit to the orthopedist.
Similar Injuries:
Lateral Epicondylitis is a pretty clear-cut diagnosis, however additional overuse injuries of the elbow include medial epicondylitis, elbow osteochondritis dissecans and "little league elbow". Medial epicondylitis is marked by pain and tenderness on the inside of the elbow and is commonly referred to as "golfer's elbow". Elbow osteochondritis dissecans is seen in the younger athlete (10-15 years old) who complains of pain and locking in the elbow. "Little League Elbow" is the result of repetitive throwing in the young athlete. Complaints of locking/catching of the elbow and development of a flexion contracture are signs of this injury.
Treatment:
Initial treatment is aimed at reducing the athlete's complaints of pain. Ice is always a good idea to help decrease inflammation.
Other modalities that may be used include ultrasound, phonophoresis, iontophoresis and transverse friction massage.
The athlete's rehabilitation should be pain-free at all times. PROM/stretching exercises of the elbow, wrist and forearm are a good place to start, followed by AROM exercises.
As the athlete begins to show signs of improvement, treatment can progress to include pain-free strengthening activities…usually isometrics first and then isotonic exercises (Thera Band, putty, gripping activities, tennis ball squeezes). In some instances, the athlete may experience relief with the use of a counterforce brace, which is to be worn 2-3 inches below the elbow. This will limit excessive tension on the inflamed muscles (in theory, at least).
This is a preventable problem if proper treatment is started early.
Rest: Avoid activities that aggravate the injury. Absolute rest should be
avoided as it encourages muscle atrophy and decreases blood supply to the area
which is detrimental to the healing process.
Activity modification: Elimination of the activities that are painful is key to
improvement. Avoid any strenuous movement like carrying shopping bags, opening
tight taps, repetitive valve opening, etc.
Ice: Apply ice-packs to the elbow three to four times a day for 15-20 minutes,
especially in the early acute stage to decrease pain or stiffness.
Physiotherapy: Ultrasound with deep friction massage helps in reducing the
inflammation.
Shockwave Therapy: It is a revolutionary technique that effectively treats
tennis elbow. With shock wave therapy the body responds with increased metabolic
activity around the site of pain. This stimulates and accelerates the healing
process.
Stretching: Stretching the affected muscles helps to break down any scar tissue
or adhesions that occur with inflammation. Stretch by pulling your hand downward
towards the underside of your forearm for 10-15 seconds several times a day.
Elbow bands are designed to minimise the muscle pull on the tendon attachment at
the elbow and should be worn during play.
Cortisone injection: Injection of cortisone is preferred by most of the doctors,
which reduces the inflammation at the site of the tendon. The tendon becomes
fragile after the injection and, therefore, a week’s rest is required.
Manipulation, if done properly, can prove to be very effective and give
immediate relief.
Trigger point release: Muscle energy techniques are very effective in treating
the cases of tennis elbow.
Progressive resistance elbow exercises: Exercises with Theraband for the forearm
muscle is very effective in increasing strength.
The following exercises may be started when the pain subsides:
Finger extension: Place a rubber band around all five fingertips. Spread fingers
25 times. Repeat three times. If resistance is not enough, add a second rubber
band of greater thickness, which will provide more resistance.
Ball squeeze: Place a rubber ball in the palm of your hand, squeeze it 25 times,
and repeat this three times a day.
Reverse wrist curls: Grasp a dumbbell or a Theraband in hand with palms facing
downwards. Begin by curling the weight/Theraband upwards at the wrist and then
slowly return back. Initially, three sets of 10 repetitions should be performed
daily. Once you achieve 25 repetitions, increase the resistance.
Forearm pronation / supination: Grasp a hammer in hand, perpendicular to floor
with forearm supported. Rotate the hand to the palm down position, return to the
starting position, rotate to the palm (up position), and repeat 8-10 times.
In all cases, it's important to get to the root of the problem, so it's a good idea to take a look at the biomechanics of the athlete's sport specific skills and make adjustments where necessary. Time off from aggravating activities is almost always necessary with this injury.
Participation Status:
Athletes in stage 1 may continue to participate in sport activities as tolerated, but should begin rehabilitation and use ice regularly.
Athletes in stage 2 will have limited participation allowing for more prolonged rest of the wrist extensors, but must also participate in a rehabilitation program.
The athlete that presents with signs and symptoms consistent with Stage 3 should be out of participation completely and begin a regular rehabilitation program.
If the symptoms do not improve within 2 weeks of treatment, the athlete should be referred to an orthopedist. If conservative treatment is not successful, an orthopedist may consider anti-inflammatory medication or corticosteroid injections. The absolute last resort is surgery, which has been shown to be very effective.
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