Hello and welcome to the first of the ThreeSpires Physiotherapy blogs where we will take a look at all things physiotherapy related. In this episode we will have a look at an extremely troublesome condition: tennis elbow. Now, if you get pain on the outside of your elbow which seems to be caused by twisting actions like opening bottles or repetitive lifting then it is likely that you are suffering from tennis elbow and hopefully this blog will help you understand what it is and what can be done to help you. Despite the name tennis elbow you don’t need to play tennis to get it and unfortunately just stopping playing tennis is unlikely to make that elbow pain go away. Tennis elbow can be a real tough condition to get rid of and we would strongly recommend you get an assessment by a physiotherapist experienced with tennis elbow.

So, What is Tennis Elbow?

Well, as with most medical conditions tennis elbow has several other more formal names such as lateral epicondylitis, lateral epicondylosis and lateral epicondylalgia and is the most common elbow tendinopathy (tendinopathy simply means pathology affecting a tendon). With tennis elbow the tendons on the outside of the elbow (lateral part) have become irritated and overloaded and are causing pain when gripping any objects or trying to twist things open.

Who does Tennis Elbow Affect?

It affects approximately 1.4% of the population (Shiri et al 2006) which doesn’t sound like a lot but when you consider that the population of the UK is approximately 62million this adds up to a lot of people with tennis elbow!. It is 7 – 9 times more common than golfer’s elbow (medial epicondylitis) which is the one that affects the inside of the elbow (Walz et al 2010), can cause prolonged workplace absences (Walker-Bone et al 2012) and has been linked with handling tools and repetitive twisting and lifting actions of the forearm (Van Rijn et al 2009). This basically means that if you do manual work that involves using a screwdriver all day long (e.g. an electrician) then you are at an increased risk of getting tennis elbow.

What Causes Tennis Elbow?

So enough of the statistics and onto what causes tennis elbow and the nature of the problem. Now given how long people have been suffering with tennis elbow (pretty much since anyone first picked something up!) you would be forgiven for thinking that we should be 100% certain on what causes tennis elbow. However this is trickier than it seems, as ideas about tendinopathies such as tennis elbow have changed greatly over the last decade and continue to change as research on tennis elbow advances. Despite tennis elbow being commonly known as lateral epicondylitis current research suggests that the name itself is misleading as the word epicondylitis means inflammation of the epicondyle (part of the humerus of the elbow) and the majority of scientific evidence suggests that it is not an inflammatory condition and is instead a degenerative tendinosis (Taylor & Hannafin 2012).

For people not familiar with the language of physiotherapy and scientific study of disease processes – itis usually indicates inflammation. For example tendonitis means inflammation of the tendon. Epicondyle is a bony landmark of the elbow and in fact there are two. You can easily find them – the lateral epicondyle is the bony bit on the outside of the elbow and the medial epicondyle is the bony bit on the inside of the elbow. The word lateral means away from the mid-line and the word medial means close to the mid-line.

Okay so back to what is happening with tennis elbow – well basically there is pain but usually no inflammation which is confusing as injuries normally cause inflammation. It is currently thought that what happens is that there is an initial injury caused through overuse of the elbow (for example you use a screwdriver too much) this causes some inflammation in the early stages of tennis elbow but then instead of healing properly things go wrong and the healing process fails – leading to a degenerative tendinosis (Ackerman & Renstrom 2012; Abate et al 2009). Continued usage then leads to excess scar tissue around the tendons of the elbow being laid down and more failed healing and pain on usage. Some of the pain is currently thought to derive from tiny nerves that run alongside the capillaries that invade the tendon tissue.

How Can I Get My Tennis Elbow Fixed?

So how can I fix the problem? Well this is definitely the tricky part as current evidence is divided on this. However below we have gone through some of the most common and effective methods of fixing tennis elbow::

Eccentric Exercises For Tennis Elbow

Eccentric exercises have been the mainstay of treatment for other tendon pathologies such as Achilles Tendinopathy and for tennis elbow involve letting the wrist slowly extend under tension. Eccentric exercises involve muscles lengthening under tension and as has been mentioned have good research to support their usage in other tendon pathologies, however for tennis elbow the evidence is very limited and they are probably something you need to try to find out if they are effective with your own tennis elbow. To understand exactly how to do them, what loads to use and whether they would help it would probably be best to see a physio experienced with tennis elbow.

Cross fibre Friction Massage for Tennis Elbow

Some people with tennis elbow may find that cross friction massage over the insertion of the tendon at the epicondyle may help. In theory this works to break down scar tissue that has been laid down at the area of elbow pain around the tendon. This is an easy technique to do yourself at home if you find it helpful and simply involves massaging the tendon where it is sore. As with everything else before trying some cross friction massage I would recommend you get your tennis elbow assessed by a physiotherapist.

Ultrasound for Tennis Elbow

Ultrasound was at one point an extremely popular treatment for tennis elbow but as evidence and research has developed it has in general fallen out of favour. There is some evidence to suggest that it may help with tennis elbow but this effect is small and may not work for everyone.

Strengthening Exercises for Tennis Elbow

Although eccentric exercises have for a long period been the go-to exercise to help with tennis elbow, new evidence has slowly emerged that is suggesting that the best approach is simply to try to strengthen the actual elbow tendons up via normal strengthening methods such as wrist extensions, working on grip strength and increasing rotational strength of the elbow. Most likely to choose the best combination of exercises and the right level of discomfort you would need an assessment for your tennis elbow by a suitably qualified physiotherapist.

Bracing for Tennis Elbow

Commonly patients with tennis elbow may try braces such as epicondyle clasps which put pressure over the lateral epicondyle of the elbow and attempt to relieve the symptoms. Results from braces are extremely variable for tennis elbow but my own clinical experience is that they can help some patients with tennis elbow. Again as with other methods of treatment for tennis elbow I would suggest that you need to try this for a bit and then evaluate if it has helped with your tennis elbow.

Steroid Injections for Tennis Elbow

If a patient has tried all of the above options for tennis elbow, had an assessment by a physiotherapist and also been persistent with their exercises for a significant period but is still getting a large amount of pain in their elbow it may be worth considering a cortico-steroid injection. These can be helpful in patients who have very high pain levels with their tennis elbow and can allow the pain to settle enough for the patient to do some rehab for their tennis elbow.

Surgery for Tennis Elbow

Finally for patients whose tennis elbow has failed to improve with all of the options above there are some surgical options which can be successful but as with all surgery there are risks.

I hope that you have found this blog about tennis elbow helpful, we have covered a lot of information and have looked at what tennis elbow is, its causes, who is affected and what you can do to help fix your own tennis elbow. If you have any questions about tennis elbow or would like an assessment by a physiotherapist experienced in helping with tennis elbow then please get in touch. We are a home visit physiotherapy service based in Lichfield and serving areas such as Sutton Coldfield, Tamworth, Rugeley, Walsall and Cannock.

References:

Abate M., Gravare-Silbernagel K., Siljeholm C., Di Iorio A., De Amicis D., Salini V., Werner S., Paganelli R. (2009) Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Research and Therapy 11(3): 235

Ackerman P. & Renstrom P. (2012) Tendinopathy in Sport Sports Health: A Multidisciplinary Approach 4(3): 193 – 201

Shiri R., Viikari-Juntura E., Varonen H., Heliovaara M. (2006) Prevalence and determinants of lateral and medial epicondylitis: a population study. American Journal of Epidemiology 164 (11): 1065 – 1074

Taylor S. & Hannafin J. (2012) Evaluation and Management of Elbow Tendinopathy Sports Health: A Multidisciplinary Approach 4 (5): 384 – 394

Van Rijn R., Huisstede B., Koes B., Burdorf A. (2009) Associations between work-related factors and specific disorders at the elbow: a systematic literature review Rheumatology 48: 528 – 536

Walker-Bone K., Palmer K., Reading I., Coggon D., Cooper C. (2012) Occupation and epicondylitis: a population-based study. Rheumatology (Oxford) 51 (2): 305 – 310

Walz D., Newman J., Konin G., Ross G. (2010) Epicondylitis: Pathogenesis, Imaging, and TreatmentRadiographics 30 (1): 167 – 185