Tennis Elbow

By Dr Guy Ashburner | November 3, 2009

Tennis Elbow

Do You Have Tennis Elbow?

It’s sensible to go and see your doctor if you have elbow pain that doesn’t resolve within a day or two, as other more serious conditions have very similar symptoms. These are the main symptoms of tennis elbow:

Pain on the outside of the elbow, on and around the small bony bump. The pain also radiates up the upper arm. Weakness in the wrist, which can affect even the most simple day-to-day tasks. The bony section on the outside of the elbow will be tender to the touch. Pain at the point of the elbow when the hand is palm down, bent back at the wrist against resistance. Tennis elbow is caused by non-inflammatory degenerative change (tendinopathy) of the extensor carpi radialis brevis tendon, which attaches to the back of the hand and extends the wrist. It results from overuse, fatigue or weakness of the tendon, and possibly avascular changes (poor circulation).

WHY DOES TENNIS ELBOW DEVELOP?

Any activity involving repeated wrist extension against resistance can cause tennis elbow. Sports such as such as tennis, squash and badminton (especially the backhand swing) are often responsible, but so are a wide range of occupational and leisure activities such as carpentry, bricklaying, using hand tools, sewing and knitting. Even computer use has been shown to cause this condition. The peak incidence is between the ages of 40 and 50 years, but people of any age may be affected.

Clinically tennis elbow presents in two very different ways. The most common is an insidious onset of pain 24 - 72 hours after unaccustomed activity involving repeated wrist extension for example if you have spent the weekend laying bricks or using a screwdriver, or indulging in a orgy of sewing or knitting. Tennis players may have used a new racquet, played in the wet with heavy balls, or played a particularly heavy game hitting into the wind. The player who hits late’ (getting into position slowly), so that the body weight is not transferred correctly and there is exclusive reliance on the forearm muscles for power, is most likely to develop tennis elbow.

The other clinical presentation is sudden onset of lateral elbow pain associated with a single instance of exertion involving wrist extensors, for example lifting a heavy object or (in tennis players) attempting a backhand with too much reliance on the forearm and not enough trunk and legs.

SYMPTOMS AND DIAGNOSIS

There is a history of repetitive activity or overuse. Pain mainly affects the lateral aspect of the elbow, but can also radiate upwards along the upper arm and downwards along the outside of the forearm. Weakness in the wrist can make such simple movements as lifting a plate or a coffee cup, opening a car door and shaking hands difficult.

A distinct tender point is elicited by pressure over the outer arm (the lateral epicondyle). An accurate diagnosis will also include specific active resisted wrist and finger movement tests.

Evaluation and diagnosis should always be carried out by a registered medical professional, who can rule out other possible diagnoses such as rheumatic disorders, trapping of a nerve, a fracture, a loose body in the joint, and radiating pain caused by degenerative changes in the spine. He or she will also formulate an appropriate treatment plan.

TREATMENT

In the early stages use an ice pack wrapped in a cloth to cool the area for a couple of days. Avoid any movement that causes pain or discomfort, but don’t stop exercise completely (keep up your running, for example). Alternating a heat pack with an ice pack, for 20 seconds each until you have completed 5 minutes, is well worth trying.

When the pain has subsided and you can tolerate a handshake again, you can start actively exercising the area.

Muscle Strengthening

Start with isometric exercises (using the muscle in a stationary position). For the wrist, hold your arm out straight with your palm facing downwards. Rest your arm on a table, palm down with your wrist over the edge. Now, press down gently using your good hand and resist with the injured arm for 7 seconds, ensuring that there is no pain. Then rest for 7 seconds and repeat 7 times. This very basic exercise is called the isometric rule of seven and will stimulate the tendon to repair. Once you are able to complete it comfortably with gradually increased resistance, other exercises can be added.

Counterforce Bracing

Wear an elbow brace or support throughout the rehabilitation process to help protect the injury and reduce the load on the affected area.

Cortisone Injection

Local administration of corticosteroids is a common treatment option to relieve the pain of tennis elbow. If you don’t experience long-term relief after a total of 3 injections over the course of a year, more injections aren’t likely to help and may even be harmful. Some doctors believe that corticosteroids should not be given to children.

Studies suggest that corticosteroid injections may give short-term relief but don’t have long-lasting benefit. The direct effects on the tissue are not fully understood, but cortisone has been shown to cause weakening of tendons and softening of cartilage, and repeated injections intensify these effects and increase the risk of potential problems. This is why many physicians limit the number of injections they offer to a patient.

While the goal of the cortisone shot is to relieve the pain of the injury, the goal of the body’s own inflammatory-reparative healing cascade is to regenerate the collagen and extracellular matrix that give the connective tissues their strength and characteristic ability to handle great strain forces. Unfortunately for many individuals, corticosteroids block this normal healing process.

Other Remedies

Electrotherapeutic modalities such as laser, ultrasound and high-voltage galvanic stimulation may encourage the healing process, but I have treated many cases and reports from my patients have convinced me that machines and gimmicks don’t work. The most effective modalities for treating tennis elbow are those that address the cause!

AN OSTEOPATH’S PERSPECTIVE

An osteopath will take a holistic view of your symptoms as well as making a specific diagnosis. Many factors may predispose to and maintain extensor tendinopathy poor posture, bicep injuries, rotator cuff throwing injuries, repetitive action of wrist extensors, degeneration, age, and overuse of common extensor origin muscles, to name but a few.

In a tennis player with poor posture, for example, a sequence of altered body mechanics might ultimately result in symptoms. Rounded shoulders can cause internal rotation of the humerus (upper arm), with compensation at the elbow leading to supination (turning the forearm palm up). Shortening of the supinator and the biceps mean a taut end-point on extension of the arm, with disturbed force transference causing imbalance between the extensor and flexor muscles of the forearm. The osteopath would treat the above patient by reducing the mechanical disadvantage at the common extensor origin (lateral forearm), thus speeding recovery.

The sequence of events that would otherwise lead to extensor tendinopathy can even be avoided before it happens. Osteopathic treatment is potentially an extremely valuable preventive measure for the sportsman and sportwoman.


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