Tennis Elbow Defined
By Joanna Starkey, PT, CHT
Tennis Elbow Defined
Definition of Tennis Elbow
Lateral epicondylitis or “tennis elbow” is the most common injury at the elbow. The name is somewhat of a misnomer as rarely is tennis the cause. It occurs most often between the ages of 30 and 50, and is found more frequently in the dominant arm. The causes of tennis elbow can vary. The most common cause is a cumulative or degenerative overuse of the wrist extensor muscles, in
particular the Extensor Carpi Radialis Brevis or ECRB. This can be an acute repetitive activity, such as painting a room or a gradual onset after years of use. Although less common, tennis elbow can also be caused by an acute trauma to the outside of the elbow (called the lateral epicondyle). This can damage the tendon and lead to symptoms of tennis elbow.
Symptoms of Tennis Elbow
Symptoms of tennis elbow usually involve lateral or outside elbow pain that can radiate into the forearm and wrist. Pain is usually with gripping, lifting, and basic everyday activities. Symptoms usually have a gradual onset of pain, progressing with activity. At the beginning of onset the pain is minimal and usually just during activity. Patients often tend to “work thru” the pain instead of
resting which can lead to the progression of damage to the tendon, until the pain can be severe enough to limit all activities. This is one time where pain is a useful guide, if it hurts, don’t do it. Rest and activity modification are the most effective treatments. Other treatments will also be discussed later as well. To understand how to effectively treat tennis elbow you need understand the anatomy and mechanics of the ECRB and how to modify your activities to decrease force on this muscle.
The ECRB muscle originates above the elbow and crosses the elbow joint traveling down the forearm to attach at the base of the index finger. This muscle is responsible for extending and deviating the wrist, but can be active with elbow motion as well. While this muscle creates wrist extension, the muscle is also active when you are flexing and gripping your wrist and hand. This is because
the muscle co-contracts or stabilizes the wrist. This allow you to have a support from which to grip from. Often the extensor muscles (ECRB) are weaker than the flexor (grip strength) and can create a muscle imbalance and more stress on the ECRB muscle. This explains why most patients complain of pain with griping activities such as shaking hands, lifting groceries, etc. Because this muscle crosses more than one joint (the elbow and wrist) the forces on the muscle vary based on the position of the elbow and wrist.
When your elbow is bent and the wrist is extended the muscle is in a very shortened position. Very little stress is placed on its attachment sites when it contracts. However, when the elbow is extended while the wrist is flexed, the muscle is then being stretched and a contraction at this position would put significantly more force at its attachment site. This stress causes small micro tears of the tendon. These micro tears cause small amounts of swelling and pain. If micro trauma continues the tears can become larger causing the tendon quality to decrease and fray.
Treatment of Tennis Elbow
Treatment for tennis elbow is largely activity modification. Avoiding stress to the ECRB by avoiding picking up objects with the palm down and elbow straight is key. Common things to avoid are reaching over a car seat to grab a bag, stretching around the desk to reach the phone, etc. Try to always lift with the wrist in neutral and the elbows bent. A stretching program is also very helpful.
Painful muscles often tend to spasm or tighten up. If a muscle is tight, it will place more force on its attachment sites when you try to stretch the muscle. There are some stretches developed to help slowly stretch the ECRB. The key to remember is that the stretch should last at least 20-30 seconds to have a lasting effect, and that it should not be a very painful activity. Remember that these should be pain free. Please perform stretches 2-3 times each, 3-4 time per day and perform strengthening 1 time per day if pain free for at least two days.
When in the acute stages, modalities that can help decrease the inflammation can be helpful. This can include anti-inflammatory medication, ice massage, and electrical stimulation. When more chronic, some will recommend moist heat or ultrasound (a deeper heat) to the muscle to help increase the blood flow and extensibility of the muscle. Some studies have also found that using a form of electrical stimulation call High Volt Galvanic can increase tendon healing. Wrist braces can help keep you from extending the wrist as often and rest the muscle. Counter-force straps are also marketed for helping tennis elbow, although actual results vary greatly. This is a band that is placed over the muscle belly about 1.5 inches down from the elbow joint. It is should be snug enough to act as a reminder to not contract the muscle, but not compromise blood-flow to the area.
If you are active in racquet sports, such as tennis, you need to make sure your racquet is fitted properly to avoid extra stress on the ECRB, and you are often recommended to avoid sports for 4-6 weeks, if symptoms are severe. Once you have been pain free for at least two weeks you can begin a very gentle progressive strengthening program for the wrist. The key is again to start slowly and avoid pain. The elbow should always be bent to allow less stress to the ECRB and the focus is on endurance (light weight and high reps) rather than heavy strengthening.
If the above treatments are not helpful, your doctor may recommend a steroid injection. While the injection itself is not comfortable, steroids help take away the swelling and decrease the pain around the tendon insertion. Steroid injections are very effective at relieving the pain, but if activity is not modified the symptoms will often return. Most doctors will limit the number of injections to avoid further damage to the tendon. In a very few cases injections and conservative measures are not helpful and surgical debridement is required. Please contact your JOI clinician or doctor for any questions.
To learn more about tennis elbow, please go to: https://www.joionline.net/library/show/tennis_elbow_-_faq/
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