Tennis Elbow, also known as lateral epicondylitis is the most common cause of elbow pain. The condition is related to repetitive wrist extension and is commonly referred to as “tennis elbow”, although the majority of those affected do not play tennis (2).
Symptoms of Tennis Elbow
The classic clinical presentation includes pain over the lateral aspect of the elbow (22,25). Symptoms are typically provoked by activities that involve gripping and/or wrist extension (25). Pain may vary from mild to sharp severe pain that limits the simplest activities- like picking up a coffee cup. Rest may provide relief (22).
Who is Most Affected by Tennis Elbow?
Lateral epicondylitis affects between 1 and 3% of the general population each year. (1,17) The condition occurs predominantly in the fourth or fifth decade, and affects men and women equally (1,18). Lateral epicondylitis strikes the dominant arm in 75% of cases. (18) Lateral epicondylitis can results in an average of 12 weeks disability in up to 30% of those workers affected (19).
What causes lateral epicondylitis?
Lateral epicondylitis is a byproduct of excessive force or repetitive movement, combined with improper biomechanics and/or posture (20,21). The primary risk factors for Lateral epicondylitis include repeated wrist extension and forearm supination/pronation. Certain occupations and activities are predisposed, including: carpenters, bricklayers, seamstresses, tailors, pianists, drummers, those who shake hands excessively (politicians), and those who perform prolonged keyboard or mouse work (22). Only 5% of lateral epicondylitis patients participate in racquet sports (20), but among tennis players, 50-60% will be affected at some point in their career. (18) Lateral epicondylitis injuries related to tennis are thought to develop as a result of improper mechanics during backhands or serves (23). Additional racquet-related risk factors include: using a new, heavy, or tightly strung racquet, excessive grip size, and hitting wet or heavy tennis balls (22).
Why do people get lateral epicondylitis?
Nearly all forces associated with wrist extension are funneled through this tendon onto lateral epicondyle. The common extensor tendon, particularly the extensor carpi radialis brevis (ECRB), is relatively hypo-vascular, creating a penchant for injury and hypoxic degeneration. (4,5). While acute inflammation may accompany the earliest phase of tendon disease, it is unlikely to last more than a few days. (8) In chronic cases, inflammatory cells are absent. (2,8-11) Researchers now recognize that repetitive micro trauma does not cause inflammation but rather a failure of the natural healing process, resulting in a disorganized pathological degeneration of the tendon. (8,9,11-15).
Other issues with lateral epicondylitis:
Research suggests that up to 10% of patients with LE have co-existent radial tunnel syndrome. (28) The similarities of lateral epicondylitis and radial tunnel syndrome can make differentiation of the two conditions challenging. The pain of radial tunnel syndrome should be more acute distally. (29) Nocturnal pain is more common in radial tunnel patients than those with lateral epicondylitis (30).
Do I need x-rays or other imaging?
Diagnostics & Differential X-ray is of little diagnostic value for the assessment of soft tissue disorders. (34) Radiographs may be appropriate in the presence of “red flags” or a history of trauma, to rule out fracture, dislocation, infection, or neoplasm (34,35). MRI has the ability to demonstrate tendinosis as well as bony or soft tissue pathology. Diagnostic ultrasound is useful for evaluating the common extensor tendon for tendinitis or tearing (35).
Timeline of recovery:
The natural course of LE can be frustrating. Twenty percent of untreated patients demonstrate no improvement after one year. (36) Even those patients undergoing optimal management may require three to four months for full recovery. (16) Evidence supports the use of traditional conservative measures, including: manipulation, mobilization, exercise, friction massage, bracing, and modalities (38,39).
- Initially, patients may require selective rest and avoidance of activities involving repetitive wrist extension, pronation, or supination.
- Counter-irritant creams may provide palliative relief.
- Ice or home ice massage may be helpful for acute “tendinitis” patients, but do little to alter the long-term course of chronic tendinopathy.
- Tennis players should look for ways to improve mechanics, including not leading with their elbow and switching to a 2-hand back stroke that limits pronation (23)
- The use of a counter-force strap, applied firmly approximately 10 cm distal to the elbow joint has been shown to decrease pain and improve grip strength. (40-42,81)
- There is moderate evidence supporting the use of mobilization/manipulation of the elbow, cervical spine, and wrist for the treatment of lateral epicondylitis. (44-54,72)
- Mobilization/ manipulation of the elbow demonstrates an immediate decrease in pain and a substantial increase in pain-free grip. (45,46,54,72)
- Manipulation of the cervical and cervicothoracic region has been shown to decrease pain and disability in lateral epicondylitis patients. (47-49,51)
- IASTM (instrument assisted soft tissue mobilization) is thought to help mobilize scar tissue and increase pliability by re-initiating an inflammatory process through controlled microtrauma (51,56)
- The use of IASTM has demonstrated “significantly better” outcomes than exercise alone – with 57% resolution of complaints after one month of care, and 78% resolution after two months (57)
- Deep friction massage is another valuable tool for lateral epicondylitis (78)
- Therapeutic taping may be helpful (79)
- Anecdotal evidence suggests that dry needling may be a useful alternative for recalcitrant cases.
- Myofascial release is an effective treatment for lateral epicondylitis. (71,75) STM and stretching exercises should be directed at the wrist extensors and supinator muscle. The ECRB is a primary culprit and is most effectively stretched via elbow extension, forearm pronation, and wrist flexion. (74)
- Eccentric strengthening is thought to stimulate collagen metabolism and synthesis. (43,58)
- The “Tyler Twist” exercise, utilizing a Theraband Flexbar is a novel approach to eccentric strengthening that has shown significant pain reduction and excellent outcomes in limited trials. (69,70)
- Addressing scapular stability deficits improves outcomes in LE patients. (83)
Other treatment options:
- While corticoid steroid injections may provide some short-term benefit, these injections can be detrimental to long-term recovery (64). One study demonstrated that corticosteroid injections significantly reduce pain, with 78% success at six weeks (versus 65% improvement for standard physical therapy.) (65) Unfortunately, the same study demonstrated that at one year, those patients treated by injection were “significantly worse” compared to those managed conventionally or those who underwent no treatment (65).
- A study of 52 patient found that omitting the steroid and simply injecting with a needle, aka ultrasound guided percutaneous needle tenotomy (PNT), produced better results. (76)
- Iatrogenic soft tissue calcifications may follow steroid injections for Lateral epincondyltiis. (83)
At Creekside Chiropractic & Performance Center, we are highly trained to treat this condition. We are the only inter-disciplinary clinic in Sheboygan county that provides chiropractic, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
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