Tennis Elbow And The Role Of Physiotherapy
Lateral epicondylalgia, or tennis elbow as it is often called is a common sports medicine condition. Pain usually felt at the outer side of the elbow and is aggravated by gripping or lifting movements. The pain associated with tennis elbow usually arises gradually 2-3 days after unaccustomed activity involving repeated bending of the wrist or gripping hand movements or activities. Examples include sports (usually racquet-based) and occupational and leisure pursuits (carpentry, bricklaying, sewing and knitting, computer use). This condition can affect any age group but is most common for those between the ages of 40 and 50.
There is normally some local tendon wear and tear affecting the common area at which all the extensor muscles on the back of the forearm attach to the outer elbow. Although tennis elbow may occur as a more acute injury, more often than not the tendon has been under strain for some time then gets ‘flared up’ by doing too much of a particular activity. It must be remembered that these wear and tear changes in the tendon, which may be visible on Ultrasound, can also occur in people who never have elbow pain and it may be a part of normal aging. We don’t know exactly why some people develop a painful tennis elbow, and others don’t however it may relate to general strength and conditioning as well as the how the patient’s nervous system regulates pain and sensitivity.
A physiotherapy treatment approach is to firstly advise of the do’s and dont’s. You should avoid aggravating activities or positions such as gripping of picking up heavy items. This is not the type of pain to ‘push through’ thinking it will get better. You should carry items close to the body and with the palm facing up.
The main priority of treatment is to reduce pain and improve function. Specific focus will address any grip strength deficit and coordination impairment of the upper limb and wrist which are best achieved through specifically prescribed physiotherapy exercises, which may be done at home. Isometric contractions (muscle contractions where the joint angle and muscle length do not change during contraction) are used to commence light muscle activity and also for pain relief as they affect the descending pain inhibitory pathway. These should be performed pain free and can be held for up to one minute, max of 3 reps with one minute rest in between. These exercises may be progressed to place more strain on the tendons as the pain settles, this strain is important to restore strength to the tendon to be able to deal with normal activity in due course. Self-mobilisation with movement (MWM) can be also taught to enable you to manage your pain at home.
A course of physiotherapy treatment usually involves 6-8 weekly sessions. Progress may be slow to start, but gathers pace usually after 3-4 sessions. During the physiotherapy session, a number of techniques can be used for pain relief, to promote healing and to restore function. Low level laser therapy and ultrasound can both be effective for pain relief. Manual therapy is also very effective in combination with exercise. This may include local therapy to the elbow region as well as mobilisation to the cervical and thoracic spine if required. Active trigger points associated with muscle shortening are frequently found in the forearm muscles with tennis elbow and these should be deactivated using soft tissue techniques and/or medical acupuncture/dry needling depending on your preference.
It should be noted that cortisone injections although quicker acting, usually result in a recurrence of pain. When compared with physiotherapy treatment, at 8 weeks both treatments have the same effect. But while those receiving physiotherapy have been shown in studies to continue getting better, those who have cortisone injections usually get worse. As such cortisone injection are rarely used these days as a first line approach.
My advice is to be patient and try not to get frustrated with what might appear at first to be slow progress. Tendons are slow healers and need adequate rest and rehabilitation over a longer period of time than most other types of injuries. Treating the problem properly with proper, evidence based physiotherapy in most cases results in an excellent outcome.
Image by BruceBlaus (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons