Lateral epicondylitis (tennis elbow) is a common condition causing pain on the outside of the forearm, just below the joint line of the elbow. It is caused by repetitive movements, for example sports or occupational activity. Movements that involve constant dorsiflexion, radial deviation and supination are the normal culprits.
It is common in novice tennis players with a poor backhand technique, and other manual workers including builders, plumber carpenters etc. It can also be commonly caused by people digging holes with a spade and hitting something hard, causing a trauma around the radial head. Dog owners, with a dog that constantly pulls can trigger the condition.
The aetiology of the condition has been debated for many years. The most common injured site is the extensor carpi radialis brevis (ECRB), extensor digitorum communis and the extensor carpi radialis longus (ECRL). However, it can also be caused by nerve entrapment, bursitis, or dysfunctional movement at the radial head; normally overuse causes fibrous tissue to form in the tendon (angiofibroblastic hyperplasia – tendinosis).
Tennis elbow is the most common injury at the joint affecting 1 – 3% of the population. The condition is most commonly seen patients from 40 – 60 years old. Men are twice as likely to suffer from the condition compared to women. It is considered to be a self-limiting condition that can take from one to two and a half years to resolve.
With regards to tennis, 13% of elite players and up to 50% of non-elite players have had symptoms at some point. On average the symptoms last for up to two and a half years for 50% of this cohort.
Tennis Elbow - Examination
On examination the common tendon is tender roughly 5 – 10mm below the lateral epicondyle, the dimple around the radial head is also a common site of pain. The standard provocation tests include;
Resisted wrist extension, with the elbow bent (Cozen’s Manoeuvre).
Mills’ Manoeuvre where the wrist is flexed and the elbow extended, thus stretching the wrist extensors.
Maudsey’s Test, where the middle or ring finger is extended against resistance.
Wrist extension and radial deviation suggests the ECRB or ECRL.
The Chair Test, involves the patient picking up a chair by the back upright, the elbow is straight with the forearm pronated.
Tennis Elbow - treatment
In order to treat the condition, it should be broken down in to acute and subacute / chronic phases.
In the acute phase, the patient should initially rest from the repetitive action that is causing the issue. Ice should be used three or four times a day for no longer that 8 to 10 minutes at a time, in order to reduce pain and swelling. The use of a cryo-cuffs or similar devices is the gold standard.
Taking the pressure off the tendon via the use of an elbow brace, taping or strapping has been advoked for many years, and provides some level of pain relief.
In the sub-acute and chronic phases, a carefully designed rehab and treatment program is necessary. The process should begin with a graded program of slow stretching exercises, followed by isometric exercises initially and then working through isotonic and eventually to eccentric exercises. Ice massage after rehab exercises can also be used to reduce adverse effects.
tennis elbow - manual therapy
With regards to manual therapy, myofascial release and soft tissue techniques are useful at reducing pain. Traditionally, cross friction massage, manipulation of the radial head, articulation of the elbow and wrist joints after the acute phase are also recommended.
If the problem is related to tennis, careful examination of the players backhand technique is required, ensuring that the elbow does not lead the action and that the forearm is only partially pronated. Reducing the tension in the strings of the tennis racquet and using the Nirschl approach to racquet grip size is also recommended.
Various forms of electrotherapy have also been used, ranging from ultrasound, laser and shockwave therapy. Shockwave therapy has shown to be very effective once in the chronic phase, as it is the tendon therapy of choice.
Nitric oxide or glyceryl trinitrate releasing patches has been used to some effect on tendinopathies, as they enhance tenocyte function.
Corticosteroid injections are no longer recommended, as the benefits in the long term do not outweigh the risks of further atrophy or tendon rupture.