Tennis Elbow



Tennis elbow is referred to as lateral epicondylosis.  It is a cumulative trauma disorder, which results from repetitive activity.  It is commonly referred to as ‘tennis elbow’ because it is quite common is tennis, specifically during the backhand shot.  This is due to the large amount of stress put through this muscle while hitting the ball with an inappropriate grip, raquet, or muscle strength.  But it is not limited to only tennis players; it is also common in manual labourers and office workers.  Basically, it occurs due to repeated stress on the muscle, with little time for it to recover.


Lateral epicondylosis most commonly involves the extensor carpi radialis brevis, a muscle in the forearm which acts to extend the wrist.  It is difficult to treat, and scarring may be a problem.  A cycle of inflammation and scar formation can become chronically problematic.  The actual location of the problem is debated, and likely varies with the injury from the musculotendonous junction (where muscle becomes tendon) to the bony attachment. 


Many treatment options are listed in the literature including anti-inflammatory medications, corticosteroids, physiotherapy, immobilization, braces, surgery, radiotherapy, acupuncture, and nutritional supplementation.  The treatment should be aimed at the relief of the symptoms initially, usually reducing pain and inflammation.  Thereafter can be directed at healing, reducing the forces on the tissue, increasing strength, flexibility and endurance. 



RICE

The usual initial treatment recommended for many muscular injuries is the classic RICE protocol.  RICE stands for Rest, Ice, Compression, and Elevation.  Research has been done on this treatment protocol, and indicates that not a single RCT has been done on its effectiveness. 


Rest is usually recommended to allow the muscle to prevent further retraction of the torn ends and to reduce the size of the hematoma (collection of blood).  Prolonged immobilization  or rest though has several deleterious effects including atrophy of the muscle, excess deposition of connective tissue, and delayed recovery of strength.  Yet initial immobilization does in fact prove beneficial in that it allows the tissue to lay down granular tissue to increase tensile strength in the injured zone so that contractions will not re-tear the injury.  Thus immobilization is usually recommended for only a day or two after the injury.  After this, active mobilization should be started to enhance the penetration of muscle fibre growth through the scarred area, to limit the size of the scar, to allow proper alignment of the new fibres, and to help increase the tensile strength. 


The early use of ice has scientific backing in that is has been associated with a significantly smaller hematoma, less inflammation, and accelerated regeneration.  Compression is usually only recommended in combination to icing.  Jarvinen quotes studies that have shown icing and compression to be most beneficial in bursts of 15 to 20 minutes in duration with rests of 30 to 60 minutes between.  This was shown to result in a decreased intramuscular temperature of 3-7 degrees.


Elevation follows the physiological principle that when an extremity is raised above the level of the heart, there is a resultant decrease in hydrostatic pressure, the decreasing the inflammation in symptomatic tissue by decreasing the amount of interstitial fluid in the area.


Brace

A brace produces a counterforce preventing the muscles from fully contracting and expanding, thus decreasing the force at the musculotendonous insertions.


Injections

Invasive and potentially make the problem worse.  High reoccurrence rate.


Ultrasound

Delivers heat to the tissue thus increasing blood flow, decreased pain, and decreased muscle spasm.  Can also be used with a hydrocortisone ointment (phonophoresis).


TENS

Controls spasm, pain, and prevents atrophy.


Manipulation

Mills’ maneuver, a special technique performed by some manual therapists, may reduce tension on the scar, but can be very painful.


Soft Tissue Mobilization (like stretching, ART)

Improves mobility between layers of connective tissue.


Friction Massage

Usually applied over the common extensor tendon, perpendicular to fibre direction.  Promotes local hyperemia, massage analgesia, and reduced scar tissue. 


ASTM

ASTM stands for Augmented Soft Tissue Mobilization (Graston Technique).  This is easier on the clinician.  Gehlsen tested the efficacy of ASTM by using varying pressures on the tendons of rats with tendonitis.  They found that there was indeed a fibroblast proliferative response (a beneficial cellular response) to the treatment, and that it was pressure dependent.  A normal tendon would exhibit parallel fibre orientation, while a tendon with tendonitis would exhibit fibre misalignment and an increased number of fibroblasts.  Moderately applied ASTM exhibited a greater response than light pressure, but not as great as heavy pressure.  This shows that the proliferation of fibroblasts, which is essential to healing, is dependent on the pressure applied.  By increasing fibroblasts, the tensile strength of the tissue will be improved. 


Brace VS Physio VS Combo

Struijis did a study to compare the effects of brace, exercise, or a combination of both.  Ability to perform daily activities, decreases in inconvenience were higher in brace than in physio.  Severity of complaints and satisfaction of treatment was best in a combination treatment rather than a brace alone.  Combination treatment also was favoured over exercise alone in pressure pain threshold.  Many of the reported benefits of all options were only for the short term though, as any statistical significance disappeared after 26 weeks.


Strengthening

When working on a strengthening program for a patient with lateral epicondylosis, isometric exercises should always be employed first.  These may include clenching the fist, or simple isometric activation of the common extensor group. 


The next progression could be moving into more eccentric exercises.  Alfredson studied the effects of eccentric training and found that after twelve weeks of exercise the eccentric group had made significant increases in strength and were back at their pre-injury levels.  They also decreased their pain levels significantly.  They hypothesize that because most load is applied to the tendon during eccentric activity that this would increase the remodeling of the tendon. Following this, some therapists may employ a type of plyometric exercise to the area.  This should only be performed under the supervision of a qualified therapist though, because if it is done improperly, it can lead to further pain and damage.


Questions?  Contact us!


Writen by


Dr. Craig Coghlin, B.A., CPT, CSCS, D.C.

Empowerment Health and Fitness


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References:


1.  Alfredson, H.; Pietila, T.; Jonsson, P.; and Lorentzon, R.  Heavy load eccentric calf muscle training for the treatment of chronic Achilles tendonosis.  The American Journal of Sports Medicine.  1998, Vol. 26, No. 3.


2.  Cappadona, J.; Pearce, D.; and Ciccotti, M.  Tennis and golfer’s elbow: A two sided challenge.  The Journal of Musculoskeletal Medicine.  2002, Vol. 19.


3.  Gehlsen, G.; Ganion, L.; and Helfst, R.  Fibroblast responses to variation in soft tissue mobilization pressure.  Medicine & Science in Sports & Exercise.  1999, Vol. 31, No. 4.


4.  Jarvinen, T.; Jarvinen, T.; Kaariainen, M.; Kalimo, H.; and Jarvinen, M.  Muscle injuries: Biology and treatment.  The American Journal of Sports Medicine.  2005, Vol. 33, No. 5.


5.  Sevier, T. and Wilson, J.  Treating lateral epicondylitis.  Sports Medicine.  1999, Vol. 28, No. 5.


6.  Struijs, P.; Kerkhoffs, G.; Assendelft, W.; and van Dijk, C.  Conservative treatment of lateral epicondylitis: Brace versus physical therapy or a combination of both – A randomized clinical trial.  The American Journal of Sports Medicine.  2004, Vol. 32, No. 2.