Tennis Elbow – Diagnosis, Treatment, Causes.

“Tennis elbow” (TE) is known clinically as lateral epicondylalgia or previously lateral epicondylitis, or extensor tendonitis . It is diagnosed in the presence of pain located over the lateral (outside) epicondyle of the elbow, with gripping and / or manipulation of the hand. The extensor muscles of the wrist originate at the elbow in the form an a common extensor tendon, which attaches into the lateral epicondyle, and is generally implicated as the source of the problem. This common and painful condition is a complicated one to treat and understand. Scientific studies have shown that changes occur throughout the nervous system, shoulder and neck that could act as potential causes, which reinforces the need for global and holistic treatment. ¹

Who gets Tennis Elbow ….. not just tennis players

• men and women,most commonly aged 35-54  (but any age), generally in the dominant arm
• those that play tennis, or in industries that requires manual tasks with a combination of force, repetition and poor posture^2,3,4
• Tennis elbow is very common amongst hockey players and golfers owing to the forces required to manipulate the stick and club respectively
• Occurs presumably when repetitively high forces are put through the elbow and the extensor tendon, which does not absorb the forces properly. For more on this read about stress shielding and the role of shear/compression force in this condition¹
  • Stress shielding, and tendon compression occur when there is an unequal distribution of forces through the tendons of the body, which is a phenomenon also implicated in achilles tendonopathy

What is happening to my elbow? –  It’s degeneration, not inflammation!

There are two major reasons there is pain at the elbow – a change in the tendons / muscle, and changes in the nervous system.

Musculotendinous changes in TE 

There is a general consensus that although there is pain, there is no actual extensor tendon inflammation occurring at the site of injury¹. Typically TE is a case of repetitive strain and degeneration of the tendons of the forearm extensor muscles. The forearm extensor muscles are on the back of the forearm, and are used to pull the wrist back, such as when giving a high five. The most important role of this muscle group is to eccentrically resist wrist flexion (a difficult job) while gripping, manipulating or holding objects in the hand, which puts a great deal of load through these muscles and their tendons.

The tendons of these forearm extensor muscles, namely the extensor carpi radialis brevis, begins to degenerate from repetitive strain. The cause of the degeneration is not entirely understand but a lack of strength seems to be a key factor. This degeneration causes the following changes to the tendon:

• the tendon fibres become disorganized like a spider’s web, instead of being nicely aligned,
• blood vessels begin to grow in the tendon where they should not (called neovascuarlization), which is thought to be a major cause of pain (^5-7)
• chemicals (neurochemicals specifically) that irritate the local nerves become increased in concentration ^8,9

Strength is almost always affected with this condition at the wrist, elbow and shoulder. It is likely that some of the weakness experienced at these sites is both a consequence, and cause of the condition. Besides the changes in the nervous system mentioned below, which can lead to weakness, local muscle changes have also been observed including muscle fibre death, and wasting, amongst others.

Grip strength and more importantly, pain-free grip force (PFGF) is reduced. PFGF is the maximum amount of force a patient can produce before pain is felt and is one of the best outcome measures of this condition we have. TE sufferers often demonstrate reduced strength of the shoulder, biceps, triceps and forearm flexors. More importantly, studies have shown the strength deficits exist beyond the resolution of symptoms and highlights the need for proper rehabilitation. Even when pain is alleviated, exercises that are part of a good rehabilitation program should be continued to restore strength to, and beyond its initial levels . ¹

Nervous System Changes in TE¹  

There are changes in the peripheral nervous system (the nerves of the arms and hand) and the central nervous system too (the brain and spinal cord) that maybe creating your TE pain.

Peripheral Nervous System Changes

• local nerves at the elbow become sensitized due to the build up of neurochemicals (ie substance P = pain generator) and are more sensitive to touch and painful stimulus
• Secondary hyperalgesia (this is incredibly interesting – brace yourself): This is the process in which nerves away from the initial site of injury become more sensitive to painful and nonpainful stimuli. The radial nerve is the nerve that provides sensation to the lateral elbow, and it has been shown to become more sensitive to pain at other points away from the elbow.
  • Tennis elbow sufferers are more likely to report pain elsewhere along the radial nerve, in the neck, and even at the same spot on the other elbow!

Central Nervous System Changes

• Some studies have demonstrated that the presence of secondary hyperalgesia and increased sensitivity of the brain and spinal cord, can lead to bilateral elbow changes
  • Some studies have shown increased sensitivity to pain, poorer movement awareness, and reduced strength at the uninvolved elbow. ^10-12 WOW 

 Do I need an x-ray or MRI?

As long as your doctor does not think that a major medical condition is ongoing, an x-ray, ultrasound or MRI is not considered necessary to make a diagnosis of TE. The diagnosis can be made by listening to the patient history and touching the elbow, shoulder and neck to ensure that the pain is coming from the elbow. Your health care practitioner should determine the extent to which the shoulder and neck are involved. Research has shown that diagnostic ultrasound might be most efficient and effective in confirming the diagnosis of TE but it is rarely necessary.¹

Prognosis and natural history: How long is this going to last

Without treatment, the natural history of TE can see symptoms last months to years based on the lifestyle factors that one is exposed to. The condition may spontaneously resolve with rest though it is more likely to recur and go unresolved.

The prognosis for treatment of TE varies depending on the mode of therapy used. Typically, studies evaluating manual therapy and chiropractic like treatments demonstrate the successful resolution of symptoms by 1 year in the 70%-100%, with resolution of symptoms common by 8-12 weeks with treatment.

Treatment

By and large, Tennis Elbow responds well to manual, multimodal care provided by a good chiropractor. Studies examining what treatment is best are limited. However studies where manual therapy, and rehab exercises are combined, show better results than doing-nothing or corticosteroid injections¹³. No particular treatment is guaranteed to be effective for all patients, and it is likely a combination of treatment modalities will be most effective.

Some important notes before treatment

• TE is a stubborn condition that often requires 6-24 months to heal without treatment
• 89% of TE sufferers report being symptom free by one year¹
• Corticosteroid injections appear to be effective in the short-term BUT the there is a high reoccurrence rate (up to 72% in one study compared to no treatment, when contrasted at one year’s follow-up¹)
• Ask your doctor or pharmacist about the role of other drugs
• There is a lack of evidence to conclusively say determine the success of low-level laser therapy, shockwave therapy, or soft tissue / massage therapy for the treatment of TE
  • These therapies may provide some great results for some sufferers of TE
• Treatment of tennis elbow should extend beyond the site of pain owing the multifactorial causes (neck dysfunction, nervous system changes, local elbow dysfunction.¹

How I treat and fix tennis elbow¹⁴

The following is a general approach to how I treat, and approach treating tennis elbow and the scientific rational behind it. It is by no means a complete summary but is meant to give a general overview. The following treatment options are supported in the literature as being helpful in its treatment.

Acupuncture 

• is used to help reduce pain, and reduce the aforementioned nerve sensitivity commonly found in patients with lateral elbow pain
• Acupuncture has been shown to be very beneficial in reducing acute pain and for treating this condition
• By relaxing the nervous system which is ultimately responsible for relaying the pain signal to the brain, we help to reduce your pain quickly and restore the function of muscles and joints more quickly

Active Release Technique

• is used to relax and improve the function of tight and tender muscles at the elbow and above
• when tight muscles in the neck and shoulder are believed to be contributing to irritation of the radial nerve to goes to the lateral elbow or increasing your symptoms, we work to relax this tight structures

Mobilizing and manipulation the neck

• treating the neck is essential in the treatment of tennis elbow. As mentioned, lateral elbow pain is often associated with neck pain and dysfunction, causing increased irritation of the nerves carrying the pain signal from the elbow
• By treating and sometimes adjusting the neck, we can reduce the tightness of muscles in the neck and shoulder, and help to reduce pain at the elbow

Exercise

• a proper rehabilitation program is vital to the treatment of this condition. Not just knowing what exercises to perform, but knowing when to use each will provide the outstanding clinical results you are looking for
• It is vital to focus on the muscles above the elbow, in the shoulder and in the neck. It is likely that a lack of strength in the shoulder stabilizers, lead to an increased amount of strained being forced into the lateral elbow. Retraining the upper limb to perform better with work to balance the forces travelling through the elbow and work to create an environment for the tissues heal, free from excess repetitive strain

References

• Coombes, B. K., Bisset, L., & Vicenzino, B. (2009). A new integrative model of lateral epicondylalgia. British journal of sports medicine, 43(4), 252-258

• Shiri R, Viikari-Juntura E, Varonen H, et al. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol 2006;164:1065–74

• Gruchow HW, Pelletier D. An epidemiologic study of tennis elbow. Incidence, recurrence, and effectiveness of prevention strategies. Am J Sports Med 1979;7:234–8.

• Viikari-Juntura E, Kurppa K, Kuosma E, et al. Prevalence of epicondylitis and elbow pain in the meat-processing industry. Scand J Work Environ Health 1991;17:38–45.
• Uchio Y, Ochi M, Ryoke K, et al. Expression of neuropeptides and cytokines at the extensor carpi radialis brevis muscle origin. J Shoulder Elbow Surg 2002;11:570–5.
• Ljung BO, Forsgren S, Friden J. Substance P and calcitonin gene-related peptide expression at the extensor carpi radialis brevis muscle origin: implications for the etiology of tennis elbow. J Orthop Res 1999;17:554–9.
• Ljung BO, Alfredson H, Forsgren S. Neurokinin 1-receptors and sensory neuropeptides in tendon insertions at the medial and lateral epicondyles of the humerus. Studies on tennis elbow and medial epicondylalgia. J Orthop Res 2004;22:321–7.
• Nirschl RP. Elbow tendinosis/tennis elbow. Clin Sports Med 1992;11:851–70.
• Regan W, Wold LE, Coonrad R, et al. Microscopic histopathology of chronic 
refractory lateral epicondylitis. Am J Sports Med 1992;20:746–9.
• Bisset LM, Russell T, Bradley S, et al. Bilateral sensorimotor abnormalities in unilateral lateral epicondylalgia. Arch Phys Med Rehabil 2006;87:490–5.
• Pienimaki TT, Kauranen K, Vanharanta H. Bilaterally decreased motor performance of arms in patients with chronic tennis elbow. Arch Phys Med Rehabil 1997;78:1092–5.
• Alizadehkhaiyat O, Fisher AC, Kemp GJ, et al. Upper limb muscle imbalance in tennis elbow: a functional and electromyographic assessment. J Orthop Res 2007;25:1651–7.
• Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;333:939.
• Bisset, L., et al. “A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia.” British journal of sports medicine7 (2005): 411-422.