What is tennis elbow?

Tennis Elbow is a common overuse injury which typically causes pain at the outer aspect of the elbow. Although it can occur at any age, it is commonly seen in patients between the ages of 40-50. The group of muscles at the back of the forearm are called the forearm extensors and these muscles act to extend the wrist and fingers (bend the wrist backwards and straighten the fingers) and have a common insertion at the outer aspect of the elbow called the lateral epicondyle. During contraction of the forearm extensors, tension is placed through the extensor tendon at its attachment to the bone. When this tension is excessive due to overuse or excessive force the tendon becomes damaged, inflamed, and may degenerate over time at its bony attachment. It is usually due to muscle tightness and gradual wear and tear associated with overuse, however, the condition may also occur traumatically due to a specific incident.   The symptoms associated with this condition usually develop gradually over a period of time. Initially, symptoms may present as an ache following an aggravating or unaccustomed activity. This may often be felt first thing in the morning. Patients usually experience localized elbow pain 1-2cm down from the bony lump on the outer aspect of the elbow (lateral epicondyle – figure 1) that increases on firmly touching this region. Occasionally, pain may radiate into the forearm.   In less severe cases of this condition, patients may only experience a minor ache. In more severe cases, pain may be quite incapacitating and can keep the patient awake at night. Usually pain is experienced as an ache that increases to a sharper pain with activity. Occasionally, this condition can be associated with neck or upper back pain on the same side. In longstanding cases muscle weakness and reduced grip strength may also be present.   Patients with tennis elbow often experience an increase in pain during everyday activities such as gripping activities, picking up a cup, turning a door knob, opening a jar, shaking hands, carrying groceries or turning the steering wheel of a car. Elbow stiffness may also be experienced and is typically worse first thing in the morning.    

What are the common causes of tennis elbow?

Tennis elbow is more commonly seen in non-tennis players than in tennis players. Patients typically develop this condition in association with:
  • forearm extension muscle tightness
  • gradual wear and tear associated with overuse
  • after trauma or a specific incident to the forearm
  • activities involving repeated wrist extension against resistance
  • activities involving grip
  • tennis, squash, badminton
  • manual work such as carpentry, painting, chopping wood, repetitive use of a screwdriver
  • working on a keyboard and computer
  • a sudden increase in activity  such as  tennis tournament over consecutive days
  • a change in something about the  activity like a new racket, tightening strings, using a new technique, hitting balls in the wet, hitting the ball too hard
   

What is the prognosis of tennis elbow?

With appropriate management, most minor cases of tennis elbow that have not been present for long can usually recover within a few weeks. In more severe and chronic cases recovery can be a lengthy process and may take up to 6 months in those who have had their condition for a long period of time. Early physiotherapy intervention is therefore vital to hasten recovery.  

How can physiotherapy and massage do for tennis elbow?

Manual Physiotherapy

Your manual therapy assessment for Tennis Elbow will focus on restrictions and tightness within the various forearm muscles, those that attaches the forearm extensor muscle group to the lateral epicondyle. Most of the focus early on is vigorous releasing of the forearm musculature to reduce tension on the insertion and reduce inflammation. Sometimes a tennis elbow or golfers elbow strap is helpful to disperse the force and ease the tension. Laser therapy is also very effective in reducing inflammation. When inflammation has reduced, direct scar tissue techniques such as friction massage performed on the tendon directly to breakdown thickening and reduce the risk of recurrence. Regular massage and myofascial rolling and stretching techniques are also important.   Tennis elbow may be compromised and or secondary to a shoulder and neck problem. Specifically the levels that supply the extensor muscles may be facilitated (facilitated segment) causing a disruption in the peripheral nervous supply and subsequently disturbing the muscles and resulting in pain and injury. Arthritis in the joints of the neck, nerve compression by either joints or soft tissue, and or nerve tension and poor posture can cause this effect in the muscles of the forearm. A Manual Physiotherapist will assess the neck as well as the shoulder in determining a physiotherapy impression and diagnosis.

   

Massage Therapy

One of the most effective techniques for a local tennis elbow, is soft tissue techniques and your massage therapist can perform myofascial techniques and Swedish massage techniques in order to restore soft tissue suppleness. Often, the work is directed also to the neck and upper back as these structures are compromised during working postures and when overused, can create an imbalances that leads to poor movement patterns.

   

Rehabilitation

The first step in supporting this condition is to assess the neck and upper back and scapula, for joint restrictions and soft tissue restrictions and strength imbalances. These can be corrected by physiotherapy and by an individualized postural exercise development program. Refer to this section for complete details.    

How can exercise and physical development help after tennis elbow?

The Kinetic Chain

Our body functions best and with minimal stress when it is in optimal alignment and posture. Proper structural correction is achieved with proper footwear and support. With an optimal base, and with proper pelvis and spinal alignment and posture, the upper extremities can function with optimal mechanics.  Proper neck and back posture in essential in tendonitis of the shoulder and elbow and this requires skill development and neuromuscular training and is the science of motor learning. The kinetic chain is a integrated functional unit of systems that work interdependently to allow structural and functional efficiency. It is made of the soft tissue system (muscle, ligament, tendon, and fascia), the Neural system ( peripheral nervous system of nerves and the central nervous system or brain), and the Articular system (joints). If any of these systems do not work efficiently, compensations and adaptations may occur in the other systems. A dysfunction in the kinetic chain leads to decreased performance and predictable patterns of injury.  Imbalances may result from postural stress, a pattern of overload, repetitive movement, a lack of core stability, and a lack of neuromuscular efficiency. All functional movement patterns of the upper body, involve deceleration, stabilization and acceleration, which occur at every joint in the kinetic chain and in all planes of motion at varying speeds.   Optimum posture and alignment provides optimal structural and functional efficiency to the kinetic chain. If one component is out of alignment, it creates predictable patterns of tissue overload and dysfunction, leads to decreased neuromuscular control and initiates the cumulative injury cycle. Muscle imbalance leads to abnormal neuromuscular control leads to overloaded tissue and tissue fatigue which leads to inflammation and eventually leads to tissue trauma or injury. The most common patterns of compensation in the upper body is the Forward Head Pattern and this pattern can occur in isolation or in concert with a pronation pattern or the equivalent in the lower body.  These two patterns are the focus of our screen examination and our subsequent corrective preventative exercise plan. Identification of biomechanical imbalances in a way that is specifically related to the multi planner movements and that involves acceleration, deceleration, stabilization and occurs at multiple speeds in those specific body positions and posture activities of daily living.  Assessment of the muscular system (functional anatomy) the articular system (functional biomechanics) and the neural system (motor behavior) becomes important in the prevention and treatment of overuse injuries and repetitive strains. In order to live a healthy and active lifestyle, one has to train their body the way it moves during daily functional movements.

   

Exercise Training and Physical Development

Spinal alignment and stability and posturing is the most important physical training that you can do to prevent and maintain good shoulder and elbow mechanics and reduce abnormal stresses on the tendons and muscles of the upper extremity. As for Tennis Elbow itself, often strength training will cause more tightness and subsequently overload the tendon and make it worse. This overuse injury does well with soft tissue techniques and laser techniques and by decreasing inflammation first, strengthening movements may then be possible.   Everyone should strive to develop their bodies so that they can live a long and healthy life. This is especially important after you have suffered an injury or are unable to be as active while you were rehabilitating. All of our staff have a combination of health sciences and sports sciences training, having dual training in both kinesiology and physiotherapy and allowing us to provide a biomechanical focus at healthfx. We focus on:  
  • Biomechanics of human movement
  • Posture and alignment (static and dynamic)
  • Ergonomics and workplace
  • Functional movement screens and analysis to identify individual muscle imbalances
  We start with a functional movement screen that looks at some of the essential movement skills for daily living and also for an activity based lifestyle. This information in addition to our previous orthopaedic assessment findings will allow us to develop a personal improvement plan just for you. This plan will have specific goals, be measurable, will call you to action, will be realistic, and will be time sensitive so that you will see progress and we will monitor and support your success from a medically based standpoint and from a sports science stand point.    

How can low intensity laser therapy help with overuse injuries like tennis elbow?

Low Intensity Laser Therapy (LILT) is the use of monochromatic light. Meditech Bioflex has been producing this technology for 20 years and has an extensive in house clinical lab.   The light source is placed in contact with the skin allowing the photon energy to penetrate tissue, where it interacts with various intracellular biomolecules resulting in the restoration of normal cell morphology and function. This process also enhances the body's natural healing propensities.   Low Intensity Laser Therapy does not heat or cut tissue. Unlike many pharmacological treatments that mask pain or only address the symptoms of the disease, Laser Therapy treats the underlying condition or pathology to promote healing. The technology utilizes superluminous laser diodes to irradiate diseased or traumatized tissue with photons. These particles of energy are selectively absorbed by the cell membrane and intracellular molecules, resulting in the initiation of a cascade of complex physiological reactions, leading to the restoration of normal cell structure and function.   The process is curative and therefore results in the elimination of symptoms including pain. In addition, it enhances the body’s immune system response and facilitates natural healing. The therapy is completely safe and has no adverse side effects. The technology is highly effective in the treatment of musculoskeletal conditions, arthritis, sports injuries, wound healing and a wide range of dermatological conditions. Whiplash injury typically involves injury to muscles, ligaments, and joints and typically involve several levels and a more wide spread area of injury due to the force full nature of the injury. Muscles of the neck, although short, cross over several joints and so the discomfort is generally more global initially. Laser therapy directed by multiple diodes are able to reach these tissues.    

Physiological effects of Low Intensity Laser Therapy

With LILT there is an increased production and release of:  
  • Endorphins which - natural analgesics
  • Cortisol – a precursor of cortisone
  • Growth hormone – instrumental in tissue repair
  • ATP – improves and regulates cellular metabolism
  • An increase in protein synthesis – collagen, DNA, fibroblasts
  • A facilitated venous and lymphatic flow
  • Increased angiogenesis – the elevation of oxygen saturation
  • Enhanced immune response
  These responses are some of the many processes that accelerate cellular regeneration (cartilage, epithelium) and restore normal cell morphology and function. Treatments are typically 25 minutes to over 1 hour depending on the condition and area being treated   The most popular technical / clinical information requested is available on the Meditech website under Laser Reports. You may visit the Meditech website research section directly for detailed abstracts, case profiles and articles on a variety of topics relating to the use of low intensity laser therapy in the treatment of various medical conditions.  

What life style and self-care measures can you do for yourself for tennis elbow?

To treat tendinitis at home, Rest, Ice, Massage, and sometimes Heat. This treatment can help speed your recovery and help prevent further problems.  
  • Rest. Avoid activities that increase the pain or swelling. Don't try to work or play through the pain. Rest is essential to tissue healing. But it doesn't mean complete bed rest. You can do other activities and exercises that do not stress the injured tendon. Ask your physiotherapist which activity is best. Although rest is a key part of treating tendinitis, prolonged inactivity can cause stiffness in your joints. After a few days of completely resting the injured area, gently move it through its full range of motion to maintain joint flexibility.
  • Ice. To decrease pain, muscle spasm and swelling, apply ice to the injured area for up to 15-20 minutes, several times a day. Ice packs, ice massage or slush baths with ice and water all can help. For an ice massage, freeze a plastic foam cup full of water so that you can hold the cup while applying the ice directly to the skin.
  • Heat. For more chronic tendon conditions, and if the goal is to release tight soft tissue, heat can be helpful in increasing blood flow to the muscle and tendon. This includes deep heat, moist head, and hydrotherapy
  • Over the counter Meds. Ask your doctor about medications. You can also try over-the-counter medications, such as aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve) or acetaminophen (Tylenol, others), in an attempt to reduce the discomfort associated with tendinitis.
  • Physiotherapy and Massage Therapy. Book an appointment with your physiotherapist and massage therapist for an assessment and treatment. Soft tissue techniques that release the tension in the muscles and or release the myofascial tensions placed on the extensor tendon will not only rehabilitate the injury but also prevent further injury and reoccurrence.
  There are many decisions to be made when it comes to the care of and prevention of all types of overuse injuries including tennis elbow. An experienced practitioner, a well executed assessment process, and a well thought out personal improvement plan can help.

   

Prevention

To reduce your chance of developing tendinitis, follow these suggestions:  
  • Develop Strength and fitness. Often those who develop tendonitis have are not prepared physically to perform either the volume or intensity of the activity which they participate in. If your goal is to be active, talk to your physiotherapist to help you develop the components of fitness that are most important to the activities that you do.
  • Prepare your muscles to play. Strengthening muscles used in your activity or sport can help them better withstand stress and load.
  • Recover from activity and get ready for the next. Ask your therapist about the strategies that are best for you to recover from your specific activity. Heat, ice, massage, baths, stretching and include.
  • Warm up first. Before you exercise, take time to increase your core temperature and break a sweat and then stretch in order to maximize the range of motion of your joints. This can help to minimize repetitive microtrauma on tight tissues. Remember, regular massage by your physiotherapist and or your massage therapist helps too. 
  • Use proper workplace ergonomics. If possible, get an ergonomic assessment of your work space and adjust your chair, keyboard and desktop as recommended for your height, arm length and usual tasks. This will help protect all your joints and tendons from excessive stress.
  • Mix it up. If one exercise or activity causes you a particular, persistent pain, try something else. Cross-training can help you mix up an impact-loading exercise, such as running, with lower impact exercise, such as biking or swimming.
  • Improve your technique. If your technique in an activity or exercise is flawed, you could be setting yourself up for problems with your tendons. Consider taking lessons or getting professional instructions when starting a new sport or using exercise equipment.
  • Ease up. Know your body. If you are not fit to perform the activity ease up, avoid activities that place excessive stress on your tendons, especially for prolonged periods. If you notice pain during a particular exercise, stop and rest. If you are unable to progress and develop your sport, seek help from a physiotherapist who understands how to develop athletes.
   

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