Tennis Elbow (Lateral Epicondylagia)

What is Tennis Elbow?

Tennis elbow is the most common overuse syndrome in the elbow. It involves the extensor muscles of the forearm with pain typically occurring at the common wrist extensor origin – the lateral epicondyle of the humerus. It most commonly affects 35-50 year olds.
Most commonly involves the Extensor Carpi Radialis Brevis (ECRB). It can also involve the Extensor Digitorum (ED), Extensor Carpi Radialis Longus (ECRL), and Extensor Carpi Ulnaris (ECU)

What causes it?

• Repetitive overloading of the extensor muscles of the forearm
• Overloading causes microscopic tearing and degeneration of the muscle tissue at their origin of the lateral epicondyle.
• The body is normally stimulated to repair and rebuild the muscle stronger. However, in the case of tennis elbow, injury is repeated without allowing recovery, overwhelming the body’s ability to repair
• This can occur with repetitive activities involving wrist extension and supination
o Activity: Computer, heavy lifting
o Sports: Tennis, squash, badminton, baseball, swimming
o Occupations: Electricians, carpenters, gardeners

 

How does it present?

• Pain is the most prominent symptom

o Local tenderness at the epicondyle and over the extensor tendons
o The pain can radiate along the upper arm, downwards along the outside of the forearm, and in rare case even to the third and fourth fingers
o Pain and/or weakness on resisted wrist/finger extension
o Pain and reduced range of motion
• Difficulty with lifting and gripping – from pain and/or weakness

 

 

 

 

What is the latest evidence for treatment?

Recent evidence is showing that Resistance Training is useful for reducing pain and improving function in Tennis Elbow
• A random control trial investigated which combination of resistance training had the greatest impact on reducing pain and improving function
• The first group underwent eccentric training, the second had eccentric and concentric training while the third performed eccentric and concentric alongside isometric training
• The eccentric-concentric training combined with isometric contractions produced the largest effect in reduction of pain and improvement in function at the end of treatment and at any of the follow-up points.
 Isometric Exercise: Position the arm with the elbow supported and only the wrist and hand hanging off the surface. Perform wrist extension holds with a weight/theraband – 5 reps for 30-45 seconds. Moderate discomfort is okay when performing tendon loading exercises.
 Wrist Extensor (Heavy-Slow curls): Extensor curls through full range of motion, working the wrist extensors both concentrically and eccentrically – aim for 3-4 sets of 6-12 reps

Another trial demonstrated that the addition of Scapular Muscle Strengthening reduces pain and improves muscle function in Tennis Elbow
• This study investigated the effect of strengthening middle traps and serratus anterior using outcomes associated with pain and function.
• For nearly all outcome measures there was a significant difference in favour of the group that received scapular strengthening.
• They concluded that scapular muscle strengthening should be used alongside conventional therapy in individuals with chronic LE to reduce pain and improve function.

 

 

Physiotherapy Management can also include:

• Education and Advice
• Controlling pain through activity modification
• Controlling inflammation in early stages – RICE, ultrasound
• Stretching of the extensor muscles – best stretching position for ECRB is elbow extended, forearm pronated, wrist flexed in ulnar deviation.
• Joint mobs – rotation at the proximal radioulnar joint
• Kinesio Taping

 

Golfer’s Elbow (Medial Epicondylalgia)

What is Golfer’s Elbow?

Golfer’s elbow involves the wrist flexor muscles of the forearm with pain occurring at their origin – the medial epicondyle. It also most commonly affects 35-50 year olds. It most frequently involves flexor carpi radialis and pronator teres. It can include palmaris longus, flexor digitorum superficialis and flexor carpi ulnaris

What Causes it?

• Repetitive overloading of the extensor muscles of the forearm
• Overloading causes microscopic tearing and degeneration of the muscle tissue at their origin of the lateral epicondyle.
• The body is normally stimulated to repair and rebuild the muscle stronger. However, in the case of tennis elbow, injury is repeated without allowing recovery, overwhelming the body’s ability to repair
• Can occur in repetitive activities involving wrist flexion and pronation
o Sports: Golf, baseball, bowling, archery, javelin, American football
o Occupations: Manual trades where gripping is involved – carpentry, plumbing – due to repetitive concentric and eccentric loading of the wrist flexors and pronator muscles

How does it present?

o Pain is the most prominent symptom
o Local tenderness over the medial epicondyle and tendons of the flexor group
o Pain and/or weakness on resisted wrist/finger flexion and pronation
o P can radiate down the ulnar side of the forearm and occasionally in the fingers
• Pain and reduced ROM
• Difficulty with gripping – due to pain and/or weakness
• Elbow can feel stiff

What is the latest evidence for treatment?

There is evidence showing that the addition of Eccentric Resistance Training has been effective in reducing pain and improving function in Golfer’s elbow
• This study investigated the effect of eccentric strength training in addition to standard Physiotherapy treatment on pain and function in daily life of individuals with Golfer’s elbow.
• They used the DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire as their outcome measure for treatment. This score was recorded before and after treatment.
• The isolated eccentric wrist flexor strengthening exercise involved twisting a rubber bar
• The addition of eccentric strength training demonstrated marked improvement in the DASH questionnaire from before to after treatment.

Physiotherapy can also include:

• Advice and education
• Controlling pain through activity modification
• Controlling inflammation – RICE, ultrasound
• Strengthening Exercises – concentric, isometric?
• Stretching of wrist flexor muscles
• Elbow Joint mobilisation