What is Tennis Elbow?
Tennis elbow or lateral epicondylitis is a condition where the forearm tendons begin to strain from overuse. Repetitive irritation of the tendon can lead to more pain and tenderness through the elbow.
Before going any further, let’s go through the anatomy. The extensor carpi radialis brevis (ECRB) and extensor carpi radialis longus (ECRL) are the main muscles involved. They are located along the top of the forearm.
As seen in the image above, these are the muscles start from the elbow and attach to the base of our 2nd and 3rd digits, respectively. Tendons are connective tissue which bridges the muscles to the bone. The ECRB and ECRL are primarily responsible for wrist extension or bending of the wrist backward.
In activities that require repetitive wrist movements, constant stretching and contraction of these muscles begin to create strain through the tendons of the ECRB and ECRL. As a result, microscopic changes in the forearm tendons occur (e.g. tears, thickening of the tissue, etc.).
Tennis Elbow Symptoms
“So, what does tennis elbow feel like?”
A common question asked by those with tennis elbow. For the majority of cases, the hallmark of tennis elbow is sharp outer elbow pain. Not to be confused with golfers’ elbow, which is more consistent with inner elbow pain. Generally, those with this condition will also find:
- Pain when extending the elbow
- Tenderness along the outside elbow if bumped or knocked
- Aggravation with wrist movements
Tennis Elbow Causes
Tennis elbow is usually caused by overuse. Repetitive movements and strenuous activity strains the forearm muscles, including the ECRB and ECRL.
Sudden increases in activity, such as starting a gym program or moving houses, can trigger the onset. Ignoring the pain and continuing to perform aggravating movements can cause ongoing pain. This is why seeking physiotherapy treatment is recommended immediately after pain develops.
Some everyday activities which might cause tennis elbow includes:
- Gripping and lifting activities (e.g., weight lifting, manual labour, twisting/turning jars, etc.)
- Repetitive wrist movements (e.g., typing, writing, opening doorknobs, etc.)
- A sudden increase in physical activity (e.g., upper body gym exercises, increased office work, etc.)
In some instances, tennis elbow might be caused by other underlying problems. As a physiotherapist who has treated multiple tennis elbow patients, more than half will also experience deficits else where.
Cervical radiculopathy for example, can also lead to pain along the outer elbows. Cervical meaning “of the neck.” Radiculopathy meaning “pathology of the nerve.” Compression or pinching of these nerves may increase the sensitivity of the muscles it controls (e.g. ECRB, ECRL).
As seen in the graphic above, the radial nerve is a known culprit for tennis elbow. As seen in the image above, radial nerve originates from the neck and travels near the outer surface of the elbow. During this journey, the nerve can be compressed by structures, including the bone and overlying muscles. When this occurs, the affected nerve can mimic the symptoms associated with tennis elbow.
Diagnosing Tennis Elbow
Tennis elbow is diagnosed with a few simple tests. Two very frequently used tennis elbow tests include the resisted extension of the wrist and the 3rd digit (as per the video below). A positive test will is defined by pain in the outer elbow.
In some instances, further investigations such as ultrasound imaging can be ordered to confirm the diagnosis. However, this type of assessment is not always necessary.
Other Elbow Pain Conditions and Differential Diagnosis
Although tennis elbow is the most common reason for elbow pain, other conditions can often be mistaken for it. Each of these types of injuries needs needs to be managed differently. Consulting with a health professional, such as a physiotherapist or doctor will help differentiate between the following injuries:
- Golfers Elbow
- Olecranon bursitis
- Referred pain from the neck
- Radial head instability
How to Treat Tennis Elbow
The majority of patients with tennis elbow can be managed through rehabilitation and without the need for surgery. Your physiotherapist will provide you with an exercise program and daily recommendations. Below will be a detailed outline for the best tennis elbow treatment and strategies that you can use.
Physiotherapy is typically the gold standard for tennis elbow treatment. Usually, consistent therapy needs to be followed over 3-12 months or until the condition settles. During a consultation with a physiotherapist, you will typically be provided with:
- A physical examination
- Hands-on treatment (e.g., soft tissue massage, electrotherapy, dry needling, etc.)
- Specific rehabilitation and home exercise program
- Strategies to modify daily activities
Tennis Elbow Pain Relief
For those with persisting symptoms, the following treatment strategies can be used to subdue pain. Although undergoing physiotherapy and rehabilitation are pivotal for recovery, these strategies can also temporarily ease your discomfort.
Massage along the forearm muscle bulk can reduce the muscular tension and strain felt in the elbow. As demonstrated in the video below, this is performed by applying pressure with the other hand (with some massage cream). Alternatively, those with a massage gun can achieve a similar or better outcome with less effort.
2. Ice/heat therapy
Although patients report mixed results, ice and heat packs are another option to help with temporary pain relief. Ice or heat therapy can be applied for 15-20 minutes at a time to ease your symptoms. Typically, ice packs should be considered when the injury is acute and has just started. Whereas heat packs are recommended for when the tennis elbow
3. Pain relief medication
If the elbow pain continues to persist, taking NSAIDs or anti-inflammatories can be an option for short-term relief. Over the counter medication, such as Voltaren and Neurofen can be considered if appropriate. Consulting with your GP or physician is recommended for specific advice about medication.
Tennis elbow support
For those who can’t avoid performing aggravating movements (e.g., manual labor, office work, etc.), wearing a tennis elbow brace or tennis elbow strap can be an option. Braces and straps can help absorb the forces going through the elbow and forearm during activity. When positioned in the right area, it can help relieve and prevent additional pain.
Although the tennis elbow supports can be restrictive, they can help you get through the day in less discomfort. When selecting the right elbow support, you should shoulder consider the following:
- Size: Most braces and straps will come with dimensions. Ensure your forearm diameter and size aligns with these
- Silicon pad: An adjunct to the brace for targeted compression of the forearm muscles and tendon
- Material: Neoprene and nylon are the two primary materials used when manufacturing tennis elbow braces or straps. Neoprene is typically preferred for its durability, whereas nylon tends to be more breathable (for those with sensitive skin)
3 Exercises for Tennis Elbow
For long term management of tennis elbow, forearm strengthening and flexibility exercises are the standard gold treatment. Below are three typical exercises we recommend in the first stage of our tennis elbow rehabilitation program. As your tennis elbow begins to heal, more advanced exercises will be included to continue your progression.
Your physiotherapist will be able to determine the appropriate amount of repetitions and weight.
There has been a bunch of research that suggests that performing isometric exercises can help reduce pain in tendon injuries. Isometric exercises are “static contractions of a muscle without visible movement from the joint.”
These exercises require less effort on the tendon and would be beneficial for those with severe tennis elbow or severe pain. When watching the video below, the exercises are performed with additional weight to strengthen the affected muscles and tendon.
One of the most common complaints of those with tennis elbow is difficulty with twisting movements, such as turning a doorknob or opening up a jar. The wrist supination and pronation exercises help build the strength in the relevant muscles and during these movements.
As discussed prior, the two main muscles that impact tennis elbow help extend the wrist. Strengthening these muscles up is a priority for helping the tendons tolerable day-to-day activities, such as lifting or handwriting. Like the supination and pronation activities, they can be performed with a dumbbell.
Tennis elbow can be a very tricky condition to manage. If left untreated, there’s a chance it can become chronic and worsen over time. The earlier you seek treatment, the more likely you’ll recover quicker