Lateral epicondylitis (also called tennis elbow) is an overuse injury occurring in the lateral side of the elbow region, where the tendons of the forearm muscles attach (see picture below). Repeating the same motions, again and again, leads to damage from overuse of the forearm muscles and tendons, causing pain and tenderness on the outside of the elbow. Despite it’s name suggest a strong link to racquet sports, this condition can also be caused by activities of daily living, playing guitar, climbing, etc.
It is the most common overuse injury of the elbow and accounts for approximately 90% tendinopathy at the elbow (10% of elbow pain is caused by medial epicondylitis). The muscles attaching at the lateral epicondyle are the:
- Extensor carpi radialis brevis
- Extensor carpi ulnaris
- Extensor digitorum
- Extensor digiti minimi
- Supinator
- Anconeus
Causes
Overuse or repetitive strain:
1. Concentric wrist extension and supination (screw driver).
2. Repetitive eccentric wrist flexion (tennis racket, badminton, hammer).
3. Repetitive finger flexion and extension (typing).
4. Repetitive ulnar and radial deviation (grocery scanner).
Improper technique (check hints).
Often associated with rotator cuff pathology or imbalance, bicipital tendinitis.
Diagnosis
History. Symptoms of tennis elbow develop gradually, usually the pain begins as mild and slowly worsens over weeks and months. Patients may complain of pain at the lateral epicondyle (lateral area of the elbow) and weakness on grasping (example lifting a book or turning a door knob). Symptoms are often worsened with forearm activity and there is usually no specific injury associated with the start of symptoms.
Physical examination. Patients with lateral epicondylitis may show:
1. Local tenderness around lateral epicondyle and tendon attachment, no local swelling and no signs of inflammation.
2. Normal active and passive ROM.
3. Pain with resisted wrist extension, extension or flexion of middle finger.
4. Pain at the end ROM of wrist flexion when elbow is extended.
• Provocative test. Cozen’s test, Mill’s test, middle finger extension test (muscle test of extensor digitorum) may confirm the diagnosis.
• X-rays can confirm and distinguish possibilities of existing causes of pain that are unrelated to tennis elbow, such as fracture or athritis.
• MRI may be ordered if your symptoms are related to a neck problem, such as herniated disk or arthritis in the neck.
• EMG may be ordered to rule out nerve compression.
Treatment
Non surgical treatment can give excellent results, however patients should be warned that it can be slow to respond thus avoiding to get discouraged.
Early phase:
1. Avoid aggravating/repetitive activities such as playing tennis, opening car door, for as long as it takes (2-3 weeks usually are enough).
2. Ice
3. Osseous mobilization/manipulation of wrist, elbow, shoulder and spine.
4. Tape, K-tape, Cho-pat.
5. Cross friction massage, myofascial release, TrPs
6. Dry needling/Acupuncture HT3,PC5, PC6, SI3,SI4,SI7.
7. Ultrasound
8. Vitamin supplements.
Post acute phase:
1. Massage therapy
2. Osseous mobilization/manipulation of wrist, elbow, shoulder and spine.
3. Ultrasound.
4. Ice after treatment and after activity.
5. Stretching rotator cuff, biceps, forearm muscles
6. Strength core stability and rotator cuff.
If you are a tennis player:
• Change racket, avoid high string tension and use a bigger grip.
• warm-up and stretch.
• strength core stability and should girdle muscles.
• Avoid graphite racket (transfer too much of impact to the hand).
• Use new/dry balls and play on slower surfaces.
• Use a brace for few weeks.
• Improve technique and use 2 hand back hand
Read the research: Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial.
Hints
• A poor backhand technique in tennis may cause lateral epicondylitis. If the wrist is bent when striking a back hand the huge forces are transferred through the tendons to the elbow rather than through the entire arm.
• Check the racket, a small racket grip makes the muscle working harder increasing the forces through the tendon.
• Check the strings, if the strings are too tight, more shock and energy will be transmitted through the forearm from the ball.
• Remember rotator cuff may refer pain to elbow.
• Proper grip sizing for tennis racket: middle finger to palm crease or one finger width gap between finger tip and heel of hand when gripping handle.
• Isokinetic eccentric training has been shown to be an effective treatment for chronic lateral epicondylosis, however this treatment option may not be available, may be too expensive, or may be impractical for many patients (isokinetic dynamometers are expensive and not widely available).
• Lateral epicondylitis is often associated with rotator cuff imbalance.
Dott. Emanuele Luciani
Osteopath, physiotherapist, hatha yoga teacher
Osteopath registered with the General Osteopathic Council (GOsC)
(number 8232http://www.osteopathy.org.uk/home/)
"Centro Studi Tre Fontane"
Via Luigi Perna 51, Rome
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