Lateral Epicondylalgia – Tennis Elbow

Summer is here and with it comes an increased trend of the number of patients I see with elbow pain, specifically lateral epicondylalgia, or what most people call ‘tennis elbow.’ It is called ‘tennis elbow’ because it reflects pain that a lot of people get as a result of the gripping mechanism and force, much like someone would get if they grip a tennis racquet. This can potentially be a very debilitating injury that affects a lot of activities that require gripping or excessive wrist/finger movement such as computer typing…. or because of the festive season and the warm weather gripping and drinking beers. In all seriousness though, the pain from this condition can be so severe that being able to grip and open a jar, or holding the phone up to the ear very difficult. So let’s dive in and find out more about what causes this injury and how we can best manage it.

Anatomy

Before we get into the cause of the injury we must know our anatomy. So the lateral epicondyle is the bony point on the outside of the humerus, which is our main arm bone between the shoulder and elbow. At this epicondyle is the common attachment and origin of the tendons from the muscles of our forearm that work mainly to extend (lift) our wrist and fingers. So for each movement of our elbow, wrist and fingers there is a pulling or shearing force placed upon the common extensor origin (CEO).

Presentation/Symptoms

The typical story for a person who develops Lateral Epicondylalgia is that they have increased their amount of exercise or activity in short period of time, especially if that exercise involves heavy gripping. For example a new gym program involving lots of deadlifts and chin-ups, or a chef who is coming back from holiday and back chopping lots of food gripping a knife, or a massage therapist who has a really busy week of deep tissue massage using their hands. Other professions that seem to develop this type of injury include – tennis players, trades that require hands on gripping tools, painters, typists/administration etc. At this time of year it could even be from any extra gift wrapping, holding of shopping bags or gripping stubbies of beer!

Cause

As described above, the load/motion that is incurred at the wrist/fingers is directly transferred up the forearm and into the origin of all those tendons. If the force is more than what the tendon can withstand then there will be damage to the tendon and the area that it attaches to. This causes the onset of pain, some relevant inflammation and it is most important to know that it affects the health of the tendon – reduced tensile strength, poor collagen alignment, fibroblast number increases and reduced tendon stiffness (Coombes, Bisset & Vicenzino, 2009).

Treatment and Management

For every presentation we need to be looking at activity modification and load management. The initial thing that needs to be addressed is limiting the movement or activity that is thought to be the root cause of the injury. That could mean holding your heavy handbag on the other hand, using your opposite hand to hold the phone, or using a mixed grip for deadlifts and/or underhand grip for pull-ups. In doing this we are reducing the forces applied to those tendons that have the common origin at the lateral epicondyle. Once the activity that we think is causing the pain can be reduced or modified than we can begin to strengthen the muscles around the forearm without aggravating the tendon itself. No strength program is the same, and it must be adjusted according to each individual case, but there is a fairly common progression of exercise prescription. Starting with some isometric holds with a low load of weight and then into some eccentric control with low weight is something that is supported by evidence and research.

Other management tools such as dry needling, massage, trigger points and joint mobilisation can be helpful.  A thorough assessment of contributing factors such as thoracic mobility, strength and shoulder function needs to be done as well.

This Information is a guide for what to expect and some basic information on the condition, but for specific diagnosis and treatment please refer to a skilled physiotherapist or health care professional. 

Reference

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