26. Treating Tennis Elbow 101: Ace Your Recovery

Why does my elbow have to do anything with me playing or never having played ‘Tennis’?

In this Blog, we’ll attempt to simplify Tennis Elbow for non-clinicians and clinicians alike.

To avoid complicated jargon, I won’t go deep into the ‘HOWs’ of various treatment modalities.

Let’s begin with;

What is Tennis Elbow?

Tennis Elbow, Lateral Humeral Epicondylitis, Lateral Humeral Epicondylalgia, or Lateral Elbow Pain, is a painful condition of the Elbow specifically localized to the Lateral Humeral Epicondyle (The outer bony part of the elbow) often dubbed as the Common extensor origin (Because the muscles that extend/straighten our wrist and fingers originate here/are anchored to this segment).

It’s seen that one of these ‘Extensor muscles’, the Extensor Carpi Radialis Brevis is the most commonly affected structure by this painful condition (accompanied/followed by a few less likely candidates).

Although this much is readily explained about Tennis elbow, there are a lot of slip-ups in this simple explanation.

• Tennis elbow isn’t related to Tennis players as closely as the name would suggest, it's often seen in golfers, baseball players, clothing pressers, salespersons, violinists, blacksmiths, telephone operators, and homemakers alongside tennis players (only 5% of all cases)

• Lateral Epicondylitis (Inflammation of the Lateral Epicondyle[LE]) is a misnomer as well, tissue analysis reveals the healthy tissue of ECRB (the muscle) is invaded by immature fibroblasts and nonfunctional vascular buds, with disorganized surrounding and hypercellular tissue, termed as “angiofibroblastic tendinosis” by Nirschl et al.

(Roughly a mismatch between the Degeneration and Repair environment of the LE)

It is widely considered an overuse injury or a result of piled-up microtrauma over the years of moving (repetitive motion) & loading (frequent and without significant rest or recovery) the elbow, especially in genetically predisposed individuals.

(Additional Ref.1, Ref.2, Ref.3)

Who gets it? What are my odds?

It’s a fairly common condition (considering the overall incidence) affecting 1–3% of the general population and upwards of 50% of the sporting population having experienced Lateral elbow pain at least once in their career.

• The peak incidence of lateral elbow pain is seen at 40-50 years of age.

• Prevalence increases noticeably (by 10%) in women of age: 42-46 years.

Reported risk factors (pointers which combined with frequent and repetitive elbow use might increase the chances that you get lateral elbow pain) for developing it are:

• Age 30–50 years (closely connected to the prevalence)

• Manual labour

• Smoking

• DeQuervain’s tenosynovitis

• Carpal tunnel syndrome

• Oral corticosteroid therapy

• Repetitive activities > 1 h/day

• Poor social support

• Poor tennis mechanics(anecdotal)

• Fluoroquinolone antibiotic use (Speculated.)

• Unrecognized trauma

What treatment options do I get? and What should I choose?

A vast array of pharmacological(drugs), surgical, and non-pharmacological treatment options are available for lateral elbow pain.

First, you have to keep in mind the milestones that you want to achieve,

• Pain relief: Including pain at rest, with activities, and with resisted/sports-specific movements.

• Functional improvement: Including grip strength (dynamometer), the efficiency of daily living activities, and recovery/recreational tasks.

• Quality of life: Global improvement: includes return to work, normal activities, or both (overall patient-reported improvement).

• Recurrence (Self-reported by patients).

For those who have pain and activities affected by lateral elbow pain for a duration of fewer than 12 weeks (there is no clear consensus on what counts as chronic lateral epicondylalgia), it’s often recommended to stick with conservative care (pharmacological and non-pharmacological treatments)

• Exercise: Optimal loading of the tendons via graded load exposure and self-management (adjustment of the exercise programming) of aggravating and straining loads by the patients (explained by and experimented with under the supervision of a trained physiotherapist) is one way of managing lateral elbow pain, preserving function and other outcome measures (stated earlier: the milestones) through exercise.

• Electrotherapy modalities:

(a.) ECSW(Shock wave): might be applicable (although with expectations aligned with short-term symptomatic relief) in the rare scenario of calcification being demonstrated in a common extensor origin tendon,

(b.) Other electrotherapeutic modalities like PEMF, Ultrasound, Laser(LLLT), Iontophoresis, and NMES are not recommended often as better effect sizes for similar durations of time (short-term symptomatic relief) might be achieved with other more convenient modes (drugs).

(c.) Manual Therapy: MWM and Mill’s manipulation are considered useful for very acute(short-term) symptom-free gripping, unlikely to be beneficial beyond that.

• Pharmacological:

(a.) NSAIDs(anti-inflammatory meds): as previously established that lateral epicondylalgia isn’t an inflammatory condition, but NSAIDs are still found to be effective in improving pain experience (whereas no functional benefits are likely) and their effectiveness beyond the initial 5-12 months is questionable.

Topical(Skin application of) NSAIDs are associated with fewer adverse effects and provide similar effects as oral(tablets) administration.

(b.) Injectables

• Corticosteroid Injections: Although they are linked to significant symptom reduction initially, administration of any form of corticosteroid therapy comes with caution. The usual trend is to avoid corticosteroid injections to tendons due to their adverse effects on the structure of the myotendinous units on a cellular level. (Shouldn’t be used with symptom duration of fewer than 12 months)

• PRP(Platlet-rich plasma): It is believed that chemical and cellular components can influence the regenerative capacity of the myotendinous units (basically they’ll be able to heal themselves better), but even after a significant amount of effort put into explaining how and how much truth resides in this belief, we have a dearth of supportive literature on the clinical efficacy (usefulness) of PRP in the treatment of lateral elbow pain. Although it’s generally considered safe (comparatively) and preferred over corticosteroid injections for improving short-term subjective outcomes (pain and function) in lateral elbow pain.

• Dry needling/acupuncture: application of dry needling and acupuncture for lateral elbow pain is questionable in the absence of cogent explanations and rationale for their effects and mechanism of action. (Although pain and self-reported daily function can still be improved using this modality for a very brief period).

• Orthotics(elbow wraps and tennis elbow brace): Lack of research into the efficacy of orthotics in lateral elbow pain leaves us with generalized advice: Choose whatever orthotic you like, can afford, feel comfortable using, and can comfortably use, it can be helpful in self-reported pain improvements, but it is not going to augment (support, offload or splint) the elbow or ‘heal’ it in ways advertised.

• Surgery: It’s a vast collection of procedures done to achieve roughly the same outcome improvements, presently there isn’t enough evidence to support or reject the role of surgical management, its efficacy(utility), and the size of the effect(relief) it may have if any, again coming to generalized advice:

You can achieve similar results (albeit better in some cases) using less invasive (cutty&snippy) modalities.

“All techniques described probably work in a similar manner (to botulinum toxin), by forcing an initial rest on the patient who then gradually reloads the tendon as the pain of the surgery diminishes.”

(Additional Ref.4, Ref.5, Ref.6, Ref.7, Ref.8, Ref.9, Ref.10, Ref.11, Ref.12, Ref.13)

Should I panic?

Funnily enough in a trial comparing Corticosteroid therapy, Physiotherapy modalities, and a wait-and-watch (no treatments just expectant watchfulness) protocol, 80% of people with elbow pain of already >4 weeks' duration recovered after 1 year. (yes without any treatment).

Although, in a minority of people symptoms persist for 18 months to 2 years, and in some cases for much longer. Multidisciplinary treatment seems to be quite satisfactory & effective in resolving the condition.

In conclusion, there is little to be concerned about when it comes to lateral elbow pain because like most musculoskeletal conditions it is generally considered a self-limiting experience.

For more go to Physio Explored Blogs

Disclaimer: This blog is for educational purposes only.

Cover Photo by alena-darmel from Pexels