Tennis Elbow Treatment - Brisbane MSK Therapy Clinic
What is the main cause of Tennis Elbow?
The medically named condition Lateral Epicondylitis(Tennis Elbow) can occur for many reasons and is commonly seen and treated in the MSK Clinic setting. Many people are more familiar with the widely known term tennis elbow. Tennis players are not the only ones to suffer from lateral epicondylitis symptoms. Tennis players can experience tennis elbow symptoms due to many factors relating to technique, equipment, surface, training, the forces involved and repetition. Many other activities rely heavily on forearm extensor muscles, including hammering, playing many instruments and intricate dextrous work. Such activities also involve other soft tissues such as, ligaments, tendons, muscles, bursae fascia and parts of joint structures. Changes to such tissues can impact joint mechanics, stability and tensional forces.
The forearm extensor muscles are easy to see when lifting a weight, such as in the kettlebell image. However, Tennis Players may also suffer from Golfer's Elbow or Medial Epicondylitis. Tennis elbow is a type of Repetitive Strain Injury (RSI) is common in certain professions or trades like mechanics, carpenters, plumbers, electricians, manual therapists, office workers, hairdressers and musicians.
Although myofascial trigger points may have a controversial historical basis, evidence continues to demonstrate their relevance in myofascial pain conditions (Gerwin et al., 2014; Jaeger et al., 2013; Gerwin et al., 2016; Barbero et al., 2019). Myofascial trigger points appear to develop due to trauma and overuse, which is the widely agreed consensus within the research community (Bron et al., 2012). Such injury mechanisms are also the primary causes of Tennis Elbow pain and studies have detected the presence of myofascial trigger points (Shmushkevich et al., 2013; Fernández-Carnero et al., 2015; et al., 2007).
Biotensegrity effectively explains how force application changes within the body and affects biomechanics (see the Biotensegrity Article). Lateral epicondylitis occurs due to two main injury mechanisms: direct trauma or overuse. The human body's response to injury and healing involves an inflammatory response. Tennis elbow is no different and results in inflammation affecting forearm extensor muscles and the tendon(s) at the origin end or near the elbow. Often, people ask what the difference is between tennis elbow and tendonitis. In acute or early stages of Tennis elbow, the condition is a form of tendonitis, with minimal cellular structural changes to the tendon and surrounding tissues.
Many MSK-related inflammatory conditions tend to be easily irritated, leading to conditions becoming chronic if poorly managed (see the article on Persistent Pain). If tennis elbow goes untreated and further damage occurs, the injured tendons can develop tendinosis. Repeated injury and attempts by the body to heal tissues can result in microscopic physical changes to the cell structure of tendons. Changes result in the collagen fibre cellular structure becoming disorganised, resulting in a thickening of the tendon. These microscopic changes then negatively impact the properties of the tissue and function. Hence, stopping activities that rely heavily on forearm extensor muscles is usually best and, while symptomatic, like lifting weights. Luckily, the tennis elbow is easily treatable with the right approach, and early intervention is best.
In some cases, such as obvious trauma, the reason for symptoms of the lateral epicondylitis symptoms may be clear, though this is often not the case. Even with a specific direct trauma, many people never seek any treatment, often resorting to anti-inflammatory medications, rest until symptoms appear to subside or resort to a tennis elbow brace. Direct traumas frequently occur due to blunt force trauma, such as a fall or bashing one's elbow. Falls can typically impact many body areas, even if the elbow appears to have taken the brunt of the fall.
What does the pain of tennis elbow feel like?
As with many types of inflammatory type conditions, symptoms often include pain, swelling and even a burning sensation. Sometimes, symptoms can feel better with activity or as tissues warm up, only to worsen later. Equally, depending on the types of activities that one does, symptoms may improve throughout the day and then seem worse in the morning or after rest. One may also feel that stretching the affected area makes symptoms seem better at the time, though only to feel much worse later. The classic pain location for Tennis elbow pain is on the outside forearm near the elbow, with symptoms of tenderness. Besides pain, forearm muscle weakness is another common symptom, such as grip strength weakness.
How do you get tennis elbow to go away?
A reasonable degree of research supports the effectiveness of using specific myofascial release techniques to treat tennis elbow (Lateral epicondylitis). However, there is very little research into the treatment of Golfer's Elbow (Medial Epicondylitis), which is most likely due to the difference in condition prevalence. It is essential to understand that there are limitations of the research, and equally, Tennis Elbow is a far more commonly seen condition than Golfer's Elbow. There are many ways to treat tennis elbow and various forms of self-care and professional help. However, it is important to understand that although tennis elbow symptoms may be similar between people, actual causes or injury mechanisms can vary substantially. Hence, effective treatment approaches need tailoring to individual circumstances, not a one-fit-all approach. Self-help can prove useful, though there are limits to what is achievable. Many patients take over-the-counter anti-inflammatory medications (pills or creams), ice the area, stretch the tissues, use a tennis elbow brace, etc. These strategies may provide short-term relief but do not resolve the actual cause. There are also well-known longer-term issues with relying on anti-inflammatory medications or other over-the-counter pain relief medications. Equally, some people use kinesiology tape, which in many respects can prove helpful and much like a tennis elbow brace in the short term. However, constantly relying on tape can prove expensive and not address the reason for symptoms.
Many professional-based treatment options exist and with varying cost levels. Some therapists still treat soft tissue injuries with ultrasound or newer, more expensive technologies such as shockwave therapy. In the author's 16 years of clinical practice, he has found that myofascial release techniques can work exceptionally well in treating many musculoskeletal conditions and injuries, including tennis elbow. The research is slowly catching up with what the author has observed in clinical practice. Some soft tissue therapy treatment methods have little or no research due to a lack of funding. Clinically a technique with no apparent research could be very effective, as research limitations exist. However, many other soft tissue therapies have an increasing research base. Myofascial release treatments cover a broad category of specific soft tissue techniques that work directly or indirectly with myofascial trigger points. Trigger point Dry Needling is one such method with a good evidence base for the treatment of tennis elbow (Uygur et al., 2017; Güngör et al., 2022; Uygur et al., 2021). However, there are also many dry needling techniques, some of which, such as "pecking" and electro-needling, can prove more painful/unpleasant than other techniques. Studies have also shown other myofascial release techniques involving ischemic compression are just as effective as trigger point dry needling(Togha et al., 2020; Ziaeifar et al., 2019; Cagnie et al., 2015; Behrangrad et al., 2020; Togha et al., 2020; Ziaeifar et al., 2019; Cagnie et al., 2015; Behrangrad et al., 2020). Such ischemic compression techniques might include Neuromuscular therapy or Positional Release Technique.
Massage can be good for tennis elbow pain, but massage is a general term, and training can also vary hugely. Massage therapy could quickly worsen symptoms if the therapist has not identified the root cause and or applies the wrong treatment approach. Individual injury characteristics and professional experience dictate the most appropriate techniques in any given situation. Often, patients ask if heat is suitable for tennis elbow, though heat increases blood flow (fluids) to the injured tissues. The inflammatory response is a critical aspect of soft tissue repair, though too much inflammation and fluids can create additional cellular damage. Hence, it is often better to cool the injury site within the first 72 hours using cold gel packs (icing) or something similar to that to reduce initial inflammation levels. However, tissues still need to heal, and too much icing can effectively slow down the healing process.
How does a Tennis Elbow Brace Work?
Although a tennis elbow brace may help reduce symptoms, it does not address the root cause of the problem. Such braces effectively work by applying a form of soft tissue lock to the specific muscle(s). In its simplest form, a muscle will have two physical attachment points: an origin (Point A) and an insertion (Point B). The muscle section that attaches to the bone is a tendon and has different properties or characteristics from the muscle tissue. Many muscles have multiple attachment points, which can further complicate things. The soft tissue lock created by the brace effectively alters tensional forces between the origin (Point A) and insertion (Point B). However, changing applied forces in one area creates a change in forces in other regions (Biotensegrity). Tennis elbow braces are placed on the outer forearm and near the muscle origin. Such placement reduces tension within tissues between the brace attachment point and the muscle origin, including the section of the tendon and the area of symptom pain. Elbow braces can still prove helpful in the short term and as part of a broader treatment approach. There is relatively little point in wearing a tennis elbow brace overnight, as the forearm extensor muscles should be at rest.
The first photo represents a muscle of the forearm, the extensor digitorum of the hand, though without all the hand attachment points, normally, there are four. Instead, this example has just one origin (Point A - near the elbow) and insertion (Point B - back of the hand) for ease of explanation. There is also a representation of a piece of connective tissue near the wrist (extensor retinaculum of the wrist ). The extensor retinaculum of the wrist is a form of connective tissue that helps direct forces during movement by keeping the tendons of the forearm in place. The tendons can glide underneath the retinaculum, as seen in the images. As per the photo, flexing the wrist stretches the elastic representing the muscle, pulling on the origin (Point A) and insertion (Point B) attachment points.
Left forearm extensor muscles and tennis elbow
The second photo shows the same muscle and the same flexed hand position, with the addition of a strap representing a tennis elbow brace (Point C). The positioning of the strap is purely for illustrative purposes. One can see reduced tension or slack between the brace and the muscle origin (Point A) near the elbow.
Forearm extensors and how tennis elbow braces work
Many inflammatory conditions are easily irritated, and tennis elbow braces aim to reduce further irritation to already injured tissues by changing the force applied to the injury site with relevance to Biotensegrity and Soft Tissue Adaptation. However, doing so increases tensional forces on the other side of the brace, between it and the muscle insertion point. Effectively, everything has trade-offs, and a tennis elbow brace may be useful in some circumstances, though it is not likely to resolve a problem. Typically, a brace will not address soft tissue adaptions caused at injury onset, during the healing process, or any resulting movement pattern changes. Equally, everything has consequences at some point, as tissues do not work in isolation, and movement creates more global demands on the body. Changes in one area can irritate others, though this may not become apparent until much later.
Injury Prevention and Coaches
Sadly, one often sees patients with previous unresolved injuries that have led to further injury or different and seemingly unrelated injuries. Typically, other such injuries manifest over time or with a change in activity or frequency thereof. Activities do not need to be sport-related and can involve work, hobbies, or anything involving how one uses one's body. Sometimes it is a case of making simple changes to one's workspace setup, taking breaks and taking other preventative measures (see the article on setting up an Ergonomic computer setup). Most computer work is repetitive, and a poor setup can easily lead to tennis elbow symptoms and other conditions such as Repetitive Strain Injury (RSI), Carpal Tunnel Syndrome and more. Equally, incorrect training techniques can easily result in excessive tissue demands and tennis elbow symptoms. The articles on injury prevention help explain some general injury avoidance strategies and many possible variables involved in training-related sports injuries (see the Basic Sports Injury Prevention Strategies article).
Prevention is always the best option, followed by treatment if and when needed. One must recognize the value of a good and reputable coach as part of an injury prevention strategy in sports. Advice relating to equipment and technique can play a considerable role in injury prevention. Many variables can contribute to injury, and a coach can advise on racket material, head size, grip diameter, string type and tension, playing surfaces, balls and more.
The article was written by Terry Davis MChiro, GradCertMentHlth, BSc. (Hons), Adv. Dip. Rem. Massag., Cert. WHS.
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