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Tennis Elbow

 

What is it?

Tennis Elbow, also known as Lateral Epicondylalgia is relatively common, with a general population prevalence of 1-3%. As a Tendinopathy, it's pathophysiology is quite complex. Rather than it being a true inflammatory issue as previously suggested, research shows a degenerative/dysfunctional component resulting from immature healing, often in response to overload (Rees et al, 2013). There is also a high recurrence rate associated with tennis elbow.

With tennis elbow the tendon that is affected connects the muscles at the back of the forearm and wrist to the elbow. Tennis elbow can result from both overuse and underuse of the muscles and tendons that extend the wrist and hand and supinate the forearm, leading to degeneration and tissue pathology. As the name suggests, there is an increased risk in tennis players and those working in industries requiring manual tasks with a combination of force, repetition and poor posture. Cervical spine pathology/pain has also been associated tennis elbow, particularly in the most complex and chronic cases. (Smidt et al, 2006) 

Coombes et al, 2009 breaks it down into 3 processes:

  • Local tendon pathology – a process known as angiofibroblastic hyperplasia has been found in the tendons of tennis elbow sufferers. His involves increased cell numbers and ground substance, vascular hyperplasia, increased neurochemicals and the presence of disorganised and immature collagen. In other words - a situation where there are lots of inflammatory and highly sensitising chemicals in and around the tendon. 
  • Changes in the pain system – research has shown evidence of neurogenic inflammation at the level of tendon pathology with the presence of chemicals such as substance P and calcitonin gene-related peptide (CGRP). This causes hyperalgesia and reduced pressure-pain threshold in individuals with present with tennis elbow and ultimately a picture of central sensitisation. 
  • Motor system impairments – Strength deficits have been demonstrated in this population, including a reduction in pain-free grip and wrist flexor and extensor strength deficits. On closer examination of the extensor carpi radialis brevis muscle, moth eaten fibres, fibre necrosis and an increase in fast twitch fibres have been found.

Signs and Symptoms:

  • Pain over the lateral aspect of the elbow joint and radial head
  • Pain with gripping and manipulation activities of the hand
  • Reduced pain free grip (>50%)
  • Cervical spine pain
  • Radial nerve sensitivity

 

Diagnosis:

Tennis elbow is most commonly diagnosed clinically based on history and the presence of the above signs and symptoms. Ultrasound scanning may be used to confirm diagnosis or extent of changes in the tissue.

 

Management:

  • Load modification -Initially it may be important to reduce load on the lateral epicondyle if it is found that symptoms are related to overuse. 
  • Injection therapy – mixed evidence has been found to support the use of corticosteroid injections in the management of Tennis elbow. Reports of short term relief and high recurrence rates suggest that it should not be the first intervention of choice. (Bisset et al, 2006).
  • Electrophysical agents such as low level laser therapy, shockwave therapy and ultrasound are less commonly used and again research is limited to support their use.
  • Physiotherapy including manual therapy and soft tissue techniques to the elbow can provide pain relief by affecting non-opioid descending pain inhibitory systems. In many cases treatment of the cervical spine and neural system is essential in the overall management. (Vicenzino 2003)
  • Rehabilitation – as already mentioned, motor system changes are a feature of this condition. It is important to improve the condition of the affected muscles using a combination of isometric and isotonic, concentric and eccentric exercises. Exercise also has the capacity to provide an analgesic effect. (Vicenzino 2003)

 

References:

Bisset L., Beller E., Jull G., Brooks P., Darnell R., Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection or wait and see for tennis elbow: randomised trial. 2006. British Medical Journal.

Coombes B.K., Bisset L., Vicenzino B. A new integrative model of lateral epicondylalgia. 2009. British Journal of Sports Medicine. 43. 252-258.

Rees J.D., Stride M., Scott A. Tendons – time to revisit inflammation. 2013. British Journal of Sports Medicine. 0. 1-7.

Shiri R., Viikari-Juntura E., Varonen H., Heliovaara M. Prevalence and Determinants of Lateral and Medial Epicondylitis: A Population Study. 2006. American Journal of Epidemiology. 164. 11.

Smidt N., Lewis M., Van Der Windt D., Hay E.M., Bouter L.M., Croft P. Lateral epicondylitis in general practice: course and prognostic indicators of outcome. 2006. The Journal of Rheumatology. 33.10.

Vicenzino B. Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. 2003. Manual Therapy. 8 (2). 66-79.