Sports physiotherapy management for tennis elbow and other treatment options.

Ultrasound therapy in tennis elbow treatment
(Ref: https://nesintherapy.com/)

Tennis elbow is degeneration of the tendons that attach to the lateral epicondyle. The extrinsic and intrinsic factors are responsible for developing tennis elbow. There was found an association between repetitive movements of the arms and forceful activities for developing tennis elbow. The poor muscular strength of shoulder, elbow and wrist extensor are responsible for cause- effect relationship for developing tennis elbow by microtrauma in involved tissues.

The aim of rehabilitation is to enable the athlete to return to sports with full function in the shortest possible time. A variety of treatment options have been recommended for tennis elbow. Unfortunately, there are still no universally accepted therapeutic modalities. However, the treatment of tennis usually has 5 therapeutic goals: controlling elbow pain, preserving movement of the affected limb, improving grip strength and endurance, restoring normal function of the affected limb, and preventing further deterioration. Nonoperative treatment remains the priority and mainstay for most patients with tennis elbow. Surgical intervention is available for recalcitrant cases.

(Ref: https://www.ultrasound-guided-injections.co.uk/)

Athletes will return to work within 6 weeks after rehabilitation. Tennis elbow takes from 6 months to 12 months to heal. If a tennis player covers the full rehabilitation phase, then they can return to play as early as possible. The patient can return to play at one and two months follow up by maintaining the aggravating factors.

Physiotherapy traditional treatment options include electrotherapeutic and non -  electrotherapeutic modalities. One of the most common physiotherapy treatments for tennis elbow is the exercise program which is one of non - electrotherapeutic modalities. Aiming for improving function and reducing pain by stretching and strengthening the affected wrist extensors. 

Physiotherapy manual therapy in tennis elbow rehabilitation session
(Ref: https://www.mendcolorado.com/physical-therapy-blog/)

Therapeutic exercise in tennis elbow rehabilitation program 

1. Stretching exercise: Stretching exercise was advised for 30 seconds repeated 5 times, once or twice daily. Caution should be gentle if the pain on palpation is insertional (i.e. potentially related to enthesopathy) where compressive loads (stretching) can be catabolic in nature resulting in a negative response to other interventions.

Exercise #1: stretching wrist flexor group: Start with palm up and bend wrist to backhand side.

Exercise #2: stretching wrist extensor group: Start with palm down and bend wrist to palm side.

Exercise #3: Stretching ECRB: The best stretching position result for the ECRB tendon is achieved with the elbow in extension, Lateral elbow tendinopathy forearm in pronation, and wrist in flexion and with ulnar deviation (little finger).

Exercise #4: Thumb stretch (De quervain stretch)

(2) Strengthening: There are essentially three forms of musculotendinous contractions that strengthen soft tissue structures such as tendons: (i) isometric, (ii) concentric, and (iii) eccentric. Most therapists agree that eccentric contractions appear to have the most beneficial effects for the treatment of tennis elbow. Strength exercise needs 8 - 15 reps/set for 3 sets with no - resisted or mild resistance as tolerated.  

Exercise #5: Clenching fist strongly: Squeeze hand 5 seconds and release.

Exercise #6: Isometric resisted wrist extension: Static resistance from good hand to injuried hand on backhand side for 5 seconds.

Exercise #7: Isometric resisted wrist flexion: Static resistance from good hand to injuried hand on palm side for 5 seconds.

Exercise #8: Wrist rotation with a stick.

Exercise #9: Resisted exercises all direction (backhand side - palm side - thumb side - little finger side) against small free weight slowly. 

Exercise #10: Resisted exercises all direction (backhand side - palm side - thumb side - little finger side) against easy resisted rubber band slowly. 

Exercise #11: Isometric resisted fingers extension: Static resistance from good hand to each finger of injuried hand on backhand side for 5 seconds.

Exercise #12: Isometric resisted fingers flexion: Static resistance from good hand to each finger of injuried hand on palm side for 5 seconds.

Exercise #13: Twisting a towel into the roll in horizontal and vertical plane. (Flexbar resistance bar can be used as well).

Felxbar resistance bar 

Exercise #14: Fingers extension exercise with fingers resistance band or rubber band slowly. (You can apply rubber band).

Rubber band

Exercise #15: Maximum hand squeeze with resisted equipment.

Other physiotherapy electrotherapeutic and non electrotherapeutic modalities, including

(1) Ice: Applying ice at local pain has been a traditional household remedy for aches and pains.

(2) Extracorporeal Shock Wave Treatment (ECSWT):  is one of the commonly used physical therapy modalities for treating tennis elbow, in spite of conflicting results in the available literature. The mechanism of ESWT has not been completely clarified, possibly including direct stimulation of healing, neovascularization, direct suppressive effects on nociceptors, and a hyperstimulation mechanism blocking the gate control.

ESWT as treatment option
(Ref: https://gymna.com/)

(3) Lasers: It has reported good results using lasers as a treatment for tennis elbow.

(4) Ultrasound: Pulsed and continuous ultrasound is used. Although the overall efficacy of this treatment for musculoskeletal disorders is in debate, this is my most common modality.

(5) Manual therapy and massage: For example, Mulligan’s technique, deep friction massage, myofascial fascial release. The purposes are reducing local pain, promoting tissue healing by increasing blood flow, promoting relaxation, and increasing tissue extensibility. The treating therapist is given the option of performing a variety of soft tissue techniques.

Laser therapy as rehabilitation option
(Ref: https://www.asalaser.com/en/company/blog/)

(6) Bracing and protective equipment: Many therapists use taping as an adjunct to exercise, in order to relieve pain and allow function restoration of movement patterns. Bracing is a commonly used form of intervention to immobilize and assist with pain control. Braces are used throughout the acute and chronic phases of the disease, and their mechanism of function is thought to result from counterforce control. There are many brace models, for example, Counterforce bracing or elbow strap which has been popular in the tennis elbow treatment. Using counterforce braces can significantly alleviate pain by pressing on the forearm extensor muscles and then inhibiting and dispersing the stress on the origin of affected ECRB, thereby facilitating its self-repair. Wrist extension splints, which is the functional position of the hand, is one of slight extension and pronation, and since active muscle tone. Simple cock-up splint which has the purpose to put the wrist extensor mechanism at rest. 

Counter brace or Elbow strap
(Ref: https://tenniscompanion.org/)

(7) Activity Modification: Modification of activity and avoidance of overwork are essential components for any treatment protocol. Turning the palm up while lifting and avoiding palm - down exercises can transfer the force away from the lateral epicondyle to the medial epicondyle and help alleviate lateral elbow pain.

        (8) Controlling Force loads: Controlling force loads will be vital both in the early and late treatment of lateral epicondylitis and is an important factor when considering preventative measures. Tennis patients with lateral epicondylitis should be encouraged to use a racquet with a mid- to large-size head, a lighter weight, and a reduced string tension by 3-5 Ibs. The hand grip should also be the right size. A handle with too small of a diameter will require increased grasp effort, thus presumably increasing the stress upon the wrist extensor muscle attachment. The injured player should also play with new tennis balls, since old tennis balls require more stroke force to achieve the same velocity. Clay courts, if available, are also helpful because horizontal ball velocity is decreased. The injured player should also undergo a thorough assessment of his/her playing technique. Stroke patterns that need to be examined include the player's use of weight transfer during all tennis strokes and the backhand stroke, in particular. Two handed backhand instead of a single handed backhand; turn the shoulder and trunk into the swing; and when the racket contacts the ball, the wrist should be slightly extended and deviated upward instead of flexed and deviated. In the occupational setting, an ergonomic analysis of task requirements is usually beneficial in determining which jobs may be likely to cause increased stress of the wrist extensor mechanism. Once identified, these jobs may then be altered to reduce the stress loads which may, in turn, decrease the incidence of job-related lateral epicondylitis. Assessment of playing technique and ergonomic analysis are important not only for treatment of injured clients but for preventing repetitive overuse injuries as well. downward.

One - backhand (left) is more risk in tennis elbow than two - backhand (right)
(Ref: https://tennishead.net/) 

(9) Prevention of lateral epicondylitis: Warm up exercise is a crucial part before and after participating in any sport that can reduce the further injuries and is helpful for lasting the performance.

Traditional Chinese Medicine and Western acupuncture medicine have been used for tennis elbow management as optional. However, current data from evidence-based medicine indicate conflicting results. Two systematic reviews have not concluded whether acupuncture was effective for tennis elbow, whereas three systematic reviews suggest that acupuncture is very effective in the short term, with the long-term results remaining unclear.

Acupuncture for tennis elbow
(Ref: https://glenabbeychiro.com/blog/)

Pharmacotherapy: 

(1) Autologous Blood Injection (ABI):  Autologous blood injections are thought to work by stimulating an inflammatory response which will bring in the necessary nutrients to promote healing. Current evidence suggests that ABI can achieve good outcomes in the short term; however, no benefit has been found in the medium- or long - term follow - up. In addition, it should be noted that ABI has high risks of injection site pain and skin reaction.

(2) Platelet Rich Plasma injections (PRP): The blood plasma with concentrated platelets found in PRP contain growth factors that are vital to initiate and accelerate tissue repair and regeneration. These bioactive proteins initiate connective tissue healing and repair, promote development of new blood vessels, and stimulate the healing process. The technique requires patient-blood extraction, centrifugation and re-injection of the plasma into the lateral epicondyle. Good outcomes have been reported.

PRP for tennis elbow 
(Ref: https://oneorth.co.uk/)

(3) Botox Botulinum toxin may induce a period of temporary paralysis that gives time for the soft tissue pathology to recover. 

(4)  NSAIDS: It is traditional to offer oral NSAIDS for tennis elbow as Anti-Inflammatory Medications. Notably, repeated injections of the corticosteroid may result in iatrogenic tendon rupture and muscle atrophy. Therefore, clinicians should be alert to the abuse of corticosteroids in the treatment of LE on account of poor long-term efficacy and potential adverse effects.

Oral Non - Steroidal Anti - Inflammatory Drugs
(Ref: https://www.verywellhealth.com/)

(5) Local steroid injections: The injection of corticosteroid preparation with local anesthetic is the mainstay of treatment for this condition. The physician feels for the point of maximum tenderness and then injects the cocktail using aseptic technique. However as with the treatment of many musculoskeletal complaints, the correlation between initial response and longer term follow up was poor.

            Surgery treatment
            Majority of patients with tennis elbow respond to conservative treatment and do not require surgical intervention. However, Surgical intervention can be an option if symptoms were unresponsive after a prolonged period of conservative therapy. Various reports indicate that approximately 10% of patients with lateral epicondylitis will be unresponsive to conservative methods. Numerous surgical procedures have been described for the treatment of tennis elbow. Most involve debridement of the diseased tissue of the ECRB with decortication of the lateral epicondyle. 

Reference:

https://www.ijhsr.org/IJHSR_Vol.7_Issue.4_April2017/38.pdf

https://www.researchgate.net/publication/286800895_The_effect_of_stretching_exercise_in_the_management_of_lateral_epicondylitis

https://www.jospt.org/doi/pdf/10.2519/jospt.2015.5841

https://core.ac.uk/download/pdf/289200979.pdf

https://www.oatext.com/pdf/PRR-2-119.pdf

https://bjsm.bmj.com/content/39/12/944

https://he02.tci-thaijo.org/index.php/simedbull/article/view/127705/96253 

https://www.researchgate.net/publication/335098297_Tennis_elbow_A_clinical_review_article

https://www.jospt.org/doi/pdf/10.2519/jospt.1994.19.6.357

https://www.researchgate.net/publication/230621315_Lateral_epicondylitis_A_review_of_the_literature

https://onlinelibrary.wiley.com/doi/full/10.1111/j.1758-5740.2009.00023.x

https://www.hindawi.com/journals/prm/2020/6965381/

Tennis elbow: Basic overview

 

Ref: https://uniquephysio.com.au/

Thanyapura resort is one of the most popular places for tennis players in Phuket. There are 6 tennis courts and Thanyapura unique team coaches that entice many tennis players to visit us. It is possible to see some players with tennis elbow want to see a physiotherapist which is one of Thanyapura medical services to treat and maintain their tennis package.

So, tennis elbow is one of the most common injuries which come and see me to treat. Some of them have got chronic pain, and some of them have acute pain. Patients complain of an area of pain and tenderness over the bony prominence of the lateral elbow which is epicondyle. 

Lateral epicondyle of elbow is on thumb side
(Ref: https://strivept.ca/tennis-elbow/)

Tennis elbow is an overuse injury that is common in racket sports. It was first described by Runge1 in 1873 and eventually given the label ‘Lawn Tennis Arm’ by Henry Morris, writing in the Lancet in 1882. 

Tennis elbow is a misnomer as it is predominantly seen in non - tennis players ;however, elbow pain is encountered in up to 50%of tennis players, with 75–80% of these cases being attributable to tennis elbow. Some patients answered my subjective exam that they did not get this pain during playing tennis, for example, hand the luggage during traveling, gardening, cooking, wring the clothes.

  

Squash backhand swing performs wrist extension
(Ref: https://squashmad.com/)

The background has not been well identified. However, it is commonly associated with repetitive microtrauma from excessive gripping or wrist extension, radial deviation, and/or forearm supination. Repetitive microtrauma resulting from overload or overuse can cause collagen fibril rupture and the activation of the innate immune system. 

There is a wide spectrum of severity ranging from slight tenderness to severe, continuous pain. Pain is characteristically exacerbated by resisted extension of the middle finger and also by extension of the wrist, associated with resisted wrist and finger extension and gripping activities. 

Too tight griping and wrist thumb side bending as radial deviation is one of the mechanism of tennis elbow
(Ref: https://msspc.org/)

Anatomy of tennis elbow pain

Patients complain of an area of pain and tenderness over the bony prominence of the lateral aspect of the elbow. This structure is also the common origin of the long extensor tendons for the forearm and hand and the underlying pathology appears to be an area of degenerative change within these tendons. 

The extensor carpi radialis longus

The extensor carpi radialis longus originates from the supracondylar ridge below the origin of the brachioradialis. This attachment is between the brachialis medially and the extensor carpi radialis brevis inferolaterally. The extensor carpi radialis longus crosses the elbow and carpal joint to insert onto the dorsal base of the second metacarpal and is covered by the brachioradialis over most of the forearm. Its function is that of wrist extension, radial deviation, and possibly elbows flexion. 

Extensor Carpi Radialis Longus (ECRL)
Ref: https://www.kenhub.com/en/)

    The extensor digitorum communis

The extensor digitorum communis originates from the anterior distal aspect of the lateral epicondyle and accounts for most of the contour of the extensor surface. Parts of the extensor digitorum communis are also attached to the septum and tendon from which the extensor carpi radialis brevis arises. The extensor digitorum communis insertion contributes to the extensor mechanism for the index, long, ring, and little fingers. In addition to the extension of the wrist and the digits. Wright et al., suggests that the extensor digitorum communis may assist with elbow flexion when the arm is in pronation. 

Extensor Digitorum Communis
(Ref: https://www.orthobullets.com/anatomy/)

The extensor carpi radialis brevis (ECRB)

“The extensor carpi radialis brevis (ECRB) is the most frequently affected muscle.”

 

Extensor Carpi Radialis Brevis (ECRB) Ref: https://quizlet.com/

 

             The extensor carpi radialis brevis is covered by the extensor carpi radialis longus and its fibers are almost indistinguishable from those of the extensor carpi radialis longus and extensor digitorum communis in most cases. The extensor carpi radialis brevis muscle also has additional attachment to the radial collateral ligament and the intermuscular septa between it and common extensor muscle. The extensor carpi radialis brevis tendon inserts to the dorsal surface of the base of the metacarpal bone. The unique origin of ECRB in the lateral aspect of the capitellum places the tendon at risk for repeated undersurface abrasion during elbow extension and flexion that are the factor of excessive mechanical forces. 

The main function of the ECRB is pure wrist extension with some assisted radial deviation. 

Therefore, the pronator and other extensor carpal muscles are also commonly affected.

Mechanism of injury

Tennis elbow may be believed to be the cause from activities such as tennis, badminton or squash but is also common after periods of excessive wrist use which is often caused by overuse or repetitive strain caused by repeated extension (bending back) of the wrist against resistance.

The exact origin has not been well identified. However, it is commonly associated with repetitive microtrauma from excessive gripping or wrist extension, radial deviation, and/or forearm supination that are the function of 3 muscles as above. By the way, the extensor carpi radialis brevis (ECRB) is the most frequently affected muscle that the factor of excessive mechanical forces, the unique origin of ECRB in the lateral aspect of the capitellum places the tendon at risk for repeated undersurface abrasion during elbow extension and flexion. 

Wrist function 
(Ref: https://www.revolutionarytennis.com/)

Although, tennis elbow was originally considered as an inflammatory process, especially in its initial phases. Repetitive microtrauma resulting from overload or overuse can cause collagen fibril rupture and the activation of the innate immune system. However, histopathological studies have shown that there is absence of inflammatory cells in biopsies of chronic epicondylitis.

When it becomes tendinosis, a symptomatic degenerative process characterized by an abundance of fibroblasts, vascular hyperplasia, and unstructured collagen. These findings were termed as angiofibroblastic hyperplasia. The mechanical properties of tendons are commonly determined by the structure of protein molecules and the composition of the extracellular matrix.

Poor forehand alignment ball impact can develop tennis elbow as well
(Ref: https://www.patcash.co.uk/)

The main cause of tennis elbow is degeneration, additional pathophysiological mechanisms also contribute to the development of tendinosis. Patients with painful symptoms often involuntarily lead to “underuse” or stress shielding of affected tendons, which subsequently results in structural weakening of the tendon, making it more sensitive to injury. Meanwhile, increasing shear forces promotes fibrocartilaginous formation at tendon enthesis, which contributes to weakening at the tendon-bone junction and initiating development of tendinosis. 

In situations of repetitive stretching, multiple microtears of the tendon potentially cause an irreversible denaturation of matrix proteins and proliferation of fibrous tissue. Over time, these scar tissues are vulnerable to repetitive forces, with subsequent further tears. High - frequency cyclical trauma and immature repair result in more severe tears, with consequent alteration and failure of musculotendinous biomechanics and worsening of symptoms. Emerging evidence indicates a significant link between the strain degree of tendons and the extent of injuries.

Ref: https://www.kachathailand.com/

Injury rate is equally common among men and women, occurs more frequently among whites and in the dominant arm, and increases with age, peaking between the ages of 30 and 50, with a mean age 42. It seems to occur equally among blue-collar and white-collar workers and among socioeconomic classes. The natural course of the condition seems to be favorable, with spontaneous recovery within 1–2 years in 80–90% of the patients.

“Not only racket sports activities gripping develop tennis elbow including; (1) A poor backhand technique in tennis. (2) A racket grip that is too small. (3) Strings that are too tight. (4) Playing with wet, heavy balls, but also common after periods of excessive wrist use in day-to-day life and it may be caused through repetitive activities such as using a screwdriver, painting or typing.”

 

Very tight hammer working as very tight grip

Clinical  presentation & Diagnosis

Pain around the lateral epicondyle is known by a variety of names, and was described as periostitis, extensor carpi radialis brevis (ECRB) tendinosis and epicondylagia. The most commonly used names are “tennis elbow” and “lateral epicondylitis”. The use of the terms ``periostitis” and “epicondylitis” was questioned over time, as histological studies failed to show inflammatory cells (macrophages, lymphocytes and neutrophils) in the affected tissues. 

The onset of pain is usually gradual. The tenderness is most notable at the anterior aspect of the lateral epicondyle and the lateral forearm that above the epicondyle will indicate that the extensor carpi radialis longus is involved, while anterolateral tenderness would arise from extensor carpi radialis brevis tissue inflammation. Palpation of the radial collateral ligament may elicit exquisite tenderness and is usually increased with varus (adduction) stress to the elbow.

Tenderness point of tennis elbow
(Ref: https://www.sportsinjuryclinic.net/)

Swelling or ecchymosis is rare, except in cases of external trauma. The arm is painless at rest and during passive range of motion. In most cases, the lesion will involve the junctional tissue at the common extensor muscle origin of the lateral epicondyle, specifically, the extensor carpi radialis brevis. If the extensor carpi radialis brevis is involved, extension of the wrist will be more painful if resistance is given at the heads of the metacarpals rather than at the fingertips. Radial extension will more specifically indicate the extensor carpi radialis brevis or extensor carpi radialis longus. Pain with resisted extension of the middle finger is present when the extensor carpi radialis brevis is involved. Grip strength may be decreased by pain. 

Swelling in tennis elbow
(Ref: https://www.scripps.org/)

Diagnosis of tennis elbow may be confounded by regional nerve involvement, referred to as radial tunnel syndrome. The deep branch of the radial nerve may be compressed (by pronation and flexion of the wrist) as it passes dorsal to the arcade of Frohse along the fibrous edge of the supinator muscle. Differential signs include increased pain with deep palpation of the radial head and isometrically resisted supination of the forearm, suggesting radial tunnel syndrome, as opposed to tenderness to palpation of the lateral epicondyle and isometrically resisted extension of the wrist, signifying true tennis elbow. The Posterior Interosseous Nerve (PIN) is believed to be crushed under the free edge of the supinator muscle. PIN decompression has been shown to be effective in relieving pain in this region.

Radial tunnel syndrome
(Ref: https://journals.sagepub.com/doi/abs/10.1177/1753193420953990?journalCode=jhsc)

In most cases, the lesion will involve the junctional tissue at the common extensor muscles origin of the lateral epicondyle, specifically the extensor carpi radialis brevis. Most authors agree that involvement of the extensor digitorum communis and extensor carpi ulnaris is rare.

Treatment includes conservative and surgery that conservative is basically the first option. Basic self care such as rest and ice are recommended by me. All treatment, especially physiotherapy will be discussed next time.   

Reference: 

https://www.researchgate.net/publication/335098297_Tennis_elbow_A_clinical_review_article

https://www.jospt.org/doi/pdf/10.2519/jospt.1994.19.6.357

https://www.researchgate.net/publication/230621315_Lateral_epicondylitis_A_review_of_the_literature

https://onlinelibrary.wiley.com/doi/full/10.1111/j.1758-5740.2009.00023.x

https://journal.racketsportscience.org/index.php/ijrss/article/view/65

https://www.hindawi.com/journals/prm/2020/6965381/

https://www.researchgate.net/publication/322102357_Relation_of_Grip_Style_to_the_Onset_of_Elbow_Pain_in_Tennis_Players