What do Serena Williams, Roger Federer, and a desk jockey all have in common? Increased risk of tennis elbow.
Fun fact: Tennis players actually make up less than 5% of all tennis elbow cases.
Nagging pain on the outside of the elbow can affect anyone, but especially those performing repetitive movements with their upper extremities. Let’s look a little closer at what tennis elbow (technically referred to as lateral epicondylalgia or epicondylitis) is, why it happens and what you can do about it.
The muscle most commonly involved in lateral epicondylalgia is the extensor carpi radialis brevis. This muscle plays a large role in extending and stabilizing the wrist. The extensor
All of these little muscles share a common tendinous insertion site referred to as the common extensor tendon. This tendon attaches these muscles into the bony protuberance on the side of your elbow called the lateral epicondyle.
At a microscopic level, overuse of these muscles can lead to micro-tearing and degeneration in the common extensor tendon.1 In an attempt to repair itself, the body lays down disorganized collagen fibers. These new collagen fibers are structurally different than the fibers that primarily make up tendon structure. Tendon fibers typically run in a
In other words, the human body does an amazing job at fixing itself, but it’s not always the perfectionist we would like it to be.
What about inflammation? Research has actually found that inflammation is typically not seen in episodes of tennis elbow, hence the movement to adopt the name lateral epicondylalgia (algia= pain) instead of epicondylitis (itis= inflammation).
Overuse: Overuse is by far the most common cause of lateral epicondylalgia. People who spend a large portion of their day performing repetitive activities (i.e. typing, heavy lifting, gardening, throwing) have an increased risk of developing tennis elbow. Starting a new activity that requires increased effort through the upper extremity can also lead to overuse.
Trauma: Though it is far less common, trauma is a possible cause of lateral epicondylalgia. A direct blow to the elbow could cause enough damage to the tendon to produce similar symptoms.
Symptoms of lateral epicondylalgia can vary from case to case and generally last anywhere from 2 weeks to 2 years. Some of the most common symptoms are:
- Tenderness along the outside of the elbow (can radiate into forearm)
- Pain with lifting and/ or gripping
- Weakened grip strength
- Decreased wrist extension strength
- Difficulty carrying with a straight elbow
Tests Your PT May Do
There’s a variety of special tests your physical therapist can use to diagnose a tennis elbow case. I’ve listed the most common ones below to help you prepare! An increase in your familiar pain is considered a positive test.
Cozen’s: Start with your elbow extended and palm facing down. Your PT will have you make a fist while extending your wrist back and slightly inward. Hold this position against his/ her downward push.
Chair Test: As the name entails, a chair will be needed for this test. Your therapist will have you stand behind the chair, holding on with a three-finger grip (thumb, index and middle finger). Using this grip, you’ll lift the chair off of the ground (or at least attempt).
Mill’s: During this passive test your PT will extend your elbow, face your palm down and flex your wrist to place your extensors on a stretch.
Maudsley’s: Your PT will have you straighten your elbow with your palm facing down. While in this position, he/ she will have you extend your 3rd finger, resisting their downward push.
Check Your Neck and Shoulder: “But, it’s my elbow…”. Yes, but dysfunction at the neck or shoulder can actually be an underlying causing elbow pain. Cervical radiculopathy and decreased shoulder external rotation can sometimes be the culprits, so we’ll want to rule this out.
The goal of treatment is to initially calm down irritated structures, then build them back up. Your physical therapist will be able to tailor a treatment protocol for you based on your presentation. There are a variety of treatment techniques your physical therapist can use with you. I’ve listed some below to get you started:
Soft Tissue Mobilization
Gentle soft tissue mobilization can be used in the initial stages of tennis elbow to decrease pain levels. Deep friction massage or instrument-assisted soft tissue mobilization (though less comfortable) can stimulate collagen production and fiber reorientation. The goal is to break up soft tissue restrictions to encourage normalized fiber orientation. Some redness following soft tissue mobilization is normal, but heavy bruising and/ or lingering pain is not optimal.
We’ve gotta keep things mobile! Stretching will help to prevent shortening, maintain range of motion, and reduce tension placed on the tendon.
Strengthening the muscles surrounding the elbow is essential. Isometrics are a good place to start, eventually working up to bodyweight and weighted exercises. Your therapist will likely also address shoulder strengthening as part of your routine to ensure you have a solid foundation in place.
Eccentric loading remains the gold standard for treating tendinopathies. This involves performing a slow, lengthening contraction while the muscle is loaded. My go-to exercises to get this type of contraction are the Tyler Twist and eccentric wrist extensions. This eccentric contraction helps to realign the disoriented collagen fibers while increasing collagen production to decrease pain/ disfunction.
Altering your work station to minimize overuse is necessary to address the root cause of tennis elbow. No point in treating the symptoms if we ignore the reason you got here! One quick (and free) modification you can make is to your keyboard height. You will want to make sure it is at the same height as your elbow to avoid excessive wrist extension. Your wrists should be straight while typing.
Staying as active as possible is an extremely important part of your recovery! Remember, your elbow might not be 100%, but you’ve got 3 other extremities to work with. Try to stick to your regular routine as much as possible, and try some of these hacks to help fill in the gaps.
A little aggravation of pain is okay (remember, we need to load and strengthen impaired structures). A 3-4/10 on the pain scale is generally okay but anything beyond this might not be beneficial. Always consult with your
Use a Counterforce Brace
This has been shown to decrease the pressure placed on the common extensor tendon during exercise and may give you just the extra boost you need.
Switch Up Your Grip
Try switching to a supinated or neutral grip during different exercises to see if one causes less aggravation. Pronated gripping will typically be the most painful.
Swap Out the Free Weights
Free weights often require a lot more gripping power and stabilization which can stress your injury more. Through personal experience, I have found substituting in machine weight and even resistance band exercises to provide just enough stability to get the job done without the excess strain of stabilization.
Check out my earlier post on Training Through an Injury: How and Why for more modification ideas.
Tennis elbow is not fun, but there are a lot of things you can do to help it along. These exercises are a great place to start! In order to prevent reinjury, it will be important to address underlying cause whether that be weakness or improper workplace set up.
Looking for a physical therapist to guide you through your recovery? In the Portland, OR area? Come work with me!
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