Getting to the Root of the Problem with Tennis Elbow

What is Tennis Elbow, AKA Lateral Epicondylitis or Lateral Epicondylalgia?

This condition is considered an overuse condition that results from a tendinopathy of the extensor muscles of the forearm into the common extensor tendon. The common extensor tendon originates at lateral epicondyle which is bony prominence that can be seen on the outside of the elbow.

The primary muscle affected by this condition is the extensor carpi radialis brevis, but less so in the supinator and extensor carpi radialis longus, extensor digitorum, extensor digiti minimi and extensor carpi ulnaris. These muscles help stabilize the wrist to help with gripping, and during movement, extend the wrist. The nerve supply for these muscles originate from radial and interosseous nerves with the associated spine nerve segments to the C6, C7 and C8 that start from the lower cervical spine. If the nerves are experiencing any impairment at this level, it can be a contributor to weakness, changes in sensation and coordination of the function of the elbow in persons with Lateral Epicondylitis.

Is This Condition Related to Inflammation of the Tendons?

It is considered a degenerative condition that is affecting middle aged men and women equally. Originally the syndrome was considered painful and weak because of inflammation but biopsies of the tendon have lacked cells that are found with inflammation and it is degenerative in nature, requiring a different approach as compared to an "itis" which is inflammatory and treated more with rest, ice and protection. At times, inflammation may develop during short periods of acute overuse but the main driver of pain and weakness is related to a degenerative condition that requires loading of the tendon via a specific strengthening regimen. Many tendon conditions can be caused or attributed to overuse, deconditioning, tensile, compressive or shear forces as discussed by Coombes in 2015. Our understanding of exercise programs for tendon disorders started to change with the work of Alfredson who studied Achilles’ tendon pain.

How Did We Discover How to Treat Tendon Problems Through Strengthening?

This is the story of a chance discovery of a novel approach to treating Achilles tendon pain. In the 1990’s, a Swedish surgeon, Dr. Håkan Alfredson, (also a runner) developed tendon pain that was attributed to a partial tear in his Achilles’ tendon. In a desire to return to running, he requested that he have surgery on his tendon prior to developing a full complete tear. Due to staffing issues at his clinic in Sweden, his boss refused to grant him time for the surgery.

Frustrated over this situation and desiring surgery. He entered the gym each day and, over the course of the next 4 weeks, he proceeded to aggressively exercise his Achilles tendon by repetitive heel raises - and painful ones at that - with the goal in mind to finally tear the remaining fibers and surgery would be inevitable. Crazy, but nonetheless, a plan.

As one of my mentors, internationally known researcher and sports physical therapist, George Davies, stated during a workshop I attended in Atlantic city, “I will treat any athlete but you can take the runners that are obsessed and they will never listen to you”. They always fight you on modifying or briefly stopping their running schedule and they will do almost anything to get back to running fast. Apparently Alfredson was no different in his desire to return to running pain free.

After four weeks a strange thing occurred … he started to feel better. The heel raises or calf raises that he was specifically doing got easier and he actually experienced less pain. So as the weeks progressed, he eventually made a full recovery without surgery.

Legend has it he then took all his patients scheduled for surgery for Achilles’s partial tendon tears and put them on a similar program. He gave very specific instructions not to return calls for the first 4 weeks because he knew the program would be painful and patients would call to ask for another course of treatment. Over time many, but not all, of his patients improved with this simple program. Since then, his random desire to break his Achilles led to the foundation research of many current tendinopathies at the patella, elbow and rotator cuff.

What Causes Tennis Elbow?

It is thought that this condition may be triggered by a series of injuries in younger individuals leading to microtears in the tendon over time and into middle age. Repetitive cycles of reinjury and rest actually causes a weakening of the tendon unit predisposing to progressively worse injuries depending on the demands of the individual. In response to chronic lateral epicondylitis, a general weakness results in the upper extremity, specifically the rotator cuff and scapula musculature. These strength deficits persist even after the patient no longer has subjective reports of pain. Most times this condition can resolve on its own but may take 12-18 months and is generally self-limiting. It has been shown that this condition can resolve faster than waiting for it to resolve with the passage of time.

What Other Types of Conditions Can Mimic Tennis Elbow?

The knee jerk reaction by many patients (and a few physical therapists) is any pain experienced in the outside of the elbow is tennis elbow and the inside is golfer’s elbow. However, several conditions can present with pain and weakness at the elbow and may not be a true tennis elbow, similar to a person that is experiencing symptoms of a heart attack in the jaw or upper arm.

Here is a list of a few additional possible causes of elbow pain and weakness:

How is a Diagnosis Made by a Physical Therapist?

A diagnosis is made by considering a history of the condition, pain location, wrist extensor or grip weakness and special testing that targets the tissues of the common extensor tendon. In severe cases, patients will have a loss of elbow extension. The special tests include the Cozen's test, Maudley's test, Thomsons Manoervre, Mills test and the Chair Test which is generally looking for pain provocation in the region of the patient's subjective complaints.

Mills Test- The patient is standing with elbow flexed.The examiner then turns the forearm or pronates it while flexing the wrist maximally. While maintaining this positioning, the patient slowly straightens or extends the elbow. Pain in the region of the outside of the elbow is a positive test.

Cozens Test- The tester positions the arm with the elbow flexed while holding the upper arm, then applies pressure with the patient making a fist flexing and turning the wrist in toward the patient. Pain in the region of the outside of the elbow is a positive test.

Chair Test- Stand on the side of a chair with an armrest. Place both hands gripping the chair with palms down with shoulders slightly narrower than shoulder width. Attempt to lift the chair with the upper extremities.

How Does a Person Perform a Self Test for Tennis Elbow?

We suggest using the following 3 criteria to make a judgement as to whether you may have tennis elbow. We always suggest seeking a professional medical opinion but these tests will give you an idea of what you may be suffering from. First, you must have pain in the outside of the elbow in the area of the lateral epicondyle and possible referral along the extensor muscles. Second, you should experience difficulty gripping or opening a jar or door. Last, you should have a positive Chair test which can be performed easily at home.

Do You Need an MRI or Xray to Make a Diagnosis?

Most times, imaging is not necessary except in cases of concerns about joint cartilage damage or osteoarthritis or joint instability. If there is suspicion of a partial or full tendon tear, an MRI which shows soft tissue damage to tendons, muscles, ligament or cartilage can be used to make sure these structures aren't affected. Often, the patient can experience severe pain during the clinical noted before like the Chair test even without a significant tear in common extensor tendon most times the extensor carpi radialis brevis.

Most people who experience tennis elbow are not tennis players and this condition can originate from weakness in upper extremity musculature and scapula stabilizers. Also, one must make sure they are not dealing with a shoulder or neck problem referring pain into the lateral elbow region. This can occur even without pain in either region. Over 40% of patients with isolated extremity pain, who believed that their pain was not originating from the spine, responded to spinal intervention and thus were classified as having a spinal source of symptoms. This was noted in a journal article titled “A Study Exploring the Prevalence of Extremity Pain of Spinal Source (EXPOSS)” in the journal Manual and Manipulative Therapy in 2020. Cases that are unresponsive to treatments for tennis elbow should consider a professional evaluation by a physical therapist to ensure you are truly dealing with a tendon pathology.

Our Recommendations for Treatment of Tennis Elbow

In the early stages, we need to address any possible activities that caused or continue to make this condition worse. Most times this condition is not found in tennis players but more with patients who perform repetitive activities like computer work, orthopedic surgeons, carpenters, gardeners and even artists. We will address computer workstation setups, recommend taping or bracing, taking inflammatories, postural exercises and icing techniques that allow the body to repair itself prior to starting active stretching and strengthening programs.

Once the early stage of protecting the elbow has passed and pain is more intermittent and typically only with activity, we then introduce light active range of motion exercises for the wrist and elbow to slowly move the region and start placing stress on the common extensor tendons and surrounding structures. As we said earlier, especially in cases that have been going on for more than three months or an exacerbation of an old condition they have found weakness generally in the upper extremity musculature.

In an effort to protect the elbow in the early stages, using a tennis elbow or counterforce brace can lessen the amount of tension placed through the common extensor tendon and provide protection and relief. We recommend this only in the early stages of healing and only during activities that are challenging for the individual. Extensive use of the brace for extended periods can cause compression of the radial nerve and lead to other problems. In the later stages of recovery, or introducing new movements or activities, donning the brace can act like an insurance policy against serious aggravations of the tenon unit. In addition, a polypropylene sleeve can be used to ensure physiological warming prior to and during activities.

We include active range of motion at both fingers, wrist and elbows for 1-2x/day for 1-2 weeks until we have full range of motion at both the elbow and wrist - as compared to the opposite upper extremity - and until reasonably pain free.

As the range of motion improves at the elbow and wrist, we start instituting strengthening exercises from isometric to isotonic for the wrist, elbow, and shoulder girdle. The patient can often perform exercises in the upper extremity, with modifications for the shoulder girdle and modifications from day one. Our patients who have access to gyms and normally perform free weight exercises can do certain machine exercises that won’t unduly load the elbow region. This is not optimal for Crossfitters or those who normally use free weights, but allows some form of exercises earlier to decrease the amount of atrophy and speed of return once the symptoms are more controlled and the elbow region is less sensitive to gripping.

We recommend strengthening 2-3x / week, but many cannot tolerate a third day of strengthening. When in doubt, I would leave out the third day and leave at least 2 days of rest between strengthening days. The active range of motion exercises performed in the early stages can normally be done daily as we enter the strengthening stage.

In the research there is not a clear consensus on strengthening if isometric or isotonic are more beneficial. We will start with isometric for 1-2 weeks and quickly move to isotonic strengthening that consists of concentric and, lastly, eccentric strengthening. Certain people can’t tolerate isometric exercises and can worsen the condition, so if it isn’t well tolerated by the patient we quickly move to isotonic and eliminate the isometric exercises altogether.

For me, the focus of these treatments for tennis elbow is active range of motion to progressive loading of the tendon complex. As we have discussed in previous blogs, the abolishment of pain is one stage but one must improve the tolerance via strengthening to minimize the risk of this condition returning. Depending on the type of activities you enjoy, doing loss of motion or strength can have more or less of an influence on recovery and prevention. For our patients performing a power clean and press we need more range of motion at the shoulder to offset the excessive impact on the elbow. If we are talking about our middle age computer programmer he will not have to address these range of motion deficits. With more complex activities like tennis, rock climbing or being a power line worker with the demands of speed, working at end range activities, high frequency, and long duration and lastly, high loads all require a personalized program and really should be managed by a qualified physical therapist.

In addition to our primary approach of strengthening for tennis elbow, many programs also include a variety of stretching techniques for the upper extremity, especially those focused on the common extensor tendon. Also, stretching for the finger and wrist extensors, wrist flexors, supinators, pronators, elbow flexors, elbow extensors and shoulder movements in all planes, especially shoulder external rotation.

We hope this helps you get back to exercising and enjoying life with limited elbow pain. If you want more information and quicker solutions, we work with many patients with this condition every day. We’d be happy to chat with you to see if we can assist you.