Management of Elbow Pain (tennis elbow):

One Size Does Not Fit All

Tennis elbow pain is commonly associated with lateral epicondylitis. However, did you know that it can be also due to a myriad of other reasons?

Here are few of the other reasons:

  1. Entrapment of nerves around the elbow
  2. Diseases of the elbow joint and other related joints
  3. Exercise-induced pain
  4. Tight and inflamed soft tissue structures
  5. Impingement of joint covering (Plica syndrome)
  6. Chronic increase in the compartmental pressure of muscles such as anconeus muscle
  7. Neck and upper back problems (C2-T7 vertebrae)
  8. Abnormal myofascial mobility issues and presence of trigger points
  9. Tendinitis/Tendon tear/Degeneration (epicondylitis)
  10. Central sensitization processes – Pain regulated due to changes in perception of pain in the brain

 

Do I need to see a Physical therapist now?

All tennis elbow/golfer’s elbow pains are not risky. However, some of them are and you will need immediate intervention. Find out your risk level by filling out this form. (Or here)  If your score is >33 you need physical therapy management ASAP. If you happen to fill out the form please bring it with you when you come for the appointment.

 

Your risk is even higher if you had shoulder or neck problems in the past or if your job or recreation activity requires high repetition and vibration on the affected hand. If that’s you get to a clinician as soon as possible to prevent further damage.

How Do I manage my pain?

If your tennis elbow pain just started after an exercise regimen or a game, start with ice for 20 min, 4-6 times a day for the next 3- 4 days. In addition, use of an orthotic wrist splint, counterforce elbow strap, or taping can help.

Many who had a recent injury can get relief through taping. There are several types of taping such as  diamond taping (shown in the picture), McConnell taping, Kinesiotaping, Rock taping, and Glide taping employed at our office

 

 

 

My tennis elbow/golfers elbow  pain comes only with certain activities. What do I do?

Many of our patients experience pain in the elbow (Tennis elbow and Golfer’s elbow ) only with certain activities. Heat and cold only give them temporary relief. Many will wear a Tennis Elbow Strap to relieve and to reduce the impact while some will discontinue the activity that causes pain altogether. The answer may not be any of the above, as explained below.

 

Abnormal force transmission causing elbow pain

The reason for your pain and most ( tennis/ golfer’s ) elbow pain is abnormal transmission of force through the elbow. When performing activities involving transmission of impact forces, such as playing tennis, working with free weights or using a screwdriver we are designed to use a group of muscles and joints from hand to the legs.  Most of the counter force to such activities are to be generated from larger shoulder girdle muscles and core (trunk) muscles rather than the smaller elbow muscles. In the absence of a well coordinated link system in the upper body and trunk, the elbow muscles are forced to generate such high forces leading to pain and injury. The result is the breakdown of muscles in and around the elbow joint.

 

We will examine the coordination of muscle activity throughout  your body, including those muscles of shoulder and trunk (core muscles) and fine tune it with elbow movements. This will make the body work in synchrony like a well oiled machine. This is achieved through  individually tailored exercises and hands on training of accurate muscle work.

 

Clinical examination  

A thorough clinical examination may be necessary to identify (or rule out) coexisting pathologies or other reasons for your pain. During your examination the clinician might provoke pain in the affected tendon by loading.

 

For patients who do not find relief after other conservative approaches are considered for a period of 3 -6 months, cortisone injection could be used to bring relief. We recommend pain management specialist like a physical medicine MD for such services. After a short period of rest patients are encouraged to return for PT to restore proper muscle function.

 

Physical Therapy Treatment Approaches

The treatment options are as diverse as the condition and its causes. We employ all or multiple approaches to bring your pain under control.

 

Manual Therapy

There is moderate evidence for the immediate effects of several manual therapy techniques on pain and grip strength.  Many of the techniques we incorporate will cause immediate reduction in your pain. Most of them require repeated treatments for 2- 3 weeks to keep the pain at bay and transition to a full-fledged exercise program.  Manual Therapy is a hands on technique employed by the practitioner to stretch, mobilize and move tissues while you relax. This may include mobilizations directed at  joint, fascial, muscle and nerve.

 

 

 

 

Exercise Therapy

 In patients with chronic tennis elbow pain, exercise has been shown to produce regression of pain. Some of the patients might need to provoke the pain while doing the exercises and others need exercises which do not provoke any pain. Your therapist will make the call after examining the stage and severity of your condition.

Some of the exercises aim at relieving the pain while others work towards tendon regeneration and strengthening. All exercise programs must include a global perspective to reactivate whole body link systems.  (Kinetic chain exercises)

 

Sensorimotor palm-slide exercise for retraining of wrist extension

With the forearm resting in on a table, the wrist should be slowly extended by sliding the fingertips along the table and lifting the knuckles. Emphasis is placed on avoiding metacarpophalangeal extension and finger flexion. Return to the starting position and repeat 10 times.

Another form of exercises are graded exercises. In the graded exercises load on the affected muscles will be progressively increased over a period of 4 to 12 weeks.

 

Mirror image therapy

 

New understanding of how our brain perceives pain has led to this  new treatment approach. In this form of treatment we rewire the way your brain understands impulses that generate pain. This is particularly effective if your pain is chronic and hurts even without movements. The treatment will be done in three stages.

Stage 1 – Reorganizing brain’s perception of your hand through understanding its spatial orientation.

Research shows people in pain often lose the ability to identify left or right images of their painful body part(s) (i.e. when viewing pictures of body parts they are slower and/or less accurate than somebody without pain at determining whether the image is a Left or Right).

 

Stage 2 – Mental imagery of movement – Imagined movements can actually be hard work if you are in pain. This is most likely because 25 percent of the neurones in your brain are ‘mirror neurons’ and start firing when you think of moving or even watch someone else move.

Stage 3 – If you put your left hand behind a mirror and right hand in front, you can trick your brain into believing that the reflection of your right hand in the mirror is your left. You are now exercising your left hand in the brain, particularly if you start to move your right hand. Sounds tricky! Mirrors can sometimes be used by themselves but often it is best to do once you have a good ability to discriminate your Lefts from your Rights and imagine movements.

References

 

  • Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All Brooke K. Coombes, PhD, Leanne Bisset, PhD, Bill Vicenzino, PhD J Orthop Sports Phys Ther 2015;45(11):938–949. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5841
  • Alizadehkhaiyat O, Fisher AC, Kemp GJ, Frostick SP. Pain, functional disability, and psychologic status in tennis elbow. Clin J Pain. 2007;23:482-489. http://dx.doi.org/10.1097/ AJP.0b013e31805f70fa
  • Beneciuk JM, Bishop MD, George SZ. Effects of upper extremity neural mobilization on thermal pain sensitivity: a sham-controlled study in asymptomatic participants. J Orthop Sports Phys Ther. 2009;39:428-438. http://dx.doi. org/10.2519/jospt.2009.2954
  • Berglund KM, Persson BH, Denison E. Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. Man Ther. 2008;13:295-299.
  • Binder AI, Hazleman BL. Lateral humeral epicondylitis—a study of natural history and the effect of conservative therapy. Br J Rheumatol. 1983;22:73-76.
  • 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. BMJ. 2006;333:939.
  • Peterson M, Butler S, Eriksson M, Svärdsudd K. A randomized controlled trial of exercise versus wait-list in chronic tennis elbow (lateral epicondylosis). Ups J Med Sci. 2011;116:269-279