Tennis Elbow: Insights From A Physical Therapist

Update 7/27/20. Did you ever go the gym and see someone wearing a strap on their forearm near their elbow? Ever wonder why and what is going on? Well, most likely that person has tennis elbow or lateral epicondylitis. Did they get tennis elbow playing tennis? Probably not.  In this review, I'll help educated fitness professionals – and the public about tennis elbow, which is more of a chronic overuse injury, where the wrist extensor tendons, mainly the extensor carpi radialis brevis is overused, breaks down, and becomes degenerative. Along the way we will bust some myths and I'll also help personal trainers help their clients if and when tennis elbow occurs.

 

What Is Tennis Elbow?

Lateral epicondylitis, as the name sounds is NOT an acute inflammatory condition – as the –”itis” would indicate – unless the injury just happened.  Rather tennis elbow is mostly a chronic, overuse injury. When the condition is chronic, the proper technical term for this condition is a tendinosis. Basically people with tennis elbow did too much of an exercise and caused a breakdown of the wrist extensor tendons.

You can tell if you have tennis elbow by:

1.  Having pain with resisted wrist extension, as well as resisted 3^rd digit extension due to ECRB’s insertion to the proximal 3^rd metacarpal base.

2.  Tenderness along the proximal insertion at the lateral epicondyle of the humerus (on the bone).  If you are tender along the extensor mass,  you are more likely to have radial nerve irritation.

Contrary to the name, tennis elbow is not strictly something only tennis players get. The condition got its name from when tennis players used a too small or too wide of a handle on a tennis racket or when they use the wrist too much during a volley or forehand/ backhand.

 

Are There Different Types Of Tennis Elbow?

No, but there is golfer’s elbow (medial epicondylitis) where the pain occurs on the inside or medial (inner) part of the elbow. In the case of golfers' elbow, the symptoms mentioned above, are reversed.

 

Treatment For Tennis Elbow

To help treat tennis elbow you can do a few things.

1.  Wear a counterforce forearm band to help take the stress of the proximal tendon by decreasing tension on it. (You can do a little test with a partner. Make a fist while your partner squeezes the wad of muscles together to see if symptoms are decreased).

 

2. Wear a wrist cock up splint in about 15 degrees of extension to allow the extensor tendons to rest and to decrease painful symptoms.

 

3. Grabbing and picking up objects with your palm up versus palm down as palm down decreases tension along the extensor tendons, including the extensor carpi radialis brevis ( ECRB).

 

4. You can use heat to promote blood flow to bring in the blood to remove waste products and to promote healing at least 2 times a day for no more then 15-20 minutes at a time.

 

5. A newer trend/ treatment exercise for tendinosis is utilizing eccentric contractions. In the case of the wrist extensors, this helps promote healing by breaking cross-links/ scar tissue of the chronic inflammation that goes along with tendinosis.   Some studies have shown that by strengthening your scapular stabilizers (especially the lower trapezius) can help as well. The following exercises demonstrate how to strengthen the trapeziums.

Pictures by Visual Health Information exercise software, courtesy of Chris Blessing.

Remember, tennis elbow treatment takes a long time to get better. The reason why is because tendons have poor circulation that hinders the healing/ circulatory process. Tennis elbow doesn’t always require surgery, but when surgery is performed, it is to either to repair the tendon that has eventually torn or to remove of the necrotic (dead) tissue.

 

Exercises That Can Cause Tennis Elbow

Exercises that tend to cause tennis elbow, besides improper use of wrist extensors in sports are exercises that excessive put strain on the elbow.  Any exercises that cause a pronated (palm down) grip are more likely to cause/ exacerbate symptoms.  This includes many popular triceps extension exercises although any arm exercise that has too many sets and reps can promote tennis elbow.

Beginners – who hire personal trainers the most – should never have “arm day” as this can most certainly increase the odds of tennis elbow and other problems too – including rhabdomyolysis.

 

Exercises For Tennis Elbow

Initially, after tennis elbow, you would want to use the wrist cock up splint at 15-45 degrees and/or the counterforce forearm band with the sole purpose of calming down symptoms.  When the acute symptoms subside (pain at rest and pain with ALL movements), stretching the wrist extensors (with elbow extended) can be performed.   There are some studies that show scapular stabilization exercises , such as those listed above can be beneficial.

 

Ultrasound And Tennis Elbow

Ultrasound is something a physical therapist will use to help your tennis elbow get better. The ultrasound machine has 2 settings:

1.  Pulsed (non-heating)

2. Thermal (heating)

The nonthermal is mostly used in acute cases where its purpose is to promote the healing process, speeding up the metabolism of macrophages (a type of white blood cell) and scar tissue cells. This isn’t used much in physical therapy since most of the time when patients are in the acute stage they haven’t been seen yet in physical therapy. In other words, people wait too long. By the time the PT sees them, they are in the chronic stage of tennis elbow.

 

The thermal aspects are what are mostly used in PT.  Since we see them mostly in a chronic state (pain with activity ONLY) the thermal aspects of ultrasound are most beneficial. As discussed earlier, since tennis elbow is a degenerative condition, utilizing heat via ultrasound or any other means, loosens up connective tissue, bringing in the blood to remove waste products and to promote healing as well as making the tendons and muscles more extensible and also to relieve pain.

 

Tennis Elbow And Physical Therapy

A physical therapist can help with this problem mainly to help decrease pain, increase function, and educate people about the mechanics of the tennis elbow as well as self-management, to avoid tennis elbow from reoccurring.

How physical therapy works is mostly you need a referral from your physician. This, however, can vary from state to state as in some states you can go directly to PT without a referral from a physician which is called direct access.

The best way to find a physical therapist is either searching on the internet for one convenient to your area. You can also look on the APTA website (www.APTA.org) for physical therapists in your area as well.

 

Chronic vs. Acute Tennis Elbow

The main difference between chronic and acute tennis elbow is the time frame. Tennis elbow is considered chronic when it lists more than  3 months. Acute tennis elbow is less than 3 months. You don’t want tennis elbow to be chronic since once the scar tissue cells settle onto the insertion of the ECRB, it can be a long, slow, and tedious process to try to realign fibers cause by chronic inflammation where scar tissue cells deposit scar tissue.

 

Tennis Elbow Straps

You may have seen people in the gym wearing Tennis elbow straps around their arms. These counterforce forearm or tennis elbow straps work by decreasing the expansion of the wrist extensor muscles, which, in turn, reduces the tension and stress on the muscle and tendon.

When using a tennis elbow brace, they should be placed about 1-2 inches down from the tendon origin without affecting the ability to bend your elbow.

A simple test would be to try any activity that normally hurts than apply the brace to determine the braces' effectiveness.  If it helps reduce the pain, you are in the right area. Tennis elbow straps should be worn all of the time in acute cases and as you get better, when you know you are going to be using your arm, especially to grab or lift something.

I believe wearing them when you have symptoms is best without a particular time frame and the brand I see most in the clinic is the Aircast kind with a light green air-filled pocket.

There isn’t one brand better than the other, and it's more of a trial and error situation. In other words, find one that you like best.

 

How Long Until Tennis Elbow Improves?

In my clinical experience, there is a wide time frame for improvement, anywhere from 1 month to 3 months. I have found that the longer it takes before you get medical attention, the longer recovery takes. This is the main reason to get medical attention ASAP if you think you have a tennis elbow. Trying to rest and fix it on your own may only prolong the time you have tennis elbow.

 

Tennis Elbow Surgery

Tennis elbow surgery can be one of two ways. Either they repair the torn tendon or remove the scar tissue from the chronic inflammation.  Recovery time is approximately 6 weeks for both procedures. Again, getting medical attention quickly can reduce the odds of needing surgery.

 

Personal Trainers And Tennis Elbow

Tennis elbow is an overuse injury. In this age of high intensity, high repetition/ multiple set programs, personal trainers should always be on guard against accidentally causing this disorder in their clients. The challenge to personal trainers who work in gyms is even more great, given a typical personal training session is only 30 minutes long in many big, chain gyms. In that environment, the desire to help clients – coupled with a client's desire for “quick results” can make tennis elbow (and other overuse injuries) more likely.

When tennis elbow is suspected, Besides stopping the activity when pain develops, personal trainers can also help by making sure clients grasp with a palm up approach, and eliminate activities/ exercises utilizing a palm down approach is a good step in the right direction.

Starting new clients who are novices with only 1 or 2 training sessions per week can reduce tennis elbow from occurring by giving the body more time to heal from the rigors of training. As an added benefit, this can also reduce delayed muscle soreness from occurring too.

A client can also wear a tennis elbow band if that helps with symptoms.  If pain continues,  a referral to a health care provider like a physical therapist would be the best option.

 

Tennis Elbow And Creatine Supplements

Can creatine supplements cause tennis elbow and other overuse injuries? While studies have not shown injuries from creatine supplements in healthy individuals, in the “real world” people do sometimes report that they occur.

When discussing creatine supplements, it's important to remind clients that creatine only helps muscles get stronger. It doesn't help tendons or ligaments. Remember, ligaments and tendons, take longer than mussels to improve strength. In other words, the ligaments and tendons can't keep up with the extra weight the muscles are lifting. The result is an injury occurs.

Since most people who hire personal trainers are basically novices, it's also worth mentioning that most people who ask about creatine supplements, don't need them.

 

Preventing Tennis Elbow

The best way to prevent tennis elbow, and its reoccurrence, is to limit upper extremity use. The more sets and reps someone performs, the more likely tennis elbow is to occur.  Also, don’t put your elbow in precarious positions, as mentioned above, and if you have pain in the elbow area…STOP what you are doing go to your doctor. Remember, the longer you have symptoms, the harder it is to get better.

 

Tennis elbow can be a difficult problem to treat/ handle if not managed early and correctly. Initially, the best option in dealing with tennis elbow is to allow the tendon to rest, modify the activity you are doing and if needed, use an elbow strap around the elbow region.  No pain, no gain doesn’t apply here. If exercises continue to cause pain after approximately 2 weeks after the initial onset, I would recommend a referral to a health care provider to seek medical attention.

 

Christopher Blessing is a board-certified physical therapist in both New Jersey and Pennsylvania and has been practicing in outpatient orthopedics for over 16 years.  He received his undergraduate degree from Rutgers Camden College of Arts and Sciences in Biology, a Masters’s degree in Kinesiology from West Chester University, and his Masters’s degree in Physical Therapy from Nova Southeastern University in Florida.  He is also an Orthopedic Clinical Specialist from the American Physical Therapy Association.

He is an active member of the American Physical Therapy Association and the Orthopedic Section of the APTA.  He is also a member of the New Jersey Physical Therapy Association and the National Strength and Conditioning Association.

Chris is a certified strength and conditioning specialist and he combines that knowledge with his physical therapy background to provide a hands-on approach to his treatment, as well as very active and individualized programs for each of his patients. He is currently a senior physical therapist working for the Medical Center at Princeton in Plainsboro, in Princeton, NJ.

Any Questions?