Physiotherapy Management of “Tennis Elbow” vs Actual Tennis Elbow
My thoughts, opinions and experience on treating Lateral Elbow Tendinopathy aka “Tennis Elbow”
The past year (2021) for me has been a year of Lateral Elbow Tendinopathy aka “Tennis Elbow” managed differently, using some simple, yet important concepts that form the foundation of conservative management of musculoskeletal conditions.
I gather my treatment modalities and methods from working with a large variety of professionals including Hand Therapists, Hand Specialists/Surgeons, Elbow Specialists/Surgeons, Physiotherapists and Sports and Exercise Physiotherapists.
Over the past year I have had much improved outcomes with patients who are surprised and happy about “how little it took” to help them, some of whom saw me for second opinions after 1–2 years of “Tennis Elbow”. Many of the concepts and tips I discuss in this article I have shared with my peers and colleagues who work alongside me and they’ve found them very helpful.
Let me be blunt: I think we (health professionals) can do a much better job at managing “Tennis Elbow” as a whole. I’ve seen some very important basic concepts of treatment often missed in favour of some very specific and sometimes unnecessary treatment modalities, some of which I have the feeling stir up symptoms more often than calm them down.
“Too much medicine occurs when the provision of either investigation or intervention (or both) is unjustifiably excessive.” Lewis, J. S., Cook, C. E., Hoffmann, T. C., & O’Sullivan, P. (2020). The elephant in the room: too much medicine in musculoskeletal practice. journal of orthopaedic & sports physical therapy, 50(1), 1–4.
Keep in mind that there is still a time and a place for many of the commonly prescribed treatment modalities and ‘Tennis Elbow Exercises’, however I feel many of them are required less often for less of the patients, and only then in the mid-later stages especially if they have had the injury for a longer time. In the early stages, this condition is quite easy to stir up by doing the wrong exercise or treatment at the wrong time.
I’ve kept this article for free for everyone, as I have learned much along the way for free via Blogs and Podcasts without paying a cent so I’m simply ‘passing it on’. However if you’ve enjoyed it or have taken something away from it that helps you, please consider ‘Buying Me A Coffee’ (https://www.buymeacoffee.com/nickilicphysio), any small donation is appreciated and helps keep my wife happy that I’m not wasting my personal, non-clinical time, writing nonsense that nobody reads.
This is a long-piece. If you are here looking for quick and easy answers, perhaps it is not for you, as one really needs to fully understand this condition and the people that get it in order to treat it well. Often when I publish or share blogs like this I inevitably get the question: “Hi, what will help my Tennis Elbow”… the answer is always: A thorough assessment by an experienced, registered and regulated Health Professional who takes the time to listen to your story.
Let’s Begin!
This:
is a wooden tennis racquet.
It does not date back to gladiator times; it dates back a few decades.
Technology has changed the game of tennis forever. Lighter (yet more powerful) racquets have turned the game of tennis into a game of explosive power and athleticism.
The single-hand backhand, used by most players mid last century, has given way to double-hand backhands. Baseline grinding has been the norm for the past 20 years, particularly in the Womens game, except for a few athletic players who have mastered the art of serve-volley (eg: Federer).
“Tennis Elbow” as a term dates to the days of the heavy wooden racquet. The number of players who get Tennis Elbow throughout their life has decreased. For the first 100 years after it was first described in 1873, even in the 1980–1990’s it was common to see the incidence of ‘tennis elbow’ up in the 75–85% ranges (Gruchow and Pelletier, 1979, Giangarra et al., 1993, Cabrera, 1986).
Whereas, now the incidence is down to 10–30 per 1000 (1–3%), and mostly affecting 35–55year olds.
For the purposes of this long-piece, I am going to refer to “Tennis Elbow” as Lateral Elbow Tendinopathy, and ‘Actual Tennis Elbow’ as Actual Tennis Elbow.
Clinically, I rarely see Actual Tennis Elbow (Lateral elbow pain that is caused by Tennis) in both the Elite and the Recreational Tennis Players, they are much more likely to get wrist or shoulder complaints in the upper limb. More often it is Golfers Elbow (the other side, the medial elbow), and when it is “Tennis Elbow” it is caused by something else and Tennis lets the patient know about it. For example, often in recreational tennis players it is something occupational, home renovations or gardening that causes it, but the mechanical load of hitting balls sets off the symptoms.
The incidence of “Tennis Elbow” as a clinical entity is on the decrease but perhaps as we have just become better at picking up differential diagnoses such as Radial Tunnel Syndrome, or Posterior Elbow Impingement or maybe just because we have changed the label we give it therefore it’s harder to collate the research (Sanders Jr et al., 2015). There are many different names that this condition can fall under: lateral elbow pain, lateral epicondylalgia, tennis elbow, wrist extensor tendinosis, wrist extensor tendinopathy, lateral elbow tendinopathy… the list goes on.
Lateral Elbow Tendinopathy is the current term favoured by the researchers/academics and experts in this area. When the great Bill Vicenzino himself corrects you on tendon terminology, you sit up and listen!
What is it?
Lateral Elbow Tendinopathy involves the common tendon of the wrist extensors, where they all blend at the attachment onto the lateral epicondyle of the humerus (the outside lumpy part on the bottom of your upper arm bone). Lateral Elbow Tendinopathy more commonly involves the ECRB tendon (extensor carpi radialis brevis) and sometimes the ED/EDC tendon (extensor digitorum communis).
I also differentiate between “Bony Tennis Elbow” and “Tendony Tennis Elbow” as I notice a subtle difference in prognosis and how aggressive I am with activity modification if it’s more of an enthesis issue (bony attachment of tendon) than a mid tendon issue, and that’s true for all enthesis tendon related issues across the body. I have to really nail the activity modification when it’s “Bony Tennis Elbow” and I find the prognosis is better (how long the condition goes on for is reduced) than “Tendony Tennis Elbow”.
When it comes to understanding exactly what is happening to the tendon I think we’re still in the ‘wild wild west’. The more we know the less we know (a common Scientific conundrum).
Or as the Husband of my Great Grandmothers Cousin (Mileva Maric) used to say: The More I Learn, the more I release how much I don’t know — Albert Einstein (yep, I’m related his first wife)
Mileva Maric wrote a lot of his work, when they eventually divorced, because he was a naughty philanderer, he paid her for her work so she could support her disabled son, read more here https://blogs.scientificamerican.com/guest-blog/the-forgotten-life-of-einsteins-first-wife/).
The research suggests that this condition does not appear to be inflammatory but seems to involve some sort of ‘overload’ injury to the tendon. The repetitive mechanical overload causes an accumulation of the prostaglandin protein which attracts water causing effusion, leading to a ‘proliferative vascular granulation or angiofibroplastic hyperplasia’ (Nirschl, 1992, Nirschl and Ashman, 2003).
For those who don’t wear suspenders, own 5 ant farms and know the Periodic Table Song, all of this means: New Blood Vessels Grow Where They Shouldn’t (in the tendon) aka neovascularisation, and where blood vessels go, nerves go too, which is annoying because tendons are generally avascular (no blood vessels) and aneural (no nerve endings).
As to why the neovascularisation occurs in the first place, it sounds as though it is a whacky ‘disrepair’ response from the body, an increase in prostaglandins attracts water into the extra cellular matrix (between the collagen fibers in the tendon) and this water cleaves apart the collagen and tenocytes, this cleaving apart of tenocytes breakdowns communication links between the tenocytes (causing further tendon chaos), and where there are gaps in the extra cellular matrix, neurovascular ingrowth can occur, which includes autonomic nerve fibres which can change to become nociceptive (“pain” fibres”).
It is thought the key to reversing tendinopathy is to apply an appropriate load (different for every tendon) in the correct position (different for every tendon) to the right amount of time (different in every patient) in order to squeeze the effusion out, much like pulling on a soggy rope will ‘wring’ the water out.
This reduction of effusion will allow the tenocyte communication links to reform and the tendon health to re-establish itself, the blood vessels and nerve fibres will gradually retreat.
This is where the tendon research on rehabilitation has led us, using isometric (holding load) and isotonic (moving load) exercise to target the tendons in a graduated manner (hold load -> move load-> move load faster).
Lateral Elbow Tendinopathy (….unrelated to Tennis)
A big randomised controlled trial over a decade ago (Bisset et al., 2006) randomised ‘Tennis Elbow’ patients into a Physiotherapy group (education, manual therapy, home exercises), a corticosteroid injection (1ml 1% lidocaine with 10mg triamcinolone acetonide) with a 2nd injection if ‘deemed necessary’ in 2 weeks, and a ‘wait and see’ group (patients reassured and educated on the condition, activity modification, encouraged to remain active).
Although there were short-term improvements (at 6 weeks) in the Physiotherapy group compared to the injection and wait and see group there was no difference at one year. The injection group also had more issues in the long-term.
This is an often referred-to study by both Physios (sold as “…they will feel better sooner if they see us”) and Surgeons (who counter “.. yes but there’s no difference at one year, they might as well wait and see), however we now think a little differently about this condition compared to 14 years ago (2006). For example, it is more common to see weights instead of resistance bands for elbow rehab.
We’re less inclined to do the classic “wrist goes up, wrist goes down” rehab (wrist flexion/extension with a dumbbell in hand) in favour of global upper limb push/pull tasks with a weight in hand, challenging the wrist extensor as a repetitive gripper and wrist stabiliser rather than a prime mover. We are also less likely to do wrist extensor stretches, as pronated wrist flexion could be causing more harm than good.
Tendons tend to not like internal and external compression. External compression includes rubbing tendons (eg: cross friction massage) as well as wearing “offload” braces.
Internal compression involves a loading of the tendon in an anatomical position that compresses the tendon against another structure, usually tendon on bone. For Insertional Achilles Tendinopathy this is Dorsi-Flexion (eg: Calf stretch), for Proximal Hamstring Tendinopathy this is hip flexion (eg: glute/hams stretches), for Gluteal Tendinopathy this is hip flexion and abduction (eg: glute stretches) and for Tennis Elbow/Lateral Elbow Tendinopathy this is pronation and wrist flexion.
If you add a longitudinal load (such as a free weight) to the tendon in this position, it increases the compressive effect. For the Wrist Extensor Tendon complex, the radial head compresses the tendon in pronation, wrist flexion in pronation further increases the compression. The below ultrasound picture demonstrates this effect.
It is due to this ‘internal compression’ effect that I also avoid ‘supination strengthening’ exercises such as the classic ‘hammer/broomstick’ twists.
Finally, although that big 2006 Randomised Controlled Trial had an extensive exclusion list/criteria, there may have been a hidden subgroup (see the below ‘wait and see ’ subgroup and the ‘non-responders’ subgroup) that were not going to be responders to treatment (physio or corticosteroid) anyway, such as people with poor baseline grip strength (<45lbs) and those with yellow flags such as poor mental health.
WOAH!! Hang on a sec! Aren’t you throwing out all the recommendations from recent research?
The 2006 Bisset paper gave out a ‘home exercise program’ for patients which was based on a Vicenzino paper (Vicenzino, 2003) a few years earlier that described a program consisting of grip strength, wrist extensor and flexor strength, pronator/supinator strength and a whole bunch of other exercises.
Give this program on a ‘handout’ to a patient, you’ll never seem them again.
These have been the focus of Physiotherapists for the past 15 or so years. There is a big mix of exercises, some very complex, however in my experience most of them done at the wrong time can stir up patients and what I’ve found is that I can simplify things right back to one or two key exercises and still get a good outcome. A more recent paper doesn’t go into specifics but concludes that all forms of ‘exercise therapy’ for this condition are superior to other forms of treatment such as electrotherapies, manual therapy and braces (Bisset and Vicenzino, 2015).
Much like other areas in the body, I try not to get too specific with what exactly is going wrong (because I don’t think we really know yet) or what I’m targeting with treatment, I treat the entire lateral elbow area as a ‘Lateral Elbow Complex’, much like I treat the Patellofemoral/Anterior knee as a ‘Patellofemoral Comlex’. However, like most Physiotherapists and Medical Professionals, I would rather target a ‘structure’ in my ‘narrative’ that I use with the patient, Tendons are the most convenient, which is why I use ‘effusion’ due to ‘overload’ in my narrative to the patient, it helps sell my Activity Modification and Education messages in treatment that have a focus on improving the self-efficacy of patients..
Lateral Elbow Tendinopathy — Who are they?
These are usually the non-tennis players. Usually 35–55 years old. Often diagnosed as “Tennis Elbow” and referred to Physiotherapy, often with some sort of diagnostic imaging (often unnecessary, but sometimes needed) whether it be Ultrasound or MRI, often with degenerative changes such as small tendon tears, osteophytes, degenerative joint changes etc. Not many are getting Cortisone as first line treatment anymore which is great, but they will often turn up asking about it. Some have had Cortisone in “Tennis Elbow” already (recently I had a bilateral “Tennis Elbow” patient cortisoned in both elbows then sent “for some physiotherapy”…but it was a neck/radial nerve issue…so … lower your expectations of medical management of this condition and you won’t get surprised).
Like the 2006 Bisset et al. RCT I clump Lateral Elbow Tendinopathy patients (as well as a few other common musculoskeletal conditions such as rotator cuff related pain and lateral hip pain) into three subgroups based on early assessment:
1. Responders (good outcomes/prognosis predicted)
2. Non-Responders (poor outcomes/prognosis predicted)
3. Wait&See (prognosis unknown)
To quote a 2015 review on Lateral Elbow Tendionpathy (Coombes, Bisset, & Vicenzino, 2015), when it comes to managing this condition: One Size Does Not Fit All.
Lateral Elbow Tendinopathy Subgroup — The Responders
The first Lateral Elbow Tendinopathy patient subgroup is The Responders. They are the ones that make us feel ‘warm and fuzzy’ and boost our collective ego’s…., because they get better with little-to-no intervention. Google “regression to the mean”, see Voltaire’s quote below… or as my boss puts it: much of the time we pat people on the head while they get better naturally. This whole concept allows snake-oil salesmen to get rich.
The Responders usually have a clear mechanism of injury during the subjective examination.
The Responders are usually seeing you in the clinic soon after they did ‘too much too soon in the wrong position’ (usually repetitive gripping in pronation and wrist flexion). The office warehouse worker who lifts boxes of A4 paper by the plastic strap, the middle aged man who does 10hours of landscaping over a weekend pulling up 1000s of pavers, or…. 40–60yo recreational tennis player who did one of those above things and then felt it at tennis….. (ie, not ‘Actual Tennis Elbow’).
These are easy to manage, identify the aggravating activity that caused the injury and stop it (aka Activity Modification, our most potent yet underrated weapon in the fight on musculoskeletal pain). Rest the arm from doing anything that would continue to stir it up (forceful repetitive gripping activities). You will then usually see a good short-term outcome (<6weeks) and a massive increase in pain-free grip strength. You may or may not have to provide some sort of exercise program to target the wrist extensors, I probably would if I can measure a significant weakness with grip strength (using a grip strength dynamometer) or isometric wrist extension (using a hand-held muscle dynamometer).
There is a subgroup of The Responders that I call “The Strong Responders”, these are The Responders who are strong and need a bigger stimulus to get better during their rehab, 1kg dumbbell wrist up and downs and yellow-red therabands aren’t going to cut it. They normally have a baseline grip strength >120lbs and are on the tools (aka Tradies).
Lateral Elbow Tendinopathy — The ‘Wait and See’ Patients
Some patients get better but simply take longer.
The Wait and See patients will have good short-term outcomes, usually from activity modification, but they will eventually plateau. Some will love any form of non-specific/neuromodulation-related manual therapy, but there will unlikely be >24hr effect from it.
This subgroup of patients sometimes appear to be very similar to the cohort that gets other “came out of nowhere” conditions such as Adhesive Capsulitis (Frozen Shoudler), particularly Women in the midst of Menopause.
Often the ‘Wait and See’ crowd are pretty “OK” with a 1 year prognosis as their injury is not severe enough to bother them greatly and they’re happy to modify their activities and manage it and then chase it down further if it doesn’t resolve down the track. It’s good with these ones to set a reminder to follow up with them later on.
Lateral Elbow Tendinopathy — The Non-Responders and The Risk Factors
There are many indirect and direct risk factors that would make me think a Lateral Elbow Tendinopathy patient will simply not get better. I will try and identify these patients around the 2–3rd session and having more of an idea of their psychosocial status at the time will also assist.
The Non-Responders might have no clear mechanism of injury, which should set off some suspicion, tendon pathology of any sort without a clear mechanism of injury should really have other medical issues cleared, such as: Ankylosing Spondylitis, Psoriatic Arthritis, Seronegative Arthropathy, Reactive Arthropathy, Diabetes, Hypertension, Smoking, Dyslipidema (High Cholesterol) as well as recent changes to medication such as anti-biotics (especially fluroquinolones). I will usually send Non-Responders to a good GP or a SEM Physician to screen for these medical factors.
The Non-Responders will usually have 2–3+ of the risk factors in the below list. These patients often report their elbow is worse at times of stress throughout the year which an indicator that there is more to it than just a mechanical problem. A mix bag of the below factors will usually result in a longer-term condition. Some of these risk factors are not unique to Tennis Elbow, a back pain patient (for example) who is weak, stressed, has other injuries in the area (or a history of that injury) and is workers comp will also have a lesser outcome. Some of these are ‘yellow flags’ or biopsychosocial factors that either have a direct or indirect impact on recovery.
Such is the importance of identifying these factors, some research (Aben et al., 2018) has even focused on it:
The conclusion of this paper suggests that Healthcare Professionals must identify patients in this sub-group and take more time to clearly explain the condition and take care to not increase anxiety or depressive feelings related to the condition, stressing the importance of improving self-efficacy in patients. (Which is all scientific jargon for: Healthcare Professionals should be Professional and do their job well… in my opinion).
The risk factors that I feel are more important to identify I’ll put an asterisk (*) next to as they will be more likely to become ‘Non-responders’.
- Stress/Anxiety/Depression*
- Baseline grip strength <45lbs*
- Inactive (no regular weekly exercise pattern) *
- Coexisting neck pain*
- PRTREE questionnaire score >54*
- Both upper limbs affected *
- Poor health literacy (with strong beliefs)
- Kinesiophobic (fear of moving) and has functional adaptations (fear of using it, starts using other hand for everything and adjusting habits in life)
- Workers compensation/insurance/legal involvement (which commonly delays good outcomes for all injuries due to the negative effects of delays, excessive administration, and stress on healing)
- Coexisting upper limb pain/injury
These are patients where I will shift the focus of treatment to ‘management’ and ‘lowering expectations of being pain-free’. At this point I will have also involved an Upper Limb Specialist (usually a Orthopaedic Surgeon) to also back up my position, and to especially rule out the need for Surgery, as the Specialist will usually know that the patient would have a poor outcome post-op if they have many of the above risk factors. There is a sub-group of patient that will actually respond very well to surgery (usually a tenotomy of the ‘diseased’ portion of tendon) but that topic is outside the scope of this article.
Lateral Elbow Tendinopathy — Management
Subjective/Take a history/Listen to the patient
Clinicians need to work out who the patient is, what subgroup they are in and make sure it is in fact ‘tennis elbow’, as I see many referrals for ‘tennis elbow’ that are not tennis elbow.
Clinicians have to know the patient, who they are, what they do for work, what they do for play, what’s going on in life, their health status (medical and mental), their exercise status (what they do and when), are they renovating or landscaping during COVID isolation, what are their secret hobbies (eg: crocheting) that involve hands… know them and their life, otherwise you’ll miss some small thing that will matter that will just keep re-aggravating it.
Clinicians need to identify all possible aggravating activities and stop/limit them — aka Activity Modification. This is key. This is an often missed concept in all Physiotherapy courses, in university and in continued-learning. So often we skip straight to learning about assessment and treatment, however simple Activity Modification can be extremely effective in the short and long-term and discard the need for any complex home exercise programs or in-clinic treatment if it successfully resolves the condition in the short-term.
Clinicians need to identify all secondary risk factors (already discussed).
Finally differential diagnoses need to be ruled out especially cervical spine referred pain or upper limb peripheral nephropathy (such as Radial Tunnel Syndrome, see bottom of this article for info on differential diagnoses).
All of this takes up clinical time. Those who are fortunate enough to work in a clinic that gives their clinicians 45–60min for initial consults will be all over it. Everyone else will take longer to get the same outcomes.
Objective — The Physical Assessment
Objective — Tennis elbow specific — Grip Strength
Pain free pronated grip strength drives assessment and treatment for Tennis Elbow
PFGS(Neutral) — Check pain-free grip strength (PFGS) in neutral shoulder/elbow flexion/neutral pronation, this has been shown the be the best position for non-provocative PFGS (Cooke et al., 2021). Check unaffected side first. Elbows by side and compared side to side to identify baseline strength (see ‘Wait and see’ list for subgroup with grip strength weakness), measure it in pounds (lbs).. it’s annoying but it’s what most specialists and hands therapists use. Dominant side should be a little (10–20%) stronger. If the patient has pain with grip strength in neutral, something else will be going on.
PFGS(Pronation) Then check PFGS in shoulder-flexion/elbow-extension/forearm pronation (outstretched arm, palm down). Patients with lateral elbow pain often avoid full elbow extension on this test, make sure they have full extension. Check on the unaffected side first. On the affected side, make sure you tell them “squeezes as hard as you COMFORTABLY CAN, once you get pain stop”, note this strength score, do not measure their max pronated strength, you will likely stir it up. Also take an average of 3 trials on each side to see if decreases with every squeeze as it will tell you how fast they fatigue.
PFGS(pronation) is the most important measure that I will monitor over the weeks/months to guide my management.
Generally:
- < 30lbs (<13kg) is a big problem
- 30–60lbs (13–27kg) is a problem
- 60–80lbs (27–36kg) is a mild problem
- >80lbs-110lbs (36–50kg) will be resolved in most people, but pain will usually be in the very strong (who have >130lbs baseline) and will take a little extra load in the rehab to get it to a happy state,
- >110lbs (>50kg) you should compare it to their PFGS(neutral) as a percentage (%)
When over 110lbs, once their PFGS(pronation) is >80% of their PFGS(neutral) they tend to be happy and just require general strength training to get it back to baseline, avoiding pronated loads such as reverse preacher curls or overgrasp pull-ups until it’s 100%. Eg: PFGS(neutral) = 160lbs, then rehab their tendon until it is 80% of 160lbs (~130lbs), then the rest will come from general strength training and time, avoiding heavy pronated loads.
Objective — Tennis elbow specific — Other Resistance Tests
Often I will also do resisted big finger for ECRB (“flip me the bird” test) in supination (“flip off the physio”) and in pronation (“flip yourself off”), to get a feel for what the radial head is doing to ECRB.
Rarely will I test resisted wrist extension as it is not what the job of the common wrist extensors is, unless they are an athlete. The pronated PFGS is more appropriate and too much testing of the common wrist extensors can stir them up.
Objective — Tennis elbow specific — Palpation
I will feel where the hotspot is.
Alison Grimaldi (glute tendinopathy/lateral hip pain guru) is a big advocate of “if it hurts to touch, it could be the problem, if it doesn’t hurt to touch it’s unlikely to problem”. As with other compressional tendinopathies (gluteal tendon, proximal hamstring tendon), a lack of pain, either at the site of the common wrist extensor origin, or with pronated grip strength, would indicate that it is unlikely to be Lateral Elbow Tendinopathy.
If it is mainly tendinous at the common extensor origin, just off the lateral humeral epicondyle, and not much bony tenderness at the tendon insertion, I know it will take a little longer to calm down and won’t be a “rest and wait” situation, however you’ll know off the history already that it’s a long-term tendon issue.
Compared to bony tenderness at the humeral lateral epicondyle, which usually suggests a recent too-much, too-soon issue which has caused oedema/effusion at the enthesis (bony-tendon junction), these particularly hate any wrist flexion in the rehab (wrist extensor stretches, wrist extensor strengthening where the wrist drops down into flexion), so I avoid those like the plague.
If the hotspot is further down the wrist extensors, perhaps starting about 2 inch distal from the lateral epicondyle, then it may in fact be a wrist extensor muscle issue or a radial tunnel issue.
Objective — Rule in/out everything else
It is not the purpose of this blog to tell you how to rule out/in all other conditions however ensure you have checked the neck, shoulder and upper limb for any co-existing conditions, particularly the elbow joints. However at the end of this article I’ve included a ‘differential diagnosis’ section that highlights some other conditions that occur in or around the lateral elbow and these need to be ruled out, but be careful, some can co-exist, especially in those long-term cases.
Treatment
Aim: Improve their PFGS(pronated)
Treatment — Education and Activity Modification
The ‘best practice care’ treatment of nearly all musculoskeletal conditions puts Education and Activity Modification at the forefront. I would also add ‘Reassurance’ in there once you are sure you have ruled out serious pathology (aka Red Flags). A recent 2020 article (Lin et al., 2020) discusses these in depth: https://bjsm.bmj.com/content/54/2/79
Education, Activity Modification and Reassurance is a potent treatment method, if done effectively (requires good communication skills and time) it alone can reduce a patients pain significantly and restore their PFGS(pronated). It’s otherwise known as “stop the patient from making themselves feel worse” and it requires you to fully explain to the patient, in a way that they understand, why they are injured and in pain and how it has happened in the first place. If you have not found what caused their pain in the subjective in the first place calming their elbow down is going to be difficult to achieve in the first place.
Non Provocative Arm Loading (NePAL)
NePAL is the term I use for the pathway of loading the wrist extensors which is as close to their normal function as possible, which is to stabilise the wrist in neutral deviation and 30 deg (+/- 10) of wrist extension to best allow the digits to flex.
In NePAL the wrist doesn’t go up and down (flexion/extension), or in and out (pronation/supination) against resistance until phase
NePAL Phase 1 — Hold it
aka “ The Analgesic exercise”
“There are no recipes when it comes to exercises”. I’ve heard that a tonne of times, yet it’s often said then later on in the same weekend course you’ll hear a bunch of eager-to-please young physios yell out “5x45secs” when asked about how to load a lower limb tendon isometrically.
However here is a very rough guide to how I’d start with patients depending on their PFGS(pronated) and whether they are a Responder, Non-Responder or a Wait and See type of patient.
Overgrasp holds (isometrics), pronated gripped 1–5kg for 20–30secs x 2–3 “with meals” (x3/day), then retest PFGS after first set to gauge effectiveness of chosen weight.
But it depends on what weight they can “feel it” with. They usually say “it’s not too painful, but I can feel it”. If you have caught their condition early (first few months) you will only need this before their PFGS(neutral) and PFGS(pronation) return to baseline.
If overgrasp holds as per the above picture are too provocative, even with 500g-1kg, I will then try them in a supinated position but still targeting wrist extensors isometrically by holding a weight behind their body (shoulder extension, elbow extension, wrist 30deg extension).
BUT if it ain’t broke, don’t fix it
Exercise prescription is much like drug prescription. There are side effects and it is dosage dependant. Healthy tissues don’t tolerate certain exercises. This is true with overgrasp holds. Once the patients PFGS(pronated) is 80–90% of their PFGS (neutral) you might want to make sure they have ceased doing overgrasp holds as this load (especially if progressed by the patient) can stir it up.
The focus now shifts to targeting the tendon with big lifts using the wrist extensor in its true function, holding the wrist still whilst you do heavy or repetitive stuff.
NePAL Phase 2— Build Them Up
aka “ Hold it, then move it around”
Once their PFGS(pronated) starts getting within 80% of their PFGS(neutral), you can start adding in other upper limb strength exercises that utilise the wrist extensors as a dynamic isometric wrist stabiliser.
Exercises could include simple push/pull movements such as rows and chest presses with dumbbells. Avoid resistance bands.
In general, work with supinated/palm-up and neutral grips with heavy weights then 2 weeks down the track gradually reintroduce isolated elbow exercises that target the isometric function of the wrist extensor action for those who are stronger (>120lbs PFGS(neutral)) or are upper-limb athletes (eg: boxing, tennis players) Starting with shoulder-biased exercises such as reverse flys and lateral raises, then progressing to elbow biased activities such as reverse preacher curls (dumbbells).
NePAL Phase 3 — Secondary Function
aka “The ups and down and ins and outs”
Only after you have achieved those above heavy dynamic isometrics should you then load up with isolated wrist strength, but… only if needed, particularly if you need to build forearm strength for athletic, contact or combat sports reasons.
Treatment — The Non-Specific/Neuromodulatory Therapies
After you have covered all of the above, now you can do whatever else you like to make them “feel” better.
Heat, massage, needling, joint mobilisations, taping…. I usually just use a heat pack and massage the wrist extensor muscle for Therapeutic Alliance purposes and use that opportunity for education about the condition and activity modification advice.
However, these days patients are seeing me after being referred by friends/family with less expectations that I’ll do hands-on stuff anyway (word gets around) and they’re there to get assessed and find out about activity modification advice and to get onto the home exercise program which is great. You can usually spot the patients that need a bit of ‘hands-on’. I’m all for it as long as the important things have been covered and the patient understands that what you are doing helps it “feel good” for the short-term and you are improving the patients self-efficacy along the journey.
Some patients will look at what I’m doing and ask “so what does this do?”, the urge is to make it sound science-y and sophisticated and say “it reduces muscle tension” or “it releases your tissues”, but I just say “it just makes it feel good” which generally makes them happy.
You can do a treatment strictly because it ‘feels good’, but leave it there, do not add any scientific jargon around it, just say “it feels good, so therefore I do it”.
The problem is when healthcare providers spend their entire time on things that ‘feel good’ and nothing else. It needs to be separated. But it’s ok to offer this non evidence-based ‘feel good’ treatment as long as patient are informed.
If what you are doing is an unskilled, ‘feel-good’ type of intervention, that should be provided by unskilled providers who do those things, at unskilled-provider costs, that will get healthcare costs down.
We need to take these ‘feel-good’ things out of the scientific realm and have them as what they are.
Erik Meira — Episode 161 PT Inquest 42mins+
Put another way. You can have the gravy, but first you have to eat the potatoes.
Differential Diagnosis
I love saying “Differential Diagnosis”, it makes me think I am on Dr House’s team and can solve all mysterious illness and injuries in 40mins. Spoiler alert, it is usually not “Lupus”.
A good way to rule out tennis elbow is with their pain-free grip strength, if it is >90lbs and within 10–20% of the other arm it’s unlikely they have ‘Tennis Elbow’. Also, if they are pain-free at the lateral elbow attachment site of the wrist extensors, then they are unlikely to have ‘Tennis Elbow’.
Here are some conditions I’ve seen in patients that have seen me for a second opinion for their “Tennis Elbow”:
- Posterior elbow impingement/ulnohumeral joint effusion — trauma or repetitive hyperextension activities, doesn’t significantly affect grip strength.
- Triceps tendon issues — tendinopathies and tears, doesn’t significantly affect grip strength, usually affects medial (other) side of elbow.
- Cervical-spine referred pain — these are usually given away early by the distribution of pain, Tennis Elbow is usually very pinpoint in the same area, this will spread up and down the arm.
- Radial Nerve Neuropathy — as above, it will spread away from lateral elbow.
Less commonly in a non-hands therapy environment:
- Radiohumeral joint issue
And the less common but more complex ones that are not to be missed:
- Radial Tunnel Syndrome (RTS)
- Posterior Interosseus Nerve Syndrome (PINS)
- Wartenburg Syndrome
Having worked briefly in Hands Therapy, surrounded by Therapists (Physio/Physical Therapists and Occupational Therapists) and Specialists (Hand/Wrist/Elbow Surgeons), I was fortunate enough to see RTS and PINS patients, often for second opinion as they were treated as ‘Tennis Elbow’ initially.
I will very briefly summarise these conditions:
Posterior interosseous Nerve Syndrome (motor only) — Compression injury of Posterior interosseous Nerve (motor nerve only) in the arcade of Froshe, stirred up by repetitive pronation/supination activities, can include neurological weakness of common extensors (ECRB, EDC, EDM, ECU) and deep extensors (supinator, APL, EPB, EPL, EIP. Dynamic compression can occur with repeated pronation/supination activities (Miller & Reinus, 2010).
Radial Tunnel Syndrome (motor/usually no sensory) — Also a compression of the PIN but is only a painful neuropathy not affecting sensory or motor nerves (Moradi, Ebrahimzadeh, & Jupiter, 2015) causing weakness due to pain-inhibition rather than true neurological weakness. The pain hotspot is often 3–5cm from the lateral epicondyle rather than on it. Sometimes a sensory loss in first dorsal webspace of hand. As with PINS, also stirred up with repetitive pronation/supination tasks. Can develop following surgery for other areas on the same limb, can also occur post trauma and heavy manual labour (Moradi et al., 2015).
Wartenburgs Syndrome (sensory only, no motor) — A compression of the Superficial Radial Nerve (SRN) which is a sensory nerve, from the action of brachioradialis and extensor carpi radialis longus (ECRL) during pronation/supination, it might be as a result of fascial entrapment. This can cause vague pain over the dorsal radial hand, paraesthesia (pins and needles) and numbness and a common cause (in this very uncommon condition) is wearing tight bracelets or watches, but sometimes from repetitive forearm pronation/supination occupational tasks.
The above conditions often make their way to hand therapists and specialists after being mismanaged as “Tennis Elbow”, the symptoms can be in a similar area (lateral elbow) but more often radiate down the forearm. It’s important to know that the incidence of these injuries is very low (0.03% for PIN compared with 0.1%-0.35% for carpal tunnel syndrome) (Moradi et al., 2015), have a good Hands Therapy contact in your network just in case you suspect something, these will often require some form of thermoplastic splint and your local Hand Therapist is making them expertly every day, and they have a saying: “A poorly made splint is worse than none at all.”
A final note on ulnohumeral effusion. If a patient has had a Posterior Elbow Impingement/Effusion for a while I will always recommend they see their GP and discuss a prescription of NSAIDS for 2 weeks, these are often needed to get them that last 10deg of elbow extension. Finally, any ‘Tennis Elbow’ that has been around for long enough is likely to have an ulnohumeral component to it, and vice versa, any Ulnohumeral Joint/Posterior Elbow Impingement that’s been around for long-enough will likely have some ‘Tennis Elbow’ component to it and both of these will need addressing once the primary condition has calmed down.
The 2015 review by Coombes, Bisset and Vicenzino) slipped through my grasp when writing this (highlights the importance of keeping up to date with the correct nomenclature) and I was pointed in it’s direction by Bill Vicenzino after I originally published this. It goes into more detail on differential diagnosis and the gist of this article by those who are much more switched on and have their heads in the research every day, check it out if you’d like further info on differential diagnosis, sub-grouping and an algorithm on management for this condition..
“Actual Tennis Elbow”
The single hand backhand stroke itself is a very powerful action, the elbow extends at 982deg/sec, going from around 116 to 20flexion in 0.21seconds.
Although elbow stability comes from the bony anatomy in <20flexion and >120flexion, in this ballistic backhand range (20–120 ROM) the stability of the elbow relies on the joint capsules and ligaments for stability as well as dynamic muscle control, in particular the wrist flexors to support the UCL and medial elbow (Morris, Jobe, Perry, Pink, & Healy, 1989).
The single hand backhand stroke is one of the biggest contributors to Tennis Elbow, particularly for recreational/club players. One of the main causes of the main causes of this could be the ‘wrist lag’ that recreational players can have on ball contact, where the wrist is in more wrist flexion.
Actual Tennis Elbow — Assessment of the Elite Player
By now, this article has covered the early to mid stages of rehab for everyone who has this condition (ie, Average Joe/Jane) however for athletes such as Professional Tennis Players one really needs to look at the entire body/kinetic chain. I will save exactly what I’d do for an elite Tennis Player for a future solo blogpost on it as it will be in-depth but I’ll just jot down some things one will need to look at:
- Lower limb and trunk strength and mobility deficits
- Posterior shoulder and triceps strength deficits
- Dynamic stability trunk and upper limbs
- Working with Coach to analyse technique, particularly the Serve and movement patterns on court
- Working with the Coach to analyse equipment (more on equipment below)
- and much much more
But for those of us working in Private Practice who are treating the recreational/club player, below are some areas you can explore to help them out.
Actual Tennis Elbow — Technique
From a coaching point of view it is usually because the prime candidate for Tennis Elbow (middle aged recreational player) generally have a lack of preparation and footwork, in particular getting behind the ball so that the contact point is far out in front of the body. In other words, the later the ball is struck, the further back the contact point with the ball and the more there will be wrist flexion on contact, and we know that pronated wrist flexion on an extended arm with a load on the wrist extensors will compress the ECRB tendon into the radial head, which it doesn’t like.
This technique flaw could be from the activity itself, such as hitting with a ball machine or a wall which does not give the player time to recover with their footwork and get behind the next ball and properly prepare.
Or it may be from playing excessive doubles throughout the week. Doubles play doesn’t allow for good court movement and preparation as much as singles play does. There’s also more volley work and backhand volley may also load the recreational 40–60yo elbow more often. I’ve written about this in another blog called: Doubles Trouble — Upper Limb Pain in Club Tennis Players
Another technique change that can lead to tennis elbow is dropping the finger off the end of the racquet in the serve. Players will do this if they’re trying to increase their wrist radial to ulnar deviation range of motion, however dropping the little finger off the racquet makes the middle and ring finger work harder to generate grip strength, as the little finger locks in grip strength. Increasing the use of the middle finger for grip strength can overload the ECRB tendon and lead to ECRB related tennis elbow.
Actual Tennis Elbow — Equipment
A racquet that is too heavy (usually 330g+ for recreational players), a head heavy balance, and/or a string tension that is outside the comfortable range for the player (usually 46–54lbs for recreational players), can increase the risk of developing Tennis Elbow in recreational players.
Hitting against a wall can require a high demand on recovery and preparation for the next shot causing delayed contact repetitively, a risk factor as aforementioned. Likewise, regular hitting with a ball machine can lead to lack of preparation and movement with every shot and overloading the forearm.
A worn overgrip on the racquet handle can reduce friction between the hand and the racquet requiring extra force from your forearm to stop it from slipping, please never play with overgrips that have sign of wear.
I’ve heard many theories about the size of the grip and its effect on Tennis Elbow, but (like footwear and many foot conditions) it just comes down to comfort. If having an extra overgrip on makes it feel more comfortable, do it. If you are more comfortable feeling the bevels and having less padding over the grip, do it. The general rule for grip size is to have one-fingers space between the tip of your fingers and your palm (see below).
Playing with dead balls or damp/wet balls (eg: winter nights) can also put an extra load on the upper limb. Although Golfers Elbow (medial elbow) is more likely stirred up with dead and heavy wet balls, and Tennis Elbow can also be stirred up. When in doubt, use fresh balls when possible.
If I had Research Funds
I’d do the first study looking at Tennis Elbow patients in three groups:
1. Wait and See as a control.
2. Activity Modification/Education and wait and see
3. Activity Modification/Education and ‘Non Provocative Arm Loading’ (NePAL)(NePAL being the term given to my process of loading Tennis Elbow described in the above blog).
Comparing the 3 groups over 6/12/24/52 weeks, the determine the effect of activity modification/education vs wait & see as well as activity modification/WNePAL vs wait & see. This is to validate the NePAL rehab and/or activity modification as effective treatment.
Then the second study would compare three groups:
1. Activity Modification/Education and NePAL
2. Activity Modification/Education and ‘Commonly Prescribed Physiotherapy Exercises’ (based on Vicenzino 2003 and Bisset 2015)
3. Activity Modification/Education, ‘Commonly Prescribed Physiotherapy Exercises’, and Manual Therapy.
Comparing the 3 groups over 6/12/24/52 weeks, the determine the effect of my described NePAL vs common Physiotherapy exercises and manual therapy.
Finally, the third study would compare three groups:
- Wait and See as a control
2. Activity Modification/Education and NePAL
3. Activity Modification/Education, NePAL and Manual Therapy
Comparing the 3 groups over 6/12/24/52 weeks, the determine the effect of combining WNL and Manual Therapy (and passive exercises such stretches). This is probably the “best practice” at the moment, combining active and passive treatment modalities depending on the patient.
This is VERY similar to how what I’d like to study over 3 studies in Golfers Elbow.
Summary
Well …. There you go, we’re at the end. Thanks to all 3 of you who made it this far, including you Mum.
I can’t call myself “The Tennis Physio” without writing something on “Tennis Elbow”, it’s been long overdue but I thought it would be worth sharing as I’ve had a great year professionally due to some small changes in my management of this condition.
What started off as ‘Nicks summary on how he manages Tennis Elbow differently and simply’ turned into 28 pages in a Word Document and eventually a big 30–40min read on here, the interwebs.
Once again, do things your way if it works, my method is one way of many tackle a complex musculoskeletal condition. However, if there is a simple way to make a complex issue resolved that also improves the self-efficacy of the patient where they are confident that they can take control of their own condition, I will always gravitate towards it.
As already mentioned, we are still in the ‘Wild Wild West’ when it comes to managing this tricky condition. There is still much to learn. However at the same time there is much to unlearn.
I think it requires a good amount of Clinical Time in the first appointment (45–60mins) for the Clinician to take a thorough history, fully assess the arm/neck, explain the condition, provide activity modification advice that relates to the patient, trial a home intervention and reassess, and then provide treatment as required, using pain-free grip strength as a guide.
Did you enjoy this blog or learn something new that will help you with your clinical practise?
Are you a patient and has this helped you in some way?
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References
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