Lateral elbow tendinopathy, commonly known as tennis elbow, is a prevalent condition that affects individuals engaged in repetitive arm movements. It is characterized by pain and tenderness on the outer part of the elbow, often resulting from overuse or strain of the common extensor tendon. This condition can significantly impact a person’s ability to perform daily tasks and engage in sports, particularly those that involve gripping or wrist extension. In a recent podcast with musculoskeletal physiotherapists Dr. Leanne Bisset, key strategies for the assessment, treatment, and rehabilitation of lateral elbow tendinopathy were explored. This blog post synthesizes her insights, offering a comprehensive overview for practitioners or individuals suffering from this condition looking to enhance their understanding and management of this condition.
Risk Factors for Lateral Elbow Tendinopathy
Lateral elbow tendinopathy is a condition that affects many individuals, particularly those who engage in repetitive arm movements or strenuous activities. While commonly associated with athletes, this condition can occur in anyone whose daily activities strain the tendons of the forearm. By understanding the key risk factors, you can take proactive steps to identify and address the condition effectively.
Age as a Contributing Factor
Age plays a notable role in lateral elbow tendinopathy, with the condition more frequently occurring in individuals over 40 years old. Degenerative changes in the tendons, which naturally increase with age, are a significant contributing factor. However, this does not mean that younger individuals are immune to the condition—it is simply much less common in those under 40, and very rare in individuals in their early 20’s or younger.
Thus, for younger patients, symptoms that resemble lateral elbow tendinopathy should prompt careful consideration of other potential causes. In some cases, acute trauma may result in tendon, ligament, or larger areas of damage that mimic the condition. Therefore, if a patient in their 20s presents with symptoms, thorough questioning and differential diagnosis are essential to determine the underlying cause.
The Role of Repetitive Strain
Repetitive strain is one of the primary drivers of lateral elbow tendinopathy. Activities that involve repetitive gripping, particularly with the wrist extended and pronated, place substantial stress on the extensor tendons of the forearm. Over time, this can lead to microtears, overuse injuries, and tendon degeneration.
Manual laborers, office workers, and recreational athletes are particularly at risk due to the repetitive nature of their tasks. For example:
- Manual laborers often perform tasks requiring forceful gripping or lifting, which strain the tendons extensively.
Athletes in sports like tennis, golf, or squash frequently engage in repetitive arm movements, which increase the risk of developing the condition, especially when techniques or equipment are not optimal.
By addressing biomechanical factors such as racket grip size or lifting posture, you can reduce the likelihood of overuse injuries and help patients recover more effectively..
Precipitating Events: Acute Trauma vs. Degeneration
Although lateral elbow tendinopathy is generally associated with chronic overuse, a specific precipitating event can sometimes trigger the condition. For instance, a sudden, forceful motion or injury may cause significant tendon damage, leading to symptoms.
In such cases, the injury often results in more extensive tissue damage, such as tears, compared to the gradual degenerative changes typical of the condition. Identifying these events through careful questioning is essential, as they may impact the severity of the condition and influence the treatment plan.
Assessment of Potential Lateral Elbow Tendinopathy
Assessment begins with a thorough patient history and an understanding of the mechanisms of injury and specific pain triggers. After carefully listening to the patient and discarding potential red flags, assessment typically continues by palpating the elbow, particularly focusing on the lateral epicondyle and the surrounding musculature, which includes the common extensor tendons.
During palpation, clinicians apply pressure to these areas while asking the patient to perform specific movements. This process helps pinpoint the exact location of the pain and identifies any relationship to the tendons involved. Additionally, the clinician should also assess the patient’s range of motion and functional abilities to understand the condition’s impact on their daily life and activities. Functional assessment may include observing the patient’s ability to perform tasks that exacerbate their symptoms, such as gripping or lifting objects. Thus, understanding how the patient’s pain correlates with their daily activities is crucial for tailoring an effective rehabilitation program.
Differential diagnosis
In cases of lateral elbow tendinopathy, the pain is highly localized to the lateral epicondyle. A key characteristic of this condition is that pain can be pinpointed directly over the lateral epicondyle and the first centimeter of the tendon. If the pain is strictly localized and does not spread, it is likely an isolated tendinopathy. Conversely, if the presentations are severe or the patient reports pain extending around the back, down the side, or over the dorsum of the forearm, you should explore other possibilities and the involvement of other structures.
The LCL has been implicated in individuals with severe presentations, trauma, and in those who have received corticosteroid treatment. While there is no confirmed causal relationship between corticosteroid injections and the involvement of the LCL, some research and speculation suggest a possible connection. The LCL serves as the primary restraint to varus forces at the elbow, and it has been shown that in 40% of lateral elbow tendinopathy cases, there is involvement of the LCL. Additionally, valgus force occurs in many daily activities, such as lifting objects, especially with an outstretched arm. In severe presentations, the LCL and the head of the radius may contribute to the pain, making it essential for you to incorporate stress testing of the LCL and radial head into your examination.
Diagnostic Testing
Tendinopathy is typically straightforward to diagnose through clinical examination. Specific tests that provoke pain in the common extensor tendon include:
- Gripping in an extended and pronated position.
- Resisted wrist extension (Cozen’s test).
- Resisted third digit extension, which directly loads the carpi radialis brevis (ECRB).
If these tests elicit the expected pain response at the lateral epicondyle without other presentations, the diagnosis is consistent with an isolated tendinopathy. However, if pain patterns deviate from these findings, further investigation should be warranted to identify other contributors.
Addressing Severe Presentations
Additionally, consider the patient’s history, including trauma or use of corticosteroids, as part of your evaluation. In more severe cases of lateral elbow tendinopathy, especially those with suspected LCL involvement, performing stress testing of the LCL and testing laxity of the radial head should be considered. You can apply, for example, the tabletop relocation test or the posterolateral rotatory drawer test.
Treating tennis elbow
1. Education and Load Management
Understanding and managing load is foundational in treatment. As a clinician, you should educate your patients on avoiding aggravating activities, such as repetitive gripping or wrist extension in a pronated position. Additionally, encouraging them to use pain as a guide can help. A general rule is to keep pain during activities at no more than 3-4 out of 10, and it should settle within half an hour to an hour after exercise. If persistent pain or worsening symptoms occur, this should signal the need for adjustments.
2. Exercise Therapy
Exercise has proven to be superior to passive treatments, although not to a great extent. Nevertheless, this treatment modality is still superior to any other, as it has the capacity to promote healing and regeneration of the tendon tissue. Pinpointing the adequate load is crucial; however, overloading will lead to tissue breakdown and aggravate symptoms. It is important to note that you should stay below a Numeric Pain Rating Scale (NPRS) of 3-4 during and after the exercises, and pain should resolve within 24 hours, but ideally within an hour or two.
Isometric Loading
Begin with isometric exercises targeting the wrist extensors. Position the pronated forearm on a tabletop with the wrist and hand extending off the edge. Start with a low load, such as 1-3 kg or less, and aim for holds lasting up to a minute, repeated three times daily. To reduce finger flexor activation and minimize load, use a resistance band looped around the hand. Furthermore, adjusting the elbow position can modify stress on the joint; for instance, performing the exercise with the elbow flexed to 90° decreases the load on the extensor group.
Progression involves gradually increasing the resistance. You can replace the band with a dumbbell or a bottle of water to add more challenge, which will engage the flexor muscles as well. A realistic goal is holding 1 to 3 kg for a few minutes. For manual workers, this goal can extend to holding up to seven minutes, reflecting the primary function of the extensor muscle group as positional stabilizers rather than primary movers.
Progression
Progression can be achieved by gradually increasing the load and switching to a more functional approach, depending on pain. For example, a tennis player can begin using a racket, focusing on proper technique and exercises that engage both the elbow and shoulder. This approach helps replicate sport-specific movements and prepares the individual for a return to activity. For manual workers, whose tasks often involve repetitive wrist movements, consider implementing a concentric-eccentric exercise program. Limit the load to a maximum of 3 kg to safely build strength and endurance in the wrist and elbow.
3. Adjunct Therapies
Several adjuncts can complement exercise therapy to optimize pain relief and support recovery:
- Taping: Techniques such as the spiral method, which supports the elbow during motion, can provide pain relief and a sense of stability. Ensure proper application to avoid skin irritation or discomfort.
- Bracing: Elbow braces may help by reducing pain on the affected area. However, patients should be instructed on their correct use to avoid complications, such as nerve compression.
- Manual Therapy: Lateral glides at the elbow can provide pain relief and facilitate exercise progression. These glides involve stabilizing the humerus and applying a lateral force to the ulna.
- Shockwave Therapy: High-level evidence suggests it is not beneficial for lateral elbow tendinopathy and may even worsen outcomes.
- Dry needling: dry needling may have a more favorable profile for pain management. While evidence supporting dry needling is less robust than for other treatment modalities, some studies suggest that it can help alleviate pain for certain patients. The primary goal of dry needling should be pain management rather than directly stimulating tendon repair.
5. Addressing Contributing Factors
- External Load Factors: For athletes, consider reviewing equipment like racket size, grip, or string tension. Stroke correction or coaching may also reduce stress on the elbow, thereby decreasing the risk of a recurring injury.
- Patient-Specific Considerations: For individuals with hypervigilance or low confidence in movement, it is crucial to build trust and gradually increase their activity levels. Addressing psychological factors can significantly enhance recovery outcomes.
6. Prognosis and Treatment Duration
Treatment typically spans 6-8 weeks for optimal outcomes. Research indicates that longer programs with consistent therapy yield better results compared to shorter interventions. If symptoms persist beyond this period, reassessment and potential adjustments in treatment strategy should be strongly considered. This may involve revisiting the initial diagnosis, evaluating adherence to the treatment plan, or considering alternative therapies to address any ongoing issues.
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