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Tennis Elbow Not Exclusive to the Tennis Enthusiast: How to Manage It and Preventative Strategies

08/29/2013 01:36 pm ET | Updated Oct 29, 2013

In my close to 20 years of practicing orthopedic physical therapy I have treated a myriad of different disorders, but there are always some that seem more challenging to fix than others. One of the diagnoses that falls into this category of refractory conditions is "tennis elbow" or medically-termed lateral epicondylitis. The patient will typically complain of localized pain along the lateral elbow region. This is where the wrist extensor tendons originate and have a role of lifting our hand/wrist during functional tasks or just supporting it in an upright posture.

The competitive tennis player is at obvious overuse risk of stressing these tendons due to the nature of the sport involving gripping the racquet as well the impact of hitting the ball. However, many of my patients have never picked up a tennis racquet yet are diagnosed with this disorder. The reason is these tendons are repetitively stressed with much of what we do during our daily lives. Some of the stresses are simply typing on the computer, as I am reminded as I write this blog. Others include lifting or repetitive gripping tasks that involve much of one's daily routines, from brushing your teeth, squeezing a jar to open it, or maybe even a heavy door, to carrying the groceries home or your briefcase to work. The two tendons typically involved are primarily your extensor carpi radialis brevis and its longer brother, the extensor carpi radialis longus.

Unfortunately, most individuals by the time they come to see me or their doctor are often in the next phase, from inflammation of the tendon or a tendonitis to more of a tendinosis. So their diagnosis may be more accurately deemed lateral epicondylosis (LE). "Lateral Epicondylosis (LE) is a prevalent and costly musculoskeletal disorder of the common extensor tendon, characterized by degeneration of the tendon and frequently reported pain at the lateral aspect of the elbow." [1, 2, 3]

In contrast to a tendinitis, tendinosis typically will not demonstrate inflammatory cells but will have three characteristic traits. These tendon changes due to LE include disorganized collagen fibers, vasscular hyperplasia and a dense population of fibroblasts (scar tissue). [1, 4, 5] One of the theories behind why this condition is more difficult to treat lies in the fact the pathophysiology is not well understood.

One of the early suggestions to my patients is to try to modify their activity, including limiting carrying items that are heavy that require a stronger grip, as well as limit these activities with a straight elbow. The stress on the wrist extensor tendons is much greater with the elbow extended, so by simply carrying or working as best one can with the elbow in a more flexed position while using the hand will help offset some of the stress on these tendons.

During the rehabilitation of one with LE, it has been shown that more of an eccentrically-focused strengthening program is best. [5] More recently, it has been suggested that the "rate" of force development is critical key measure in outcomes in patients with LE. [1] Chourasia et al suggested that strengthening exercises that address grip strength may not address the deficient rate of force development in these tissues. Therefore, the authors suggest patients need exercises that have a "velocity-dependent" component, not solely resistance training. [1]

In the below video, I will take you through some basic exercises to help strengthen the wrist extensor tendons as well as maintain proper flexibility and then suggest some "velocity-dependent" exercises to help improve the rate of force for these muscle groups. Remember, these exercises are not meant to substitute for formal treatment -- they are meant as a preventative strategy. Please seek out a physician if you have been having pain and then a qualified physical therapist to begin the healing process.

References:

1) Chourasia A, Buhr K, Rabago D et al. Relationships between biomechanics, tendon pathology, and function in individuals with lateral epicondylosis. J Orthop & Sports Phys Ther. 2013;43:368-378.

2) Johnson GW, Cadwallader K, Scheffel SB, Eperly TD. Treatment of lateral epicondylitis. Am Fam Physician. 2007;76:843-848.

3) Hong QN, Durand MJ, Losiel P. Treatment of lateral epicondylitis: where is the evidence? Joint Bone Spine. 2004; 71:369-373.

4) Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999;81:259-278.

5) Nirschl RP. Elbow tendinosis/tennis elbow. Clin Sports Med. 1992;11:851-870.

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