Tennis Elbow

By Rich Baudry, PT, DPT, OCS

Tennis elbow, also called lateral epicondylitis, is a common elbow problem. As a tennis player, I often see players strapping on forearm braces, rubbing their arms while conversing with each other about their elbows. They talk about shots, acupuncture, and stretching; discussing what works and what doesn’t work. It seems as though most tennis players at some point have either experienced or know someone who has experienced tennis elbow, and, while there are many reasons for developing tennis elbow, playing tennis is a common cause.

Technically, lateral epicondylitis means inflammation of the lateral epicondyle–the bone on the outside of the elbow. This is where the tendons of many of the wrist/forearm muscles attach. Tennis elbow is characterized by pain in the outside of the elbow. Physiologically, what appears to be happening is the muscle/tendon/bone unit incurs repeated trauma. This trauma causes micro-tearing and subsequent scarring of the soft tissues about the elbow. The body tries to heal the tissue but is not able to keep up with the repeated damage. As such, the muscle/tendon structure becomes weakened and painful.

In the beginning stages of tennis elbow, a player may feel pain while using the elbow which subsides when they stop playing or moving the elbow. These symptoms do not bother the player enough to quit so they continue to play, aggravating the injury even further. As micro-tearing continues, symptoms or pain gradually become more pronounced and more frequent. The player may take medication, like ibuprofen, to control pain so they can continue to play. They may also invest in a brace purchased at the pharmacy.  For the time being, the player is successful at keeping the symptoms controlled so they keep playing.  Eventually symptoms become bad enough to limit their play and this is when the player seeks medical advice.

While there are many sources of information and individuals giving advice, the most commonly sought advice includes:

  1. Medical Doctors, who often recommend rest, medication, and stretching. This approach usually yields quick relief of symptoms, sometimes permanently. Other times the relief is temporary, only to return when the player resumes playing. Doctors frequently refer their patients to physical therapy, and prescribe exercises to strengthen the damaged tissue. Cortisone shots may be given to decrease pain. It should be noted that while this treatment is effective you need to be careful with how many injections you receive. (Check out this article from the New York Times discussing the effectiveness of cortisone shots.) If the condition is advanced, and does not respond to conservative treatment, orthopedic surgeons sometimes resort to surgery to repair the traumatized tissues.
  2. Physical Therapists, generally prescribe treatments to decrease pain, stimulate healing, and restore the function of the arm. Treatments usually include activity modification, manual therapy, and therapeutic exercises to stretch and strengthen the area. This approach can also yield good results, but the treatment must include the right type, intensity, and frequency of exercise, as well as skilled manual therapy and an effective home program.
  3. Physical aids are often used to manage tennis elbow. There are dozens of braces and devices people use to help relieve tennis elbow. The purpose of a brace is to decrease or spread the forces across the forearm muscles.  By decreasing the trauma to the region, the tissue is allowed to heal. These braces may have some benefit for decreasing the load on the tissue allowing time to heal, but do nothing to strengthen or recondition the tissue to tolerate the repeated trauma avoiding future injury. As a result, the player may grow to rely on the brace for tennis and maybe even other activities.
  4. Rest works by decreasing strain to the tissue. While resting allows time for healing, it does nothing to recondition the tissue to get the player back to tennis. As a result, when the player resumes tennis competition, symptoms often return.
  5. Other reported treatments for tennis elbow may include visits to massage therapists, chiropractors, and acupuncturists. Treatments may include ultrasound, electrical stimulation, and manipulation.  If comprehensive, some of these approaches can help with tissue healing and pain reduction.

The truth is tennis elbow is difficult to treat; especially if the individual wants to continue to play tennis. I believe there isn’t a singular solution to curing tennis elbow as there are many treatment approaches for the problem.  I believe a comprehensive program addressing the root causes, promoting healing, and reconditioning of the tissue provides the best chance for full recovery–getting you back to the game you love.

4 keys to treating tennis elbow:

  • Early intervention. Seek out the advice of a medical professional as soon as symptoms are recognized. Do not assume the problem will just go away.
  • Make sure you clearly understand the injury and why it is happening.
  • Consult medical professionals you trust and who can provide you with a clear plan for recovery.  Your treatment should involve a strategy to decrease pain and promote healing while addressing the causes and promoting reconditioning of the damaged tissue. You need a plan that will get you back on the tennis court.
  • Work with your tennis professional for technique management and proper equipment fitting. Faulty mechanics and inappropriate equipment can definitely contribute to the problem. Specific things to address with your pro include serving, volleying, and backhand technique. Grip size, and racket weight may also be adjusted to help reduce strain to the elbow.

Tennis elbow treatment from a Physical Therapy perspective:

  1. Consult with a medical professional.
  2. A thorough evaluation is necessary in order to determine the source and contributing factor(s) associated with the injury. Some contributing factors can be postural weakness and/or pathology at the elbow or other joints.
  3. Patient education: it is imperative you understand the condition, what causes it, and how you can help the healing process. Physical therapists are well versed in this type of injury and can provide a clear understanding of the problem.
  4. Manual therapy is necessary to stimulate tissue repair triggering the healing process. Baudry Therapy Center utilizes the ASTYM system, which works by breaking down scar and soft tissue adhesions contributing to the pathology. ASTYM is a technique which has been one of the most effective treatment techniques we utilize in treating tennis elbow.
  5. Exercise with stretching and strengthening to recondition the tissue in order to tolerate the forces of playing tennis. The amount of resistance, number of repetitions, and frequency are crucial here. While generally you want to stretch and strengthen the forearm muscles, the exact exercises are determined through an evaluation process.

Once again, your best chance for recovery is a comprehensive program to decrease pain, stimulate healing, and re-condition the tissue for sport. Don’t let tennis elbow stop you at the baseline. Get some professional help and stay in the game.

Self Assessment: Muscle and Tendon Strains

By Rich Baudry, PT, DPT, OCS

We recently received an inquiry asking how to tell if you have pulled a muscle or torn a tendon without having to undergo an MRI.

First of all, let me begin with a basic description of the relationship between muscles, tendons and joints. Tendons attach muscles to the bones. A muscle/tendon unit crosses a joint to enable movement around the joint. Contraction of a muscle pulls on the bone through it’s tendon in order to create movement of a joint. As such, when someone suffers a muscle or tendon tear they will have difficulty generating pull or force to move the joint.

When an injury occurs to a muscle or tendon, pain will be felt when it is stretched and/or when resistance is applied to that structure. When stretching and resisted testing elicits pain in the tested muscle/tendon unit, you most likely have suffered an injury to the involved muscle or tendon. The severity of the injury will be known by how much pain and weakness are noted with testing. If you have no ability to resist or contract a certain muscle action you may have a complete rupture of a tendon.

If you have pain in or around a joint that hurts when you are in certain positions but does not necessarily hurt with resistance to the muscle, you may have a joint, ligament, or other structural problem.

This understanding of muscle and tendon testing can be applied to muscles throughout the body. However, please note that this is an over simplified example of muscle/tendon testing. If you think you have had a muscle/tendon injury–or any other injury–you should  have it checked by a medical professional early on. Your medical professional will be able to clearly identify the source of the injury and establish an action plan to promote a speedy recovery. When taken care of promptly, most muscle/tendon injuries respond well, getting you back in the game quickly.

Conversely, while waiting it out sometimes works, it often delays healing and leads to unnecessary residual limitations that can come back to haunt you later on. These limitations become harder to treat and take care of the longer it goes unattended. So be sure to treat your injuries as soon as possible in order to avoid long-term consequences.

Thanks so much for your questions. We value your feedback and please keep them coming!