Tennis elbow.

Anatomy of the forearm

The elbow joint is created by the coming together of the upper arm, ulna and radius. Because these bone pieces can slide neatly over each other, movements such as stretching and bending the elbow and rotating the forearm (supination and pronation) are possible. With a side view, we can see several muscles running around the elbow that all have their own (and sometimes overlapping) function in movement.

As everywhere in the body, something can go wrong with certain muscles. Here we actually distinguish two possible problem areas. A muscle (or tendon) can overload Or there may be a (partial) rupture in arise. The most common muscle problems in the elbow/lower arm region we find in the m. extensor carpi radialis (longus/brevis). These are muscles that have their origin at the most lateral tip of the elbow (and just slightly above it) and run from there to the 2nd and 3rd finger knuckle. The function of these muscles is to stretch the wrist and a so-called radial deviation (moving the wrist to the side toward the thumb side). The extensor carpi radialis longus has its attachment just a little higher on the upper arm than the brevis, hence this muscle provides some support in bending the elbow.

Quick Facts

  • A tennis elbow occurs mainly in the 40-50 age group.
  • It is a overload complaint which results from frequent repeated unilateral loading on the tendon.
  • It is a self-limiting symptom. So basically it resolves itself. This can take weeks to months. 89% of people are symptom-free after 1 year.
Elbow
What is tennis elbow

An epicondalgia lateralis (formerly epicondylitis lateralis) or also known as tennis elbow is an overuse complaint of the extensor muscles of the wrist. Usually the problem is located around the origin of the muscles in the elbow region. This is therefore where the recognizable pain stated. Despite the fact that the complaint is often referred to as a muscle-related problem, it is in fact the tendon insertion on the bone that is the problem in most cases. During any movement that requires these muscles to be active, forces are transferred to the tendons and attachments on the bones. If this happens too often over a period of time, it can lead to irritation. Often the tennis elbow A syndrome in which people develop symptoms over time. So this is because the tendon does not get enough rest after strain to recover properly. Hairline cracks develop in the tendon and, as the body's attempt to keep the tissue in order, tendon tissue of poorer quality develops. These changes in tendon structure occur when the symptom has been present for a longer period of time and could occur with imaging examination are visible. From the outside, you are not going to be able to feel or locate such changes.

Risk factors

The most well-known risk factor for developing tennis elbow is the frequent repetition of the same movements. This may be because you have to do a lot of chores and tinkering, for example, but low-intensity activities such as typing on a keyboard are also associated with the development of tennis elbow. Despite its name, in only 5% of people can tennis elbow be related to playing tennis. In addition, it is an injury more commonly seen in people who have to do a lot of lifting and the complaint usually arises on the dominant side of the body. Despite the fact that this side of the body is often better developed, the complaint arises precisely here because this side also has to endure much more. Especially in people who work a lot with their hands. A tennis elbow is most common in people between the ages of 40-50.

Complaints and symptoms

The symptom pattern in a tennis elbow consists of a confluence of several factors. So often we see that people have an occupation that involves a lot of hand work (or have done a lot more hand work recently). Further fitting the symptom picture is;

  • Pain around the outer part of the elbow with possible radiation to the forearm.
  • Complaints that develop slowly and increase over time.
  • Often relatively little trouble at rest.
  • Worsening pain with overhead lifting and wringing/ pinching.
Research

Often the diagnosis is tennis elbow already clear following all the information from the intake interview. To this, the therapist can add several tests to be sure that tennis elbow is present.

Palpation
By palpating the extensors (primarily in the area around the elbow), it can be determined if recognizable pain occurs in the area appropriate to the complaint.

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Stretch test
With the elbow in an extended position, the forearm is rotated and the wrist with the fingers fully flexed. When there is recognizable pain, the test is positive.

Cozen's test
In Cozen's test, the patient is asked to place the arm on the table in an extended position. Then, with a clenched fist, the patient is asked to apply force to dorsal flexion/extension and radial deviation. The occurrence of recognizable pain in the attachment region (lateral epicondyle) of the extensors makes the test positive.

Maudsley's test
In the Maudley's test, we see a similar performance to the Cozen's test. The starting position is the same except for the position of the hand. This is because in the Maudsley's test, the fingers remain extended and the therapist asks you to move them up against resistance. This involves the 2nd and 3rd fingers. This is because the attachment points of the extensor carpi radialis longus and extensor carpi radialis brevis are located here. Recognizable pain around the lateral epicondyle makes the test positive.

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Additional imaging studies

Performing imaging research in the form of X-ray or ultrasound is of no value in tennis elbow. Generally, the diagnosis is tennis elbow namely good to set and further investigation does not change anything about the policy to be pursued.

Treatment and prognosis

The expectation in recovery from a tennis elbow is basically good. It is just hard to say how long recovery takes because it varies tremendously from one individual to another. Research shows that 80% of people recover within six months and 89% of people with tennis elbow symptoms within 1 year complaint-free is. Sometimes, as people start to relieve the affected arm, over time you see symptoms develop in the other arm as well. This is just pure bad luck. Basically, tennis elbow is a self-limiting complaint. That means you would expect it to go away on its own someday.

When you come to the physical therapist and the tennis elbow has been established you will naturally get to work treating the complaint. The first step in the process is to provide the right information and advice. Important for the recovery is to make (temporary) adjustments in the daily use of the arm. Because in the majority of people the symptoms are work-related, you will have to see if it is possible to rearrange the work. This is going to give the tendon more time to come to rest. Of course, this advice also applies to certain sports and other activities that involve a lot of strain on the arm. How long this advice applies depends on the course we will see over time. Assume in advance that it's going to be a process of months, then it might just be better than expected.

Treatment options

The physical therapist has various methods/techniques to help shape treatment in the continuing treatment process. The following treatment methods are best known for tennis elbow symptoms:

Massage/friction
Massage or in tennis elbow complaints also called deep friction massage can bring quite good long-term results.

Exercise Therapy
Literature advocates the use of exercise therapy in tendon complaints such as tennis elbow. Primarily, eccentric loading of tendon tissue (loading as the muscle lengthens) seems to be able to provide proper stimulation to reduce symptoms over time. In addition to eccentric loading, the training method HSL (heavy slow resistance) works just as well. The idea is that through controlled high tension on the tendon, it is stimulated to start creating strong new fibers. In addition to taxing exercises, stretching the muscle is also used within the realm of exercise therapy. Holding the muscle/tendon in a stretched position for an extended period of time could produce pain-relieving effects. It is important that exercise therapy is applied with proper regularity and also sufficient rest to recover from the given strain. In principle, exercise therapy can be used in combination with forms of therapy such as friction, kinesio tape and/or dry needling.

Brace/tape/dry needling/shockwave
The use of a brace has no scientifically proven effect. In practice, patients' experiences are mixed. Some say they noticed a difference when using a brace, others did not. The question is whether, if a difference was noticeable, it was based on the use of a brace. Based on insufficient scientific evidence to date, we cannot recommend the use of a brace.

Kinesio tape has gained greatly in popularity in recent years for a variety of physical complaints. For a period of time, kinesio tape was also used very widely for tennis elbow complaints. Fairly recent studies still advocate the use of kinesio tape in the treatment of tennis elbow complaints. This is because good results can be achieved when it comes to reducing pain. However, this treatment method should be used in conjunction with exercise therapy for best results.

With dry needling, small needles are pricked directly into the muscle or tendon by the physical therapist. Its purpose is to stimulate sensors in the muscle or tendon that produce pain-relieving effects. In addition, there are indications that this form of therapy positively stimulates the body to initiate the correct recovery factors in the affected area. Research shows that dry needling gives significantly better results after several weeks and still after several months than treatments consisting of the use of only medication and a brace.

Several studies have been conducted on the effect of shockwave therapy on tennis elbow complaints. To date, results have been mixed. The literature does not currently recommend the use of shockwave on tennis elbow complaints over other treatment options due to varying results and high costs.

Medicated
Analgesic medication may be part of the treatment. This is especially advisable for people who experience a lot of pain. It should be noted, however, that the intention is of course to comply with the advice given. Depending on the symptoms and the severity of pain, a choice can be made in the use of paracetamol, NSAIDs to be applied to the skin or the prescription of ibuprofen, diclofenac or naproxen. Never just go ahead with these. Your primary care physician is the person of choice when it comes to medication use. So always consult them before starting medication.

Putting a corticosteroid injection is also a well-known drug treatment method. Basically, however, it is not recommended to use this. The pain-relieving effects of the injection are generally good. This is of course nice because then you experience less pain symptoms. The downside of this is that for most people, it causes them to quickly start straining more, which causes the symptoms to return. The injection has a pain-relieving effect, the recovery of the tendon still needs time. Annoying perhaps, but better to just let the process take its course and wait and see.

Conclusion

Several treatment methods seem to be able to offer good results when it comes to treating tennis elbow complaints. There is no gold standard and so it is always a bit of a puzzle as to what will work best. We reiterate again that tennis elbow is basically a self-limiting complaint. So it should be able to repair itself over time. The role of the physical therapist lies in advising and guiding this process. The treatment methods described can be used and will in no way impede the process of recovery. Nevertheless, the biggest challenge is that recovery may require a lot of patience on your part.

Well, there are no short-cuts when it comes to tissue repair. So do you come across someone who promises to be able to offer them? Then think twice before you start alternative treatments just like that. Before you know it, you will have not only pain in your arm but also in your wallet.

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