What is Tennis Elbow?
Acute Tennis Elbow is an injury to the muscles that extend the wrist and fingers. The injury site is typically the lateral epicondyle, a bony bump on the outside of the elbow where these muscles attach. Tennis Elbow symptoms lasting more than six weeks become sub-acute and beyond three months, as chronic tennis elbow.
Tennis Elbow Symptoms?
Typically the Tennis Elbow sufferer will experience pain when performing gripping tasks or resisted wrist/finger extension. There will be tenderness directly over the bony epicondyle, and there may be trigger points in the wrist muscles. Pain can also be present when the muscles overstretch.
Some sufferers will also have neck stiffness and tenderness, as well as signs of nerve irritation. Most elbow movements will be pain-free, despite that being the area of pain.
What Causes Acute Tennis Elbow?
Acute Tennis Elbow is caused by damaged muscle tissue when it anchors to the arm bone at the elbow. It occurs when more force is applied to an area than normal healthy tissues can handle.
Common Tennis Elbow Causes include:
- Unaccustomed hand use, e.g. painting a fence, hammering, lots of typing.
- Excessive gripping or wringing activities
- Weak forearm muscle strength or tight muscles
- A poor technique (this may be a poor tennis shot)
In some cases, such as Chronic Tennis Elbow, this can occur due to the soft tissues being in poor health, which are easily injured. Inflammation follows the injury, which leads to swelling and elbow pain.
What Causes Chronic Tennis Elbow?
Chronic Tennis Elbow is associated with degenerative changes in the muscle tissues located at the epicondyle. Historically, chronic tennis elbow was related to inflammation from overuse. However, this is now known to be incorrect.
Chronic Tennis Elbow is NOT due to INFLAMMATION!
Testing of Chronic Tennis Elbow sufferers has shown no evidence of the chemicals usually associated with inflammation. Instead, there is an increase in chemicals associated with pain transmission in the nerves. This toxic chemical mix is coupled with changes in the blood supply and changes in the coordination of the muscles when using the hand and wrist. You also see degenerative changes in the extensor tendon, where the tendon structure starts to break down.
There is now evidence that longstanding forearm muscle imbalances can distort your elbow joint position and result in chronic tennis elbow pain. A muscle imbalance results in your decreased ability to perform normal elbow activities and reducing elbow and grip strength.
For diagnostic advice regarding your tennis elbow, please seek the advice of your trusted elbow physiotherapist or doctor.
How is Tennis Elbow Diagnosed?
Your physiotherapist or doctor clinically diagnoses your Tennis Elbow. After listening to your injury history and using some confirmatory clinical tests, they may determine a provisional diagnosis of tennis elbow.
An ultrasound scan or MRI are the best tests to identify any tendon tears or inflammation. X-rays are of little diagnostic benefit.
Referred Pain From Your Neck Can Mimic Tennis Elbow.
A significant percentage of tennis elbow sufferers may feel pain in the lateral elbow but not be experiencing tennis elbow. A high incidence of lateral elbow pain is referred to your elbow from a cervical spine (neck) injury.
The most common neck joint that refers to your lateral elbow is C5/6, which transmit pain signals along the radial nerve.
Your radial nerve may also have reduced neural mobility, which can cause symptoms similar to tennis elbow.
It is imperative to assess your neck and upper limb neurodynamics. An experienced elbow physiotherapist will confirm or exclude any neck dysfunction or neural tension. Failure to do so will result in a lack of symptom improvement and the development of chronic tennis elbow pain syndrome.
Who Suffers Tennis Elbow?
Tennis Elbow occurs commonly in the community. It is present in 40% of all tennis players (hence it’s named) and 15% of people working in repetitive manual trades. It can occur at any age. However, sufferers are generally between the ages of 35 and 50.
Predictably, the side affected is usually associated with handedness, but it can occur in the non-dominant arm. Males and Females are affected equally.
Tennis Elbow Treatment
Physiotherapy is helpful in the short and long-term management of tennis elbow.
Physiotherapy aims to achieve a:
- Reduction of elbow pain.
- Facilitation of tissue repair.
- A restoration of your normal joint range of motion and function.
- A restoration of your standard muscle length, strength and movement patterns.
- The normalisation of your upper limb neurodynamics.
- The normalisation of cervical joint function.
There are many ways to achieve these and, following a thorough assessment of your elbow, arm and neck, your physiotherapist will discuss the best strategy for you to use based on your symptoms and your lifestyle. Results typically increase your pain-free grip strength.
Physiotherapy treatment may include gentle mobilisation of your neck and elbow joints. Other treatment options available include elbow kinesio taping, muscle stretches, neural mobilisations, massage and strengthening.
In some instances, a tennis elbow brace may be beneficial. Your physiotherapist will discuss what treatment options are most suitable for you.
When Should You Use a Tennis Elbow Brace?
A tennis elbow brace can be beneficial from the moment you put it on. In these instances, the brace will dissipate the stressful gripping forces away from your injured structures.
However, a tennis elbow brace does not work in 100% of cases. In our experience, we recommend that you seek physiotherapy assistance in these cases. In stubborn cases, you have a very high likelihood of referred symptoms from your C5/C6.
Only a thorough examination of your neck, shoulder, elbow and upper limb nerve structures will confirm your diagnosis and direct which treatment options will assist you the quickest.
What is Your Tennis Elbow Prognosis?
Untreated Tennis Elbow can last anywhere from 6 months to 2 years. You are also prone to recurrence.
Studies have shown physiotherapy to be the most effective way of managing Tennis Elbow when compared to steroid injections or giving of advice alone. In a recent study, when given a 6-week course of physiotherapy comprising of 8 treatment sessions, most patients show significant improvement after three weeks, increasing to a 60% or more significant recovery after six weeks of treatment. This improvement continues to around a 90% improvement at 12 months, even without further treatment.
By comparison, provision of advice only resulted in a recovery of 60% or higher being delayed a further six weeks, to three months. Over more extended periods, patients given good advice did recover, and by six months had achieved similar gains to the treatment groups. These trends were maintained over time and continued to improve.
Cortisone injections resulted in excellent initial improvements, with an almost 80% reduction in symptoms after 3 to 6 weeks. BUT (and it’s a big one) patients who received cortisone injections showed an increase in pain after six weeks, and by three months had fallen well below both the physio treatment groups AND the advice only groups in terms of their recovery. This deterioration was followed by delayed healing, resulting in the cortisone injected group, having almost 30% more pain after 12 months than if they had followed advice alone.
For this reason, researchers do not recommend cortisone injections as a stand-alone treatment for Tennis Elbow.
Further research is currently underway to assess the effectiveness of cortisone injections combined with physiotherapy management to see if the initial early gains can be better maintained.
For more advice about tennis elbow, please ask your elbow physiotherapist.
Elbow Pain Causes
Please visit the links below for some of the more common sources of elbow pain.
Elbow-Related Arm Pain
Neck-Related Arm Pain
Muscle-Related Arm Pain
- DOMS - Delayed Onset Muscle Soreness
- Muscle Strain (Muscle Pain)
- RSI - Repetitive Strain Injury
- Overuse Injuries
Other Sources of Arm Pain
Common Treatments For Elbow Pain
With accurate assessment and early treatment, most elbow pain responds extremely quickly to physiotherapy that will allow you to resume pain-free and normal activities of daily living quickly. Some conditions may require diagnostic investigations such as X-rays, Ultrasound, MRI or CT scans. Fractures, dislocations and some severe or chronic injuries may require surgical opinion or intervention.
Please ask your physiotherapist for their professional treatment advice.
Acute Injury Signs
Acute Injury Management.
Here are some warning signs that you have an injury. While some injuries are immediately evident, others can creep up slowly and progressively get worse. If you don't pay attention to both types of injuries, chronic problems can develop.
For detailed information on specific injuries, check out the injury by body part section.
Don't Ignore these Injury Warning Signs
Joint pain, particularly in the knee, ankle, elbow, and wrist joints, should never be ignored. Because these joints are not covered by muscle, pain here is rarely of muscular origin. Joint pain that lasts more than 48 hours requires a professional diagnosis.
If you can elicit pain at a specific point in a bone, muscle, or joint, you may have a significant injury by pressing your finger into it. If the same spot on the other side of the body does not produce the same pain, you should probably see your health professional.
Nearly all sports or musculoskeletal injuries cause swelling. Swelling is usually quite obvious and can be seen, but occasionally you may feel as though something is swollen or "full" even though it looks normal. Swelling usually goes along with pain, redness and heat.
Reduced Range of Motion
If the swelling isn't obvious, you can usually find it by checking for a reduced range of motion in a joint. If there is significant swelling within a joint, you will lose range of motion. Compare one side of the body with the other to identify major differences. If there are any, you probably have an injury that needs attention.
Compare sides for weakness by performing the same task. One way to tell is to lift the same weight with the right and left sides and look at the result. Or try to place body weight on one leg and then the other. A difference in your ability to support your weight is another suggestion of an injury that requires attention.
Immediate Injury Treatment: Step-by-Step Guidelines
- Stop the activity immediately.
- Wrap the injured part in a compression bandage.
- Apply ice to the injured part (use a bag of crushed ice or a bag of frozen vegetables).
- Elevate the injured part to reduce swelling.
- Consult your health practitioner for a proper diagnosis of any serious injury.
- Rehabilitate your injury under professional guidance.
- Seek a second opinion if you are not improving.
What is a Tendinopathy?
Tendinopathy (tendon injuries) can develop in any tendon of the body. You may have heard of tendinopathies referred to as its aliases: tendonitis, tendinitis, tenosynovitis and tendinosis. In simple terms, they are all tendon injury pathologies, so the medical community now refers to them as tendinopathies.
Typically, tendon injuries occur in three areas:
- tendon insertion (where the tendon attaches to the bone)
- mid-tendon (non-insertional tendinopathy)
- musculotendinous junction (where the tendon attaches to the muscle)
What is a Tendon Injury?
Tendons are the tough fibres that connect muscle to bone. Most tendon injuries occur near joints, such as the shoulder, elbow, knee, and ankle. A tendon injury may seem to occur suddenly, but usually, it is the result of repetitive tendon overloading. As mentioned earlier, health care professionals may use different terms to describe a tendon injury. You may hear:
Tendinitis (or Tendonitis): This means "inflammation of the tendon".
Mild inflammation is actually a normal tendon healing response to exercise or activity loading, but it can become excessive, where the rate of injury exceeds your healing capacity.
The inability of your tendon to adapt to the load quickly enough causes the tendon to progress through four phases of tendon injury. While it is healthy for normal tissue adaptation during phase one, further progression can lead to tendon cell death and subsequent tendon rupture.
1. Reactive Tendinopathy
- Normal tissue adaptation phase
- Prognosis: Excellent.
- Normal Recovery!
2. Tendon Dysrepair
- Injury rate > Repair rate
- Prognosis: Good.
- The tendon tissue is attempting to heal.
- You must prevent deterioration and progression to permanent cell death (phase 3).
3. Degenerative Tendinopathy
- Cell death occurs
- Prognosis: Poor!
- Tendon cells are dying!
4. Tendon Tear or Rupture
- Catastrophic tissue breakdown
- Loss of function.
- Prognosis: very poor.
- Surgery is often the only option.
What is Your Tendinopathy Phase?
It is crucial to have your tendinopathy professionally assessed to identify its current injury phase. Identifying your tendinopathy phase is vital to direct your most effective treatment since certain treatment modalities or exercises should only be applied or undertaken in specific tendon healing phases.
Systemic Risk Factors
The evidence is growing that it is more than just the tendon and overload that causes tendinopathy. People with diabetes, post-menopausal women and men with high central adiposity (body fat) seem to be predisposed to tendinopathies and will need to observe their training loads.
What are the Symptoms of Tendinopathy?
Tendinopathy usually causes pain, stiffness, and loss of strength in the affected area.
- The pain may get worse when you use the tendon.
- You may have more pain and stiffness during the night or when you get up in the morning.
- The area may be tender, red, warm, or swollen if there is inflammation.
- You may notice a crunchy sound or feeling when you use the tendon.
The symptoms of a tendon injury can be similar or combined with bursitis.
How is a Tendon Injury Diagnosed?
To diagnose a tendon injury, your physiotherapist or doctor will ask questions about your past health, symptoms, and recent exercise regime. They'll undertake a thorough physical examination to confirm the diagnosis. They will then discuss your condition and devise an individualised treatment plan.
They may refer you for specific diagnostic tests, such as an ultrasound scan or MRI.
Tendinopathies can normally be quickly and effectively rehabilitated. However, there is a percentage of tendinopathies that can take months to treat effectively.
As mentioned earlier in this article, it is important to know what phase your tendinopathy currently is. Your physiotherapist can assist not only in your diagnosis but also guide your treatment to fast-track your recovery.
Before you seek the advice of your physiotherapist or doctor, you can start treating an acute tendon injury at home. To achieve the best results, start these steps right away:
- Rest the painful area, and avoid any activity that makes the pain worse.
- Apply ice or cold packs for 20 minutes at a time, as often as 2 times an hour, for the first 72 hours. Keep using ice as long as it helps.
- Do gentle range-of-motion exercises and stretching to prevent stiffness.
When to Return to Sport
Every tendinopathy is different, so please be guided by your physiotherapist assessment. Be patient, and stick with the treatment exercises and load doses prescribed by your physiotherapist. If you start using the injured tendon too soon, it can lead to more damage and set you back weeks! It may take weeks or months for some tendon injury to heal and safely cope with a return to sporting loads.
To minimise reinjuring your tendon, you may require some long-term changes to your exercise activities. These should be discussed with your physiotherapist. Some factors that could influence your tendinopathy risk include:
- Altering your sport/activities or your technique
- Regular prevention exercises.
- Closely monitoring and record your exercise loads. Discuss your loading with your physiotherapist and coach. They will have some excellent tips.
- Always take time to warm up before and cool down / stretch after you exercise.
While most acute tendinopathies can resolve quickly, persisting tendon injuries may take many months to resolve. Long-term or repeat tendinopathies usually have multifactorial causes that will require a thorough assessment and individualised rehabilitation plan. Researchers have found that tendon injuries respond differently to muscle injuries and can take months to solve or potentially render you vulnerable to tendon ruptures, which can require surgery.
For specific advice regarding your tendinopathy, please seek the advice of your trusted healthcare professional with a special interest in tendinopathies.
Foot & Ankle
- Achilles Tendon Rupture
- Achilles Tendinopathy
- FHL Tendinopathy
- Peroneal Tendinopathy
- Tibialis Posterior Tendinopathy
Hip & Groin
- Shoulder Tendinopathy
- Shoulder Impingement
- Rotator Cuff Calcific Tendinopathy
- Rotator Cuff Tear
- Bicep Tendinopathy
- Swimmer's Shoulder
Wrist & Hand
What is Physiotherapy Treatment?
Physiotherapists help people affected by illness, injury or disability through exercise, manual joint therapy, soft tissue techniques, education and advice. Physiotherapists maintain physical health, allow patients to manage pain and prevent disease for people of all ages. Physiotherapists help encourage pain relief, injury recovery, enabling people to stay playing a sport, working or performing daily living activities while assisting them to remain functionally independent.
There is a multitude of different physiotherapy treatment approaches.
Acute & Sub-Acute Injury Management
Hands-On Physiotherapy Techniques
Your physiotherapist's training includes hands-on physiotherapy techniques such as:
- Joint Mobilisation (gentle joint gliding techniques)
- Joint Manipulation
- Physiotherapy Instrument Mobilisation (PIM)
- Minimal Energy Techniques (METs)
- Soft Tissue Techniques
Your physiotherapist has skilled training. Physiotherapy techniques have expanded over the past few decades. They have researched, upskilled and educated themselves in a spectrum of allied health skills. These skills include techniques shared with other healthcare practitioners. Professions include exercise physiologists, remedial massage therapists, osteopaths, acupuncturists, kinesiologists, chiropractors and occupational therapists, to name a few.
Your physiotherapist is a highly skilled professional who utilises strapping and taping techniques to prevent and assist injuries or pain relief and function.
Alternatively, your physiotherapist may recommend a supportive brace.
Acupuncture and Dry Needling
Many physiotherapists have acquired additional training in acupuncture and dry needling to assist pain relief and muscle function.
Physiotherapists have been trained in the use of exercise therapy to strengthen your muscles and improve your function. Physiotherapy exercises use evidence-based protocols where possible as an effective way that you can solve or prevent pain and injury. Your physiotherapist is highly skilled in prescribing the "best exercises" for you and the most appropriate "exercise dose" for you, depending on your rehabilitation status. Your physiotherapist will incorporate essential pilates, yoga and exercise physiology components to provide you with the best result. They may even use Real-Time Ultrasound Physiotherapy so that you can watch your muscles contract on a screen as you correctly retrain them.
- Muscle Stretching
- Core Exercises
- Strengthening Exercises
- Balance Exercises
- Proprioception Exercises
- Real-Time Ultrasound Physiotherapy
- Swiss Ball Exercises
Biomechanical assessment, observation and diagnostic skills are paramount to the best treatment. Your physiotherapist is a highly skilled health professional. They possess superb diagnostic skills to detect and ultimately avoid musculoskeletal and sports injuries. Poor technique or posture is one of the most common sources of a repeat injury.
Aquatic water exercises are an effective method to provide low bodyweight exercises.
Sports physio requires an extra level of knowledge and physiotherapy to assist injury recovery, prevent injury and improve performance. For the best advice, consult a Sports & Exercise Physiotherapist.
Women's Health Physiotherapy is a particular interest group of therapies.
Not only can your physiotherapist assist you in sport, but they can also help you at work. Ergonomics looks at the best postures and workstations set up for your body at work or home. Whether it be lifting technique improvement, education programs or workstation setups, your physiotherapist can help you.
Plus Much More
Your physiotherapist is a highly skilled body mechanic. A physiotherapist has particular interests in certain injuries or specific conditions. For advice regarding your problem, please get in touch with your PhysioWorks team.