Tennis Elbow
Anatomy of the Elbow:
Your elbow is made up of multiple bone, tendons and ligaments. Three bones, your humerus, radius, and ulna come together to make up the elbow joint. Several tendons of forearm muscles originate at the lateral elbow, also known as the lateral epicondyle. These muscles are mainly responsible for extending your wrist.
What is Tennis Elbow and What Causes It?
Tennis Elbow is an overuse injury. It typically occurs with repetitive movements of the wrist and arm. Although it is common in athletes who play sports such as tennis or baseball, it can also be found in those who have jobs requiring repetitive upper extremity use. For example, it is prevalent in mechanics, electricians, painters, etc.
When evaluating a patient for tennis elbow, it is crucial we assess not only their elbow and wrist, but the shoulder and back as well. Many times when working with patients who have experienced chronic tennis elbow, I have found they have notable strength and mobility deficits above the elbow as well. This could very well be contributing to the cause of their tennis elbow. It could even be playing a role in why their elbow pain has not improved despite trying some rehab exercises or resting from their work/sport.
How do we Treat it?
When treating tennis elbow, I have found there are a few keys for success:
Keep pain <2/10 with exercises, especially at the beginning when they are highly irritable
Make sure to evaluate the thoracic spine mobility
Don’t forget to assess and strengthen shoulder stabilizers
You may say, well what happens if all exercises are more painful than a 2/10? Well in that case, we can modify each exercise to a level that is tolerable.
For example, if banded wrist extension is painful, we will regress this to a wrist extension isometric hold. What this means is you will hold the wrist up into extension without continually moving the wrist up and down. For a successful isometric exercise, it is important that you hold for 45 seconds and perform 5 sets of this. From my experience, I have found that if people have some pain with this exercise, by the fourth and fifth set, the pain will improve or it will at least become more tolerable.
Check out this progression of the wrist extension exercises here:
As I mentioned above, if someone has lingering elbow pain that has “never gone away” or it “keeps coming back” when they try to return to their sport or work, they more than likely have deficits above the elbow joint, contributing to abnormal movement patterns at the elbow.
Let’s use tennis as an example. Say your athlete has pain while serving. First, there is a certain amount of thoracic (upper back) extension and rotation the athlete needs to meet the ball overhead in their serve. If they are stiff in their upper back, they will compensate at their shoulder and then their elbow to allow themselves to reach further overhead. This is one factor that adds stress at the elbow joint as your elbow is now required to move through a greater range of motion than it is capable of. Second, when generating power during the serve, your shoulder needs to be very strong and stable. If your shoulder musculature isn’t doing a good job controlling your arm dynamically through the serve, again the elbow will take more force than it is used to or it should.
Take a look at this video of a slow motion serve to see how much movement and strength is required through the serve from the back down to the wrist and hand:
Our bodies are great at taking the path of least resistance with movement. This can lead to many compensations, and in this case the compensations are all leading to added strain and stress at the lateral elbow. All in all, it is extremely important to assess and address the upper back and shoulder when dealing with a patient who has tennis elbow as we want to treat the whole picture.
Here two strength and mobility exercises to address these deficits at the upper back and shoulder:
Citation:
Alaina, Michael J., MD, FAAOS. "Tennis Elbow (Lateral Epidondylitis)." Edited by Stuart J. Fischer,MD, FAAOS. Ortho Info, American Academy of Orthopaedic Surgeons, orthoinfo.aaos.org/en/diseases--conditions /tennis-elbow-lateral-epicondylitis/. Accessed 23 Dec. 2022.
