Tennis Elbow Tiebreaker Truth

Anatomy

The initial pathology appears to affect the extensor carpi radialis brevis (ECRB) tendon, specifically the deep and anterior fibers (see figure 1). However, it may progress to involve the lateral collateral ligament (LCL) of the elbow, which merges with the ECRB and the annular ligament. If the condition has progressed to include these two ligaments, a successful outcome from conservative management is less likely⁽⁶⁾.

Special Tests

The extensor carpi radialis brevis is the wrist’s main isometric/static stabilizer. Clinical tests like Maudsley’s (middle finger extension) and Cozen’s (wrist extension) have a relatively high sensitivity (88% and 84%, respectively) but a 0% specificity. They do not exclude other pathologies such as radial nerve entrapment, cervical radiculopathy, osteoarthritis, inflammatory arthritis, osteochondritis dissecans, or a loose body. Mill’s test has a sensitivity of only 53% but a specificity of 100%, which makes it a very useful diagnostic test⁽⁷⁾.

The pain-free grip test is a reliable, valid, and sensitive measure of physical impairment. It is preferable to a measurement of maximal strength, which is not always impaired and is likely to exacerbate the pain, which may outlast the testing session⁽⁸⁾. Clinical pain severity and tendon pathology are not directly correlated, and there may be sensory changes on the contralateral side (pain-free), indicating the possibility of central sensitization⁽⁸⁾. A patient-rated tennis elbow evaluation (PRTEE) score of >54 is indicative of severe tennis elbow⁽⁸⁾.

Imaging

Ultrasound and magnetic resonance imaging show tendon fibril disruption, hypoechoic changes, tendon thickening, and increased neovascularity. They help determine whether the pathology has extended to the lateral collateral or annular ligaments or whether a bone spur is present. Clinicians must correlate the imaging results with clinical findings, as MRIs on the asymptomatic side show edema in 30% of cases, and 6% show tendon thickening. Imaging is helpful if there is a history of infection or a definitive acute injury (when clinicians suspect a complete rupture).

Prognosis

Tennis elbow is predominantly self-limiting, with up to 80% of cases improving within 12 months. There is no quick fix for tennis elbow but patients who receive physiotherapy have significantly better outcomes at six weeks⁽⁹⁾.

Treatment

There are multiple treatment options available to clinicians. Treatment modality selection depends on each case, and clinicians must use their clinical reasoning to identify the best options for their athletes. 

Medication may assist in some cases, but clinicians should be cautious due to the possibility of long-term and systemic negative consequences. Athletes tend to use non-steroidal anti-inflammatory drugs, but caution is warranted, whereas athletes should avoid corticosteroids. Furthermore, platelet-rich plasma (PRP) injections are not beneficial. Other options available include extracorporeal shock wave therapy and surgery when conservative management fails.

Activity Modification
As in all tendinopathies, activity modification is key. Clinicians must identify the injury stage (reactive or dysrepair) before providing activity modification recommendations. Altering the lever arm reduces the load on the kinetic chain, and clinicians should educate athletes on strategies to reduce tendon strain, e.g., lifting items closer to the body rather than with extended arms. As the pain improves, moving further away from the body to increase elbow extension and forearm pronation while gripping could be a way to gradually increase the load.

Furthermore, clinicians should advise athletes to avoid stretching to reduce tensile and compressive loads. Ergonomic advice may focus on minimizing work or athletic tasks requiring deviated wrist postures, forceful exertions, and highly repetitive movements. More drastic short-term load reductions may be beneficial in the reactive tendinopathy phase.

Equipment Modification
Correct racket grip size is essential. A grip that is either too small or too big requires increased forearm muscle activity. If the grip is too small, it is difficult to prevent the racket from twisting, and if the grip is too large, it is more difficult to change grips and inhibits wrist snap on serves. Clinicians should advise athletes to ensure that their equipment is adequately fitted.

Exercise
Exercise results in a greater and faster reduction in pain, a faster return to sports or work, and fewer medical consultations. However, the optimal intensity, frequency, and load are unknown, but tendons do not like sudden changes in activity. Exercise modes and dosage differ between patients due to their tendinopathy stage and severity. Therefore, clinicians must individualize exercise prescription and progression and ensure compliance for a minimum of 12 weeks. The primary objective should be to build tendon robustness and endurance.

Given that ECRB is a stabilizer of the wrist, beginning with isometric exercise, especially for reactive tendinopathy, is a good starting point. Isometric exercises also have an analgesic effect, which is beneficial. Athletes must begin in the least provocative position with the wrist in 20-30o extension and the elbow at 90o flexion.

In degenerative stage tendinopathies, clinicians can progress with concentric and eccentric exercise. They can commence with the elbow in flexion and restrict end-of-range flexion activities, which expose the ECRB to greater compression and is more provocative. In the case of a very irritable ECRB tendon, the opposite arm can be exercised to take advantage of the contralateral training effect⁽¹⁰⁾.

Whether exercise should be pain-free or painful is patient-dependent. Short term, it is better to experience some pain during exercise, and loading is good for tendons, but if the patient is going to be non-compliant with pain, then pain-free is better⁽¹¹⁾. Other patients may feel “no pain, no gain,” and then up to 3/10 pain is acceptable as long as the pain is no worse the following day.

Exercises should also address motor control impairments such as dissociation of the wrist from finger extension and retraining of wrist alignment during gripping. Failure to recognize and address problems with motor control, strength, and endurance may be one explanation for the persistence or recurrence of symptoms⁽⁸⁾.

Cervical and Thoracic Spine Treatment
In the cervical spine, the C4-C7 segmental levels may be symptomatic in patients with tennis elbow. The mid to upper thoracic spine is often stiff into extension. Mobilizing these segments improves pain, grip strength, and function at the elbow with a stronger effect when delivered with a supportive and empathetic approach⁽¹²⁾.

Manual Therapy
Mulligan’s mobilization with movement (MWM) effectively relieves pain and improves grip strength and function^(13). There are two techniques. One is a sustained ulna-humeral lateral glide applied with the use of a belt or the therapist’s hands while the patient grips or extends the wrist against resistance (see figure 2). The other is a posterior-to-anterior (PA) glide of the radial head while the patient grips or extends the wrist against resistance (see figure 3).

Myofascial release of the forearm extensors and along the superficial back arm line reduces tensile strain on the ECRB tendon and tethering of the radial nerve (see figure 4). Neural mobilization techniques decrease pain at the lateral elbow, specifically flossing or gliding of the radial nerve

Conclusion

Tennis elbow is commonly seen in clinical practice. Although it is a self-limiting condition, physiotherapy can alleviate pain and improve function, including pain-free grip. While managing pain, clinicians must carefully and deliberately create activity modification plans that meet the athlete’s sporting demands. Furthermore, structured exercise programs are vital to ensure long-term success. 

References

1. www.ncbi.nlm.nih.gov/books/NBK431092/
2. World J Orthop 2022 April 18; 13(4): 354-364
3. J Hand Surg Am2024 Apr 27:S0363-5023(24)00104-7
4. N Engl J Med 2023; 388:2371-2377
5. Plast Reconstr Surg 2021; 1;147(1):112-125
6. www.physio-pedia.com/Assessment_of_Tennis_Elbow#ppm18759
7. Int J Physiother Res 2014, Vol 2(6):815-23
8. JOSPT 2015; 45 (11) 938-949
9. British Journal of General Practice 2018; 68: 548–549
10. J Appl Physiol (1985). 2006 Nov;101(5):1514-22
11. Br J Sports Med. 2017 Dec;51(23):1679-1687
12. www.physiopedia.com/Lateral_Epicondyle_Tendinopathy_Toolkit:_Section_F_-_Manual_Therapy
13. Fisiomu.2023 Vol 4(1): 13-21