What is Tennis Elbow?
What is it?
“Tennis elbow” is the common name given to pain on the outside of the elbow. It is referred to in medical research as lateral epicondylitis, lateral elbow tendinopathy or lateral epicondylalgia. We think the most representative term to use is Lateral Epicondylalgia (LE).
That name can sound a little scary, but let’s break down what those words actually mean.
- Lateral just refers to which side of the elbow the pain is.
- Epicondyl- is just the name given to the bony point on your elbow. The point on the outside is your lateral epicondyle.
- -algia just means pain.
So, Lateral Epicondylalgia (LE) literally just means “pain on the outside of the elbow”.
What causes it?
LE is a tendinopathy (tendon issue) involving the tendons of the forearm, and the bony points of the elbow to which they attach. LE is the most common chronic musculoskeletal pain condition affecting the elbow, and it can cause significant pain, disability and lost productivity. Despite decades of research investigating treatments and the underlying mechanisms of LE, it remains a challenging condition for physiotherapy clinicians and researchers alike.
LE is thought to result from an overload of the forearm extensor muscles. This can be the result of undertaking some new unaccustomed physical activity, such as a weekend spent painting the house or using a hammer to repair a fence. Oftentimes however, the pain may have an insidious onset with no specific causal activity.
LE often occurs in repetitive upper extremity activities such as computer use, heavy lifting, forceful forearm pronation and supination, and repetitive vibration. People with repetitive one-sided movements in their jobs such as electricians, carpenters, gardeners, and office workers also commonly present with this condition.
Image credit: https://orthoinfo.aaos.org/en/diseases--conditions/tennis-elbow-lateral-epicondylitis/
This image shows the location of LE pain. This is the outside (right side) of a right elbow. You can see the upper arm bone (humerus) and the point where it meets the elbow - which we call the lateral epicondyle. You can see the forearm muscles attached here, via the extensor tendons. It is this attachment and these tendons that is thought to be the main source of pain in LE.
Prognosis
The prognosis for LE does vary widely, and is typically hard to predict. An initial episode of pain in response to an unaccustomed activity may just last a few days or weeks. In this case, it would not be considered true LE, just a painful/sensitive episode.
Unfortunately LE can last for years. Some research has shown that around 50% of people will still have pain at 12 months, and around 20% of people will still have pain 3-5 years later.
Common presentation
- Pain and tenderness on the outside of the elbow - typically when using the hand for gripping tasks
eg. turning a doorknob, lifting a coffee cup, using a hand tool, using a computer mouse/keyboard, lifting a weight - Pain onset may be:
- immediate with provocative activity
- 2 to 72 hours after provocative activity
- constant pain, including night pain
- Pain may radiate down the forearm as far as the wrist and hand
- Weakness of grip strength is a common sign
How to manage it
There is good quality evidence from several studies that says exercise is more effective at reducing pain and improving function than other interventions.
There are commonly 2 goals with exercise therapy for LE:
- Improve local tissue capacity (strengthen the involved muscles and tendons)
- Improve the overall function of the whole arm
So, we have quite good evidence that strengthening the muscles of the forearm that are directly involved in LE is beneficial for pain reduction and improved function. The 2 key muscle groups involved are the wrist extensors and the forearm supinators.
There is some more recent research showing that improving the function of the whole kinetic chain, may lead to better outcomes. This means exercising the entire arm, especially the shoulder.
At the end of this article, there is a link to a video showing you exactly which exercises to do.
Do any other strategies help?
Manual therapy techniques (massage, manipulation etc.) can sometimes provide short term pain relief. However, there is insufficient evidence of any long-term clinical effects (reduced pain, improved function, quicker recovery time etc). As such, we don’t routinely recommend manual therapy. If you have sought out manual therapy and it’s provided you some short term pain relief, then that's ok. But remember, this is a symptom modification tool at best - not a long term solution.
There is conflicting evidence for the effectiveness of orthoses (tape, braces or supportive bands) in providing pain relief or improvement in function. Some studies show that they can help, whereas other studies failed to identify any real benefit. There is no compelling evidence that adding an orthosis to another treatment (eg. exercise) provides any additional benefit. If you have tried an orthosis for your LE and it gives you some relief, then it’s ok to keep using it. If you have significant persistent pain that is limiting your ability to perform basic daily tasks, then it may be worth trying an orthosis. They are fairly cheap and readily available in most chemists/pharmacies. But remember, this is a symptom modification tool at best - not a long term solution.
Image credit: https://drmarkmcgrath.com.au/2017/02/05/tennis-elbow/
Corticosteroid injections have been shown in some studies to have quite good short term improvements in pain. However, these only last for 4-6 weeks, and recurrence rates (number of people going back for subsequent injections) are high. Corticosteroid injections also have long term health side effects that need to be considered. Studies looking at the long-term differences between injections and physiotherapy are significantly in favour of physiotherapy. In one study for instance, success rates at 52 weeks were 69% for injections and 91% for physiotherapy.
A large systematic review in the British Journal of Sports Medicine this year (2021) reported how exercise compared with other interventions in 30 different clinical trials. Exercise outperformed corticosteroid injections in all outcomes (pain, strength, function etc) at all time points - except for short-term (<6 weeks) pain reduction. Exercise resulted in clinically significant improvements at short-term, mid-term and long-term follow-up.
So what to do - exercise!
Check out this video as Brodie takes you through 3 exercises for LE.
Notes for LE exercises:
- There are 3 exercise shown in the video
- 1. Wrist extension
- 2. Forearm supination
- 3. Bent over shoulder fly
- Each of these exercises should be performed for 3 sets of 8-12 repetitions, with a heavy enough load that those 8-12 are quite challenging
- Rest for about 1 minute between sets
- All exercises should be done slowly and smoothly
- Perform the exercises every second day to start out with. If they are going well and feeling easy, you can increase to doing them every day
- Some pain during and after exercise is ok, just stick to an amount that is tolerable for you
- Gradually increase the weight you are using when the weight starts to feel easier
References
Bisset, L. M., & Vicenzino, B. (2015). Physiotherapy management of lateral epicondylalgia. Journal of physiotherapy, 61(4), 174-181.
Karanasios, S., Korakakis, V., Whiteley, R., Vasilogeorgis, I., Woodbridge, S., & Gioftsos, G. (2021). Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials. British journal of sports medicine, 55(9), 477-485.
Mostafaee, N., Divandari, A., Negahban, H., Kachooei, A. R., Moradi, A., Ebrahimzadeh, M. H., ... & Daghiani, M. (2020). Shoulder and scapula muscle training plus conventional physiotherapy versus conventional physiotherapy only: a randomized controlled trial of patients with lateral elbow tendinopathy. Physiotherapy Theory and Practice, 1-12.
