Tennis Elbow

Tennis elbow or Lateral Epicondylagia is a common chronic musculoskeletal condition with approximately 40% of people experiencing it at some point in their lives. It most commonly presents in men and women aged between 35 and 54 years. The condition affects the elbow and forearm and causes significant pain, disability and loss of function. Symptoms may persist for many years and recurrence is common. One plausible reason for persistent pain is the presence of sensitization, the process of making someone react to something that previously had no effect, of the nervous system and that people with lateral epicondylagia show an enhanced pain response to a variety of stimuli eg pin prick and light touch.

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Typical signs and symptoms include pain and tenderness over the outer elbow or lateral epicondyle, exacerbated by resisted wrist extension and passive wrist flexion, and impaired grip strength. Although many tennis players may experience this condition, most cases are associated with work-related activities or have no obvious precipitating event.

The name implies to a process of inflammation however more recent evidence has shown that it is not an inflammatory condition. The traditional view is that this condition is initiated by tiny tears at the common tendon of the wrist extensor muscles due to chronic overuse. As these tears attempt to unite, the healing surfaces are pulled apart with continued use of the hand, resulting in self-perpetuating and chronic inflammation. Consequently, treatment has focused on controlling the inflammatory response through the use of nonsteroidal anti-inflammatory drugs and physical modalities such as ultrasound and ice. This inflammatory model also led to the use of the term epicondylitis, which was considered an improvement over the colloquial term tennis elbow.

However studies over more recent years have demonstrated that the affected tendon (usually the Extensor Carpi Radialis Brevis [ECRB] tendon) has a dense population of fibroblasts, disorganized and immature collagen, and an absence of inflammatory cells. These findings are considered characteristic of a degenerative process called ‘‘angiofibroblastic hyperplasia,’’ now commonly known as tendinosis.

The cause of pain in the absence of an inflammatory mechanism to the tendon is therefore under discussion. It has been hypothesized that certain byproducts of increased cellular activity or tendon degeneration, such as lactic acid and chondroitin sulphate irritate the sheath surrounding the tendon which in turn causes local release of substances which cause nerve inflammation.

Lateral epicondylalgia is a complex condition and it may be years before all questions are answered. However, we cannot ignore the current literature, which provides consistent evidence that there is an absence of an inflammatory component. This would indicate that the current term, epicondylitis, is inaccurate and misleading, and use of the term epicondylalgia may, in its generality, be more appropriate. In addition to the ECRB tendon, many anatomical structures have been identified as possible sources of lateral epicondylar pain. These include local articular, ligament, and nerve lesions, as well as involvement of cervical spine structures leading to direct somatic pain, (pain from the skin, tissue or muscle) or secondary facilitation of pain through altered nociceptive afferent transmission within the central nervous system. The term epicondylalgia can encompass all causes of lateral epicondylar pain without assuming underlying pathology.

Moreover, duration of symptoms has not been found to be associated with recovery. One would anticipate that someone in the acute inflammatory phase as indicated by a short duration of symptoms would respond more quickly to treatment, especially to treatment directed towards reducing inflammation; but this has not been shown to be the case.

It is time to acknowledge that the traditional inflammatory model is both flawed and simplistic. This is more than just a demand for accuracy of nomenclature: appropriate management and realistic treatment goals and prognosis are dependent upon a correct comprehension of pathoetiology. The term epicondylalgia reinforces the concept that this is a complex condition with potentially several pathophysiological mechanisms and underlying causes of pain. It reinforces the need to conduct thorough clinical assessments on each and every patient to identify, as best as possible, the contributing source(s) of pain in order to provide optimal management strategies.

Treatment:

Physiotherapy treatment encompassing mobilisations to the neck and upper back along with soft tissue work to this area as well as the elbow and forearm will be of benefit. Also exercises for the arm done on a daily basis have been shown to be of benefit. Exercise may be more effective at reducing pain and improving function and there are a variety of exercises that you can do. If you would like help in treating your elbow clinic please contact us here at the Wimbledon Physiotherapy and Sports Clinic.

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Tennis Elbow

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