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Lateral Epicondylalgia (Tennis Elbow)

What is Lateral Epicondylalgia?

 Lateral Epicondylalgia is an overuse/degenerative soft tissue injury caused by over use of the wrist extensor muscles, most commonly extensor radialis brevis which’s primary role is to stabilise the wrist to allow hand and finger movement. The wrist extensors attach onto the bony prominence on the outside of the elbow (Lateral epicondyle) this attachment site becomes irritated and the tendon starts to undergo degenerative changes. 

Symptoms?

The pain is generally localised to the lateral epicondyle without radiating pain into any other area. Pain is reproduced by gripping, wrist extension, middle finger extension and rotating into pronation (Palm down). Over time without management, the radial nerve may become irritated in the radial tunnel which may present with pain turning the hand into supination (Palm up) and pain may radiate into the upper forearm. 

What causes Lateral Epicondylalgia?

 There is often a history of overuse (one episode or repetitive trauma), the pain then increases gradually following this episode. The injury is usually developing before the onset of pain if the injury is caused by repetitive trauma however the pain may present as a sudden onset. 

What to do?

 Tendons need optimal load in or order to remain healthy. An injured tendon needs a balance between resting to unload the irritated tendon and exercising the tendon to strengthen and repair it. Optimal load will be different depending on your strength, the activities you are accustomed to and how long the injury has been present. Optimal load is the amount of load the elbow can tolerate without bringing on pain, the amount of load tolerated will increase as the tendon strengthens and repairs. 

When and how to rest the elbow?

 If the onset of pain is recent and sudden, 6 weeks of avoiding aggravating activities may be enough to settle the pain down however if the pain has been present for more than 6 weeks of there is no reduction in pain, physiotherapy treatment and gradual loading exercises may be required. 

Activity modification to unload the lateral elbow 

  1. Reduce aggravating activities such as excessive gripping and rotating the wrist 

  2. Reduce manual labour if possible 

  3. Hold things close to your body with your elbows bent 

  4. Tennis elbow straps can be useful when doing aggravating activities to re-distribute the load onto the forearm, however should not be worn for extended periods of time to avoid irritating the area around the strap 

  5. Isometric exercises (as seen below) are useful in reducing pain as they have an analgesic effect. 

When and how to load the elbow?

  1. Loading exercises should start if initially resting the elbow has not settled the pain or if the pain has been reoccurring for 6 weeks or more 

  2. Tendons require load to be able to heal, if the tendon is completely rested the pain will return once normal activities commence (note: as the tendon heals it will cope with more load) 

  3. All loading exercises should be completely pain free (unlike lower limb tendons) 

  4. Loading starts with isometric contractions and self-mobilisation techniques (see below) and gradually progress to eccentric strengthening as pain allows 

Physiotherapy Treatment

Initially:

  1. Physiotherapy manual therapy around the elbow joint and soft tissue release of the forearm muscles 

  2. Dry needling of the wrist extensor muscles may be useful in reducing increased muscle tension 

  3. Anti-inflammatories and ice to reduce inflammation 

  4. Tennis elbow strap for when aggravating activities are unavoidable 

  5. Exercises to gradually load the tendon

Following initial treatment your physiotherapist will guide you through a series of progressive loading exercises to ensure you build up strength in the elbow and can safely return to your regular activities without flaring up the injury.

Written by Ashley Holliday

Physiotherapist

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