Musculoskeletal Physiotherapy Consultants

Tennis Elbow

By on September 6, 2016 in General with 0 Comments

tennis elbow

Tennis elbow is not seasonal but we have had a flurry of referrals of such cases recently from insurers requesting specialist physiotherapy review.

You don’t need to play tennis to get tennis elbow, it can be caused by trauma or any repetitive activity and is the most common chronic musculoskeletal pain condition affecting the elbow. It is also known as lateral epicondylitis ‘lateral’ meaning on the outside and ‘epicondylitis’ meaning inflammation of the epicondyle or little bump of bone where the muscle attaches. However, research has shown that it is not an inflammatory condition, instead there is evidence of degeneration where the extensor carpi radialis brevis muscle attaches to the bone. It’s not quiet as simple as that though. Many other structures including joints, ligaments, and nerves, as well as the neck, may contribute to lateral elbow pain. In light of this complexity, the term ‘lateral epicondylalgia’  (suffix ‘algia’ means pain) is gaining increasing acceptance since it encompass all causes of pain in this area.

Tennis elbow most commonly affects the dominant arm, and although tennis players may experience this condition, most cases are either associated with work-related activities or have no obvious precipitating event. Up to 17% of workers in industries that involve highly repetitive hand tasks experience tennis elbow. Data from WorkCover WA indicates that upper limb injuries accounted for 37% of all work-related claims in 2014/15.

Typical signs and symptoms include pain and tenderness over the lateral epicondyle, aggravated by gripping and wrist extension.  As there are a number of possible factors involved a thorough clinical assessment is essential if appropriate treatment and therefore optimal outcomes are to be achieved.

Ultrasound and MRI are useful in ruling out tennis elbow as a diagnosis, however, imaging is not particularly good at detecting the condition when it is present. In fact, structural changes on imaging are present in approximately 50% of healthy people who have no elbow pain at all.

Physiotherapists usually adopt a multimodal approach to managing patients with tennis elbow. Treatment may include strengthening and stretching exercises; manual therapy; bracing and taping; and there is reasonable evidence to show that these measures do help.

Cortisone injections have been shown to give faster relief of symptoms but a higher chance of recurrence and longer term damage when compared to physiotherapy treatment which addresses any underlying causes and results in much lower recurrence rates.

Other new approaches such as platelet rich plasma injections and extracorporeal shockwave therapy have been shown to be of some benefit but are no better than any other treatment.

Tennis elbow is often considered to be a self-limiting condition which resolves over 12 to 18 months. However, recent studies have shown that over 50% of patients have not recovered in 12 months and 20% reported ongoing pain after 3 to 5 years.

The need to measure and demonstrate the effectiveness of treatment over and above the natural course of the condition has been mentioned in previous blogs. The Patient Rated Tennis Elbow Evaluation is a condition-specific questionnaire which is very helpful in capturing aspects of pain and function that are specific to tennis elbow. It is useful not only in evaluating the effectiveness of treatment but also to assist prognosis, since there is evidence to show that higher pain and disability scores relate to a delayed recovery.

Unfortunately, the injured workers in the cases that we recently reviewed had undergone protracted treatment of largely unproven benefit. All cases presented with complex clinical features including associated neck problems and nerve sensitisation in addition to local elbow signs and symptoms. For the physiotherapists concerned, it was an opportunity to gain useful feedback on how they might improve their clinical management of this sometimes difficult condition and for the injured worker our recommendations will hopefully put them on track to achieve an optimal outcome.

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