“Tennis elbow, medically referred to as lateral epicondylalgia, is a prevalent and often debilitating condition that affects the extensor tendons that attach to the lateral epicondyle of the elbow (Shanmugam et al., 2024). Despite its name, this condition impacts a diverse group of individuals—not just tennis players—due to its association with repetitive stress and overload on the forearm’s extensor muscles.
What Causes Tennis Elbow?
Tennis elbow is typically caused by overuse, overload or repetitive stress to the forearm’s extensor muscles, particularly the extensor carpi radialis brevis (ECRB) tendon (Cutts et al., 2019). This leads to collagen disruption and degeneration (and in some cases, microtearing of the tendons) rather than inflammation, classifying it as a tendinopathy rather than an inflammatory condition.
Common causes include:
- Sudden changes in activity levels: e.g. starting a new exercise program, gardening, or painting after a period of inactivity, or a rapid increase in the amount of these activities.
- Repetitive wrist extension or gripping activities: Often seen in sports like tennis, cricket, and weightlifting, or in occupational tasks such as using tools, typing, labouring or gardening (Hanson et al., 2023).
- Poor biomechanics or technique: Incorrect form in sports or ergonomically improper setups at work.
- Inappropriate equipment: For example, heavy tools or tennis rackets with a grip size that is too large.
Who Is at Risk?
The highest incidence of tennis elbow occurs in individuals aged 40 to 60 years, affecting 1-3% of the general population (Uttamchandani et al., 2024). It is more likely in individuals with repetitive upper-limb activities or poor strength and control of the shoulder and scapular muscles, which can overload thewrist extensors. This is because the wrist is often called upon to bear load and perform tasks that require stability, especially in activities like carrying heavy grocery bags or grandchildren, gardening, or those DIY jobs around the house. Up to 50% of all tennis players develop symptoms due to various factors including poor swing technique, incorrect grip size and the use of heavy racquet (Cutts et al., 2020).
Physiotherapy Management
Physiotherapy remains the cornerstone of tennis elbow treatment, focusing on a multifaceted approach to address symptoms and underlying causes (Pathan et al., 2023):
- Load Management
- Reducing aggravating activities is critical to allowing tendon recovery.
- Patients are educated on modifying tasks like gripping or lifting to prevent symptom exacerbation.
- Exercise Therapy
- A progressive loading program targets the ECRB and surrounding forearm muscles.
- Exercises often include:
- Wrist extensions: Gradually increasing resistance to rebuild tendon capacity.
- Scapular and rotator cuff strengthening: To improve shoulder stability and reduce forearm compensations.
- Functional and sport-specific training: To ensure safe return to activity.
- Manual Therapy
- Techniques like mobilisation with movement have been shown to improve grip strength and reduce pain (Day et al., 2019).
- Soft tissue work and myofascial release alleviate muscle tightness.
- Education
- Patients receive tailored advice on load management, ergonomics, and equipment selection.
- Adjunct Modalities
- Techniques like dry needling, taping, or the use of braces may provide temporary relief and support during rehabilitation.
Signs and Symptoms
- Pain and tenderness: Localised to the lateral aspect of the elbow and worsened by gripping or lifting (Zhang et al., 2024).
- Weakness: Difficulty performing tasks requiring wrist extension or grip strength.
- Pain during specific movements: Such as resisted wrist extension or middle finger extension.
- Morning stiffness: Symptoms may improve temporarily with activity but worsen later in the day.
What Does the Evidence Say?
Recent studies emphasize the importance of physiotherapy. Eccentric exercises combined with concentric loading have shown significant improvements in pain and function (Rai et al., 2023). Mobilisation with movement combined with exercise resulted in better outcomes in grip strength and patient satisfaction compared to no intervention (Uttamchandani et al., 2024). Kinetic chain rehabilitation: Addressing shoulder and scapular biomechanics is essential for long-term relief and prevention of recurrence (Li et al., 2022).
Corticosteroid injections, although effective for short-term pain relief, have been associated with high recurrence rates and poor long-term outcomes (Sharma et al., 2022). Further with regards to PRP injections, the data in a Cochrane review (2021) did not support the use of PRP injections to improve pain, function or quality of life of patients with lateral elbow pain.
Why Is Early Physio Intervention Important?
Patients often delay treatment, attempting to “wait and see” if symptoms resolve. Unfortunately, tendinopathies rarely improve without targeted intervention. Prevent chronic degeneration of the tendon. Tennis elbow, while common and often frustrating, responds exceptionally well to physiotherapy. Through a combination of manual therapy, exercise, and education, patients can regain strength, improve function, and prevent recurrence.
Exercise
Wrist Extensor Strengthening
Aim: Strengthen Wrist Extensors
How: With a small weight in hand, your arm pronated and your elbow bent at a right angle supported by a table, simply extend your wrist lifting the weight all the way through movement to strengthen up your wrist extensors. Repeat for reps.
Grip Strength
Aim: To improve grip strength, training the finger flexors
How: Hold a stress ball in your hand. Simply squeeze the ball and hold for 5 seconds. Repeat for reps to improve grip strength and endurance.
Reformer External Rotation
Aim: Improve rotator cuff (shoulder) strength using the reformer. If external rotators are weak, we typically overuse our wrist extensors which can lead to tennis elbow.
How: In high kneeling with your core engaged and shoulders retracted while facing sideways, hold the strap with elbow bent to 90 degrees. Simply pivot from the elbow, pulling the strap outwards targeting the external rotators. Vary spring resistance to change level of difficulty.
If you or someone you care for has an injury, a flare up, requires some rehabilitation or experiences an increase in pain, give the clinic a call on 9713 2455 or book online.