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Tennis Elbow/ Lateral Epicondylitis/ Epicondylagia

tennis elbow

Tennis elbow is a common phenomenon not just among tennis players but also among people who work at a desk, people who carry heavy loads, weightlifters and body builders. Basically it could affect anybody. The classical definition of this diagnosis is the degeneration of fibers of one tendon or more or the entire the common extensor tendon of the wrist that insert to the latera l side (the outer side) of the elbow at the epicondyle (the lowest part of the humerus). This phenomenon could also involve influences from the peripheral nerve system passing through this area as it descends from the neck, innervating motor and sensory functions. In addition, dysfunctional mechanics at the elbow, shoulder or neck and upper back could influence the symptoms of this diagnosis.

General anatomy:

Joints:

The elbow joint can be divided into 2 separate joints:

  1. a hinge joint between the humerus (the upper arm) and the ulna. The ulna cradles the distal part of the humerus. This joint allows for flexion and extension at the elbow.
  2. The 2nd joint between the head of the radius and the ulna allows for movements of pronation and supination at the wrist. The head of the radius is held in a round shaped ligament (the annular ligament) attaching to the Ulna.

Muscles:

there are many muscles around the elbow: the extensor group that extends the wrist backwards (dorsi flexion). This group originate in the lateral epicondyle of the elbow and inserts into the the wrist. The flexor group originate at the medial epicondyle and inserts into the the wrist allowing the movement of palmar flexion to occur. Its important to remember the brachio-radialis muscle the provides for movements such as radial flexion, supination and pronation and elbow flexion. Originate at the humerus and inserts to into the wrist

Nerves:

The peripheral n. system of the upper limb is called the brachial plexus. It originates at the level of the cervical vertebras, passing through the scaleni muscle in the anterior part of the neck, under the clavicle, through the pectoralis minor muscle at the chest and shoulder, through the elbow until the wrist and fingers, receiving sensory information from the upper limb and carrying it to the central n. system. The data is then precessed and output signals are sent through motor pathways to the upper limb innervating the muscles. The median, ulnar and radial nerves are the big and most important nerves
of the plexus.

Injury mechanism:

If the classical definition of tennis elbow is being addressed, as mentioned in the 1st paragraph, then a friction force, an over load on the tendon will cause it to degenerate and produce pain. This could be due to sustained pressure, a direct blow to the area, repeated extension movements such as typing (or playing tennis e.g) could cause a form of RSI (repetitive strain injury). None the less, pain could be produced from trigger points in muscles such as the brachioradialis or other muscles in the elbow region.

trigger points are inner contraction points or nodules within the muscle fibers. These nodules stay contracted passively and limit the ability of the muscle to either generate a functional contraction or stretch (thus even limiting the range of motion). These trigger points might refer pain to other areas that might present symptoms of tennis elbow.

pressure on the nervous system at the neck or shoulder area could cause radiating pain in the pathway of the nerve e.g at the level of the elbow or wrist. People who sit at a desk in a slouched position are slowly narrowing the foramina or the gap between the vertebras, through which the nervous system pases. In this slouched position ,the anterio r muscles as the scaleni may shorten and cause additional pressure on the nerve. Many tennis elbow treatments and diagnosis’s are missed or wrongly diagnosed due to ignoring this element.

the common symptoms are local tenderness at the lateral aspect of the elbow especially in executing a gripping force with an extended elbow. None the less, Pain could be eminent during lifting a very light weight object such as a cup a coffee or a book. Sometimes because of the pain mechanism, objects will fall out of one's hand.

Treatment:

  1. soft tissue mobilization, dry needling for trigger points and to diminish pain, fascial treatment to the area of the elbow, shoulder or neck, depending on the source of the problem.
    dry needling
  2. Mobilizations to the elbow, shoulder and neck and upper hand to restore normal functional range of motion in the upper limb kinetic chain and improving nerve conductivity if the peripheral nervous system is in fact involved. It is important to understand that the vascularization (blood supply) to the peripheral nerves is enabled through very small arteries and capillaries. Even slight pressure on them along the path of the nerve could cause neurogenic referred pain throughout the upper limb and cause “tennis elbow” like symptoms. Also, pain has an inhibiting effect on functional motor control. Mobilization of these parts also assists in reducing the pain and thus improving motor control in the upper limb.
    elbow mobalization
  3. Nerve dynamics treatment techniques: if in fact the peripheral nervous system is involved, gliding the nerve and stretching after reliving the compressing force, can assist in the metabolism of the nerve and its conductivity.
  4. Taping: athletic taping and kinesio taping assist in unloading overloaded structures and\ or facilitating certain muscles. Taping helps to reposition a joint in its functional position for prolonged time after the treatment itself . None the less, the question if taping actually changes or repositions a joint structure is under debate. Many hypothesis' suggest that the repositioning of theses structures work more on the neural level than on the actual mechanical level.
  5. Ergonomics and education about proper posture. As explained, incorrect posture in sitting can hinder the peripheral nervous system and influence the mechanics of the neck and the kinematics of the upper limb.
  6. Steroid injection: many physicians tend to inject cortico-steroids to the affected area of the elbow out of the clinical reasoning that it is in fact an inflammation. Researches show significantly that these injections, in the case of an epicondylagia, might reduce the pain slightly at first but the pain will return in a more severe way and it will degenerate the fibers even further and cause continous damage.
  7. The diagnosis “tennis elbow” is a diagnosis that was given in the past out of thinking that it is a repetitive strain injury that involve backwards dorsi flexions as performed in back hand serves in tennis. Today, due to further researches, it is clear that the factors influencing this disorder are far more broad and do not relate only to the localized painful area. As many other disorders, the body works as a whole where each system influences
    the other. The disfunction of one system in the kinetic chain will over load other structures, an overload will be present and pain as well as dysfunction will start due to inability to withstand the load. Therefore it is essential to diagnose the dysfunctional link or links in the chain and treat them specifically as well as treating and training the entire body as a whole.

***This article mentions several methods of evaluation and treatment. These are merely guidelines. They are not an independent treatment program nor intended to replace a thorough evaluation and treatment program executed by a certified physiotherapist. Its advised to undergo such evaluation and treatment by a certified physiotherapist if such injury occurs and act upon their professional judgement call***