Tennis Elbow Management
The management approach of tennis elbow (TE), also known as Lateral Epicondyle Tendinopathy, is adapted from the general principals of tendinopathy rehabilitation. For the benefit of achieving long term goals and to meet individual's needs, rehabilitation should be a multi-modal perspective. We explored the different causes and effects of Tennis Elbow in the assessment course including central sensitization, muscle and tendon structural changes and mechanical abnormalities. Hence, there is a need to investigate on all these aspects in the history taking and objective examination and consider them when designing a rehabilitation programme.
The use of multimodal care has been found to be effective in the management of Lateral Epicondyle tendinopathy. This includes education, exercises, tissue loading management, manual therapy, steroid injection and taping. All of these management strategies can be used and tailored depending on the patient's needs, clinician's clinical reasoning and a shared decision between patient and clinician. Since exercises are the best management option available to us at the moment, TE management should be centered around exercises.
Educating patients on their condition, prognosis, management options and self-management may not be effective on the short term and cannot be used as a stand alone measure. However, it has good long-term effects if used in combination with other measures for the management of Tennis Elbow.
Patient education is defined as ''a planned learning experience using a combination of methods such as teaching, counselling, and behavior modification techniques which influence patients’ knowledge and health behavior''. Educating patients on their needs for management helps in reaching a shared-decision, stimulating patient's compliant to treatment and improves self-efficacy.
Since tendinopathy is a degenerative disease and the first stages are considered inflammatory, recovery and treatment will depend on the general health of the body. Smoking, high consumption of processed and fatty food and obesity can delay the recovery. These factors should be discussed with the patients to ensure optimum engagement with treatment.
TE is a degenerative condition characterized by increased thickness in the common extensor tendon, and the presence of different neuromuscular strategies with wrist function particularly when gripping. Pain with hand grip is the most common presentation with TE and as a result people with TE demonstrated their most powerful grip at a reduced wrist extension angle when compared with healthy individuals  and less reaction time in wrist muscle activity , particularly ECRB muscle.
Reduction of load on the tendon is an effective management strategy which has to go hand in hand with building tissue resilience to allow for gradual progression to target load by training the mechanical properties of the tendon. A good way of altering the load is to ask patient to work under their pain threshold and engage them in exercises that load the tendon below the level of exaggerated pain.
Pain and swelling will occur in response to increased load which is known as ''reactive tendinopathy''. Reducing pain is essential in this phase by pain management measures and de-loading. Identifying the contributing factors to pain and tendinopathy can help in modifying the loads on the tendon. A sudden increase in load by movements involving repetitive wrist extension from pronated forearm and extended elbow can trigger pain and inflammation on the common extensor origin. To de-load the inflamed tendon, educate your patient on lifting objects with flexed elbow and supinated forearm.
The classical model for exercises in tendinopathy rehabilitation is eccentric contraction as a standard protocol, especially with Achilles and Patellar Tendinopathies. Eccentric exercises are considered to be an effective measure for tendon overuse injuries and prevention of re-injuries. They are also better in preparing patients/athletes for return to function or athletic activities when compared to concentric exercises. Tendons response to eccentric exercises in Achilles tendinopathy were observed after twelve weeks of training. However, other studies found no difference on tendon response between concentric and eccentric exercises.
The evidence on load, speed of movement, number of repetitions, duration of contraction and type of exercise remain inconclusive.
ECRB is the main tendon affected in TE. It has a role of stabilizing the wrist statically. This supports the use of isometric exercises in TE management. Isometric exercises were found to have hypoalgesic effect both locally and in remote sites from exercised part during and after contraction.
Coombes et al compared the immediate effects of isometric exercises performed with different intensities (above and below the pain threshold) on pain perception in patients with chronic TE. Their findings support the use of exercises above pain threshold in decreasing resting pain intensity immediately after exercises compared to the other group. Another interesting finding of this study was that greater fear of movement resulted in greater pain intensity during exercises above pain threshold.
Gradual progression of exercises is essential to increase tendon tolerance to loads. The following are different ways to progress your exercises:
- Elbow and forearm position: begin with flexed elbow and forearm in supination, then progress by increase elbow extension angle.
- Fingers flexion vs extension: beginning with fingers in flexion then progressing to extension to load the long extensors.
- Adding weights: whether by an exercise band or dumbbells
- Bilateral movement. Many people report bilateral symptoms, supporting the evidence of the association of central sensitization with TE.
- Functional training exercises and targeting the whole upper limb.
- Weight bearing exercises
Exercising in the pain-free range and refraining from exercises that aggravate the pain are the common advice given in any MSK management. However, the long term benefits of exercises on loading the tendon properly and building tissue tolerance may require some pain initially.
Mobilization with movement can be utilized with other measures to reduce pain and facilitate exercises. Rehay et al  investigated the effect of Mulligan's mobilization with movement in TE and found significant reduction in night pain and pain on VAS up to 3 months after application of treatment and increase in pain-free grip strength. Another study found the same approach to be superior to wait and see and corticosteriod injection.
Corticosteriod injection has good outcomes only on the short term ( up to six weeks). The long term outcomes are poor and it was found to be linked to high recurrence rates. One study found increased pain, reduced grip strength in an intermediate follow up after corticosteriod injection. However, the short term benefit of pain relief can be sought to encourage patient's engagement with the exercise programme.
Taping has a good placebo pain relief effect and pain-free grip strength in patients with chronic TE. A study compared the effect of kinesio taping with exercises to sham tape with exercises and exercise only groups on patient-rated tennis elbow evaluation (PRTEE), visual analogue scale (VAS), grip strength, and the disabilities of the arm, shoulder and hand (QuickDASH) scales. The results of the study support the combination of kinesiotape and exercises.
- Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. Bmj. 2006 Nov 2;333(7575):939.
- Dimitrios S. Exercise for tendinopathy. World journal of methodology. 2015 Jun 26;5(2):51.
- Randhawa K, Côté P, Gross DP, et al. The effectiveness of structured patient education for the management of musculoskeletal disorders and injuries of the extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. J Can Chiropr Assoc. 2015;59(4):349–362.
- Forbes R, Mandrusiak A, Smith M, Russell T. Training physiotherapy students to educate patients: a randomised controlled trial. Patient education and counseling. 2018 Feb 1;101(2):295-303.
- Ndosi M, Johnson D, Young T, Hardware B, Hill J, Hale C, Maxwell J, Roussou E, Adebajo A. Effects of needs-based patient education on self-efficacy and health outcomes in people with rheumatoid arthritis: a multicentre, single blind, randomised controlled trial. Annals of the rheumatic diseases. 2016 Jun 1;75(6):1126-32.
- Manickaraj N, Bisset LM, Kavanagh JJ. Lateral epicondylalgia exhibits adaptive muscle activation strategies based on wrist posture and levels of grip force: a case-control study. Journal of musculoskeletal & neuronal interactions. 2018 Sep;18(3):323.
- Heales LJ, Vicenzino B, MacDonald DA, Hodges PW. Forearm muscle activity is modified bilaterally in unilateral lateral epicondylalgia: A case‐control study. Scandinavian journal of medicine & science in sports. 2016 Dec;26(12):1382-90.
- Coombes BK, Bisset L, Vicenzino B. A new integrative model of lateral epicondylalgia. British journal of sports medicine. 2009 Apr 1;43(4):252-8.
- Mascaró A, Cos MÀ, Morral A, Roig A, Purdam C, Cook J. Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy. Apunts. Medicina de l'Esport. 2018 Jan 1;53(197):19-27.
- Arampatzis A, Peper A, Bierbaum S, Albracht K. Plasticity of human Achilles tendon mechanical and morphological properties in response to cyclic strain. Journal of biomechanics. 2010 Dec 1;43(16):3073-9.
- Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clin Orthop Relat Res. 1986 Jul;(208):65-8
- Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med. 2004 Feb;38(1):8-11, discussion :11
- Rees JD, Lichtwark GA, Wolman RL, Wilson AM. The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. Rheumatology. 2008 Jul 22;47(10):1493-7.
- Naugle KM, Fillingim RB, Riley III JL. A meta-analytic review of the hypoalgesic effects of exercise. The Journal of pain. 2012 Dec 1;13(12):1139-50.
- Coombes BK, Wiebusch M, Heales L, Stephenson A, Vicenzino B. Isometric exercise above but not below an individual’s pain threshold influences pain perception in people with lateral Epicondylalgia. The Clinical journal of pain. 2016 Dec 1;32(12):1069-75.
- Manickaraj N, Bisset LM, Ryan M, Kavanagh JJ. Muscle Activity during Rapid Wrist Extension in People with Lateral Epicondylalgia. Medicine and science in sports and exercise. 2016 Apr;48(4):599-606.
- Nijs J, Van Houdenhove B, Oostendorp RA. Recognition of central sensitization in patients with musculoskeletal pain: application of pain neurophysiology in manual therapy practice. Manual therapy. 2010 Apr 1;15(2):135-41.
- Smith BE, Hendrick P, Bateman M, Holden S, Littlewood C, Smith TO, Logan P. Musculoskeletal pain and exercise—challenging existing paradigms and introducing new. British journal of sports medicine. 2019 Jul 1;53(14):907-12.
- Reyhan AC, Sindel D, Dereli EE. The effects of Mulligan’s mobilization with movement technique in patients with lateral epicondylitis. Journal of back and musculoskeletal rehabilitation. 2019 May 10(Preprint):1-9.
- Mulligan MWM for tennis elbow. Available from: https://www.youtube.com/watch?v=thUlPbCX4fU
- Olaussen M, Holmedal O, Lindbaek M, Brage S, Solvang H. Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review. BMJ open. 2013 Oct 1;3(10):e003564.
- Cho YT, Hsu WY, Lin LF, Lin YN. Kinesio taping reduces elbow pain during resisted wrist extension in patients with chronic lateral epicondylitis: a randomized, double-blinded, cross-over study. BMC musculoskeletal disorders. 2018 Dec;19(1):193.
- Giray E, Karali‐Bingul D, Akyuz G. The Effectiveness of Kinesiotaping, Sham Taping or Exercises Only in Lateral Epicondylitis Treatment: A Randomized Controlled Study. PM&R. 2019 Jan 4.
- KT Tape: Tennis Elbow. Available from: https://youtu.be/DgwQSPQv_Zo
- Meglio TV. https://youtu.be/8n5qKX8mctU. Available from: https://youtu.be/8n5qKX8mctU
- KT Tape: Tennis Elbow. Available from: https://youtu.be/GOwqNDP40TQ