Tennis Elbow, (or lateral epicondylalgia) can be a downright incapacitating condition. The internet is plagued with quick-fixes which offer short term symptomatic treatment but beware that they won't work if you actually have tennis elbow (this will make sense in a second). To properly treat your elbow, you need to understand a bit about it and then I'll run you through some things you can do to treat it for good.
What essentially happens to the elbow is the common tendon of a lot of the wrist and hand muscles gets overloaded - normally from injury or overuse. Tendon healing tends to be tricky in that they don't just heal up like muscles or bones but they go through a nasty process where little proteins called proteoglycans swell the tendon - this is what causes the pain. The downside to this is that the swollen tendon can't take as much load which leads to a chronic condition. Depending on how long you've had it can somewhat predict your recovery. If it's relatively recent, then chances are good that you can bounce back quickly. However if it's been going on for a while then you will need a solid plan of action.
Tendon problems tend to be classed into different stages. There's the reactive stage (very painful) which lasts for the first 2-3 weeks. The best thing to do is take it easy and rest the tendon if you're at this stage (check out how below). Then comes the disrepair stage which is where the swelling of the tendon weakens it so much that the daily load you place through it can swell and weaken it further and it creates a negative feedback loop. This normally goes for 1-6 months. The good news if you're at this stage is that there still tends to be good potential for reversibility, the bad news is it tends to take a while to recover. The tendon is not healing itself and needs a controlled load program (see below) to recover its loading capacity. The third and final stage sounds worse than it is but is called the degenerative stage. This is when the problem has gone on for over 6 months and the pockets of protein swelling have significantly weakened the tendon. If this is where you're at it can actually be quite useful to image the tendon with ultrasound as it can take quite a bit of time to come back from this (you definitely can) but you'll likely want to get a heath care team involved to help with your recovery.
Image from Cook and Purdam (2008) see reference at bottom of page.
At this point, you're probably pretty concerned as it's all doom and gloom - fair enough! Treatment isn't too hard but you do need to be specific and disciplined. There are three main things you need to keep in mind.
MANAGE YOUR LOAD
This is your best chance of success with management. If whoever you're currently seeing hasn't mentioned load management and has been trying to treat your tendon with passive modalities like ice, ultrasound or massage - run for the hills!
There's a few pretty simple tricks you can do to manage load on your tendon. The first thing to do is be careful how you're using your hand and wrist. This often means changing your grip and 'scooping things' when you need to pick them up. What you need to do is work out the current load tolerance of your tendon. This is the amount of time you can use tools or grip your hand without morning pain the following day. Find the 'goldilocks' amount of load - not too little and not too much. If the tendon feels stiff the next morning then that's fine. Once you've found the sweet spot, increase your load by 10% a week (no more). You'll probably want your workplace on board with this and might want to do it under the direction of a physio.
The other thing you can do is tape the tendon - check out the video down the page to see how.
2. WARM THE TENDON UP IN THE MORNING
Often the morning is the worst part of the day. Think of tendons a bit like a squash ball. When they're cold they have no bounce but warm them up and they can bounce all over the court. In the morning, the tendon is less flexible and adaptable to any load, so it's also when it's sorest. There's a couple of pretty easy things you can do to help this. First of all, wear a compression garment - it can help simply by keeping the tendon warm. Secondly, do a couple of warm up exercises before putting any load through it. Often putting outward pressure on the elbow while you squeeze your hand for a minute can be a magic exercise in the morning. This will actually help a lot with the load tolerance throughout the day (point 1). Also, don't use ice. This isn't an inflammatory condition like a muscle strain. As discussed above, the swelling of the tendon is from the proteins, not inflammation and ice can make it worse.
3. STRENGTHEN YOUR HAND AND SHOULDERS
The hand is quite a complicated part of the body. It has 27 bones, 27 joints and 34 muscles. There's a lot of capacity for good movement and biomechanics but unfortunately we rarely use our hands as they're supposed to be used. There's a few things you can start to do to help with better biomechanics. Loading the hand in a better way can do wonders to offload the elbow. It can also be a good idea to work on a bit of release through the hand and wrist. The elbow is also supported by the shoulder girdle and ribcage so if your shoulder isn't loading properly the elbow needs to pick up some slack. It's often a good idea to work on upper thoracic mobility and strengthen the scapula stabilisers with rowing or triceps push ups (as long as it doesn't hurt).
4. IT'S PROBABLY NOT JUST YOUR ELBOW
Last but definitely not least is the elbow is closely related to the neck, torso and even feet. More often than not, things like old injuries and repeated movement patterns can change how you load on your arms. So if you're only looking at the elbow but it's coming from somewhere else it can significantly delay your recovery.
WHERE TO NOW?
In my 10 years of practice I've tried all sorts of things to manage this tricky condition but there's a few key takeaways:
- Focus on active management that you can do at home (not passive treatment)
- Keep the tendon warm (don't use ice)
- Tape your elbow every day to take the load off the tendon
- If your condition has gone for more than 6 months, get some imaging done and a healthcare team involved. You may need light duties at work and lifestyle modification as well as a good treatment plan.
Cook, J., Purdam, C. (2008) Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. BJSM
McCreesh, K., Lewis, J (2013) Continuum model of tendon pathology – where are we now? Int J Exp Pathol. 2013 Aug; 94(4): 242–247.