In this installment of our “injury of the week” series we’re going to be talking about tennis elbow or “lateral epicondylitis”. We’re going to keep the same format we’ve had all along. First we’re going to start off with a review of what the injury is and talk about if this is what you have have and when you need to worry/consult your doctor. From there we’re going to take you through the steps of the A-T-A self treatment system.
Tennis elbow!? I don’t even play tennis…
Let’s take a quick look at the anatomy before we get into causes and what else it could be. The lateral epicondyle is part of the humerus. All of the little muscles that pull your wrist back (extend it) insert onto this spot.
Why is that important? The lateral epicondyle is a common insertion point. Three muscles join to share a tendon and insert there. That means that when those muscles repetitively pull on it, the tendon can get injured and even pulled off the bone. This is where the term “lateral epicondylitis” comes in. It got the name “tennis elbow” because it was common in tennis players due to the repetitive grip/forearm motions. The truth is the tennis part doesn’t matter at all. This can happen to anyone. Why? It’s an overuse injury.
How do overuse injuries occur?
The first thing to realize when talking about muscles and the body is that it is ALL connected. Thick of it like a chain. As you move to pick something up, muscles are working to grip the object all the way up into the shoulder and trunk. That means that if anything is tight along that chain or weak, the other muscles will need to work harder to make up for it. This is how overuse injuries happen. Something on the chain breaks because it was making up for something else. In the case of tennis elbow, posture can be a huge factor.
In the picture above, we have good posture. The large trapezius muscles and deltoid have the shoulder in good alignment. This keeps the humerus where it needs to be and sets the elbow up for the wrist extensors to follow.
To help demonstrate what happens when you don’t have that good set up I’m going to have you slouch forward. Now form a tight fist in your hand. Notice how your wrist and forearm are the only thing moving? Now try it again, but this time pull your shoulder blades back together first. Hold that and then make your fist. Much easier, right? The bigger muscles upstream are key. If they can’t hold everything in place, eventually the muscles in the front of your shoulder/chest will tighten up and get stuck that way. Once that happens, the muscles in the back of the shoulder won’t be able to help and the forearm will have to do all the work. If the muscles on the inside of your forearm ( the wrist flexors ) tighten up as well, then it will be double the work.
My elbow hurts. Now what?
First things firs- like we’ve said all along. This site is not designed to keep you from your doctor and healthcare team. It’s designed to teach you the things that you can do at home to help alleviate symptoms and prevent them from becoming a full blown injury. That being said, if you have any of the following, it is time to see your doctor. Visible swelling. Bruising. Numbness/tingling in the forearm/fingers. Inability to grip an object or you find yourself dropping things.
Be smart when self treating at home. If you aren’t getting better, see your doctor. I can’t tell you how many patients I get who wait weeks and even months before coming in for treatment. The longer you wait, the harder it is to get rid of. Here are some tips for finding the right health care professional:
- Find someone certified in soft tissue mobilization, whether it’s instrument assisted like Graston Technique or hands on like Active Release (ART). This is where you need to do your homework to see who’s near you. Follow the links to those sites to search their provider lists and read up on what each is all about. Graston works like a champ on tendons in particular and tennis elbow affects that common extensor tendon. ART is a great way to loosen up the muscles in the forearm and upstream into the shoulder/trunk.
- Not every PT and chiropractor are created equally. Some do very little soft tissue work and rely mostly on exercise and manipulations, others do not. We all specialize in our own little areas. Frustrating right? Nope! Most of us have websites to tell you what we are certified in. If we don’t? Pick up the phone and call us. There’s nothing worse than wasting 8 insurance visits not getting better only to switch places and have them fix it in two.
How to treat it.
Step 1- Traditional R.I.C.E. treatment:
When a new injury occurs, the first and most important goal is always to decrease pain and any swelling that may be present. In other words, we want to decrease inflammation. That means ice is mandatory. Absolutely no heat no matter how good it feels. Don’t short cut this stuff. It’s boring but it works, especially if your symptoms worsen as the day goes. It’s now easier than ever to smuggle an ice pack into the office fridge. Use that to your advantage when working to heal an injury especially if your job involves prolonged time on a computer or repetitive grip/lifts/carries.
Rest: This may sound obvious, but I’m going to say it anyway. An injured muscle/joint will require a decreased activity level to fully heal. The severity of the injury will determine if this is a full rest or more of an active recovery. A good lifting guideline is this- glue your elbows to your sides when you pick something up. If you can keep them there and pick it up, your okay. If you can’t? It’s too heavy. Let someone else do it.
Ice: while heat may feel better on stiff and sore muscles, ice only during the first 7 days following injury. This will help to decrease swelling, inflammation and pain. 10-15 minutes is sufficient and you can perform every hour as needed. Avoid direct ice to skin contact.
Compression: Ever see anyone with those little aircast elbow braces?? They are commonly used to treat tennis elbow and are routinely prescribed by PCP’s and orthopedic docs. They are designed to decrease the strain on the tendon insertion by creating a new anchor point just below it. If your doctor gives you one make sure you know how to put it on correctly. Placing this thing directly over the insertion point is a sure fire way to aggravate it and make it worse.
Step 2- Kinesiology taping:
The application for tennis elbow is designed to reduce the strain placed on that common extensor point. See the video below for full instructions.
Step 3 – Getting mobility back
The second goal is going to be to loosen up the injured area. Below I have the treatment techniques set up in levels. As a rule, you must be able to complete #1 without pain to progress to the next level. Be smart! Healing a tendon injury isn’t about no pain, no gain. Don’t overdo it in an attempt to speed up your recovery.
1) Rest/ice + gentle stretching. There should be no pain with stretching.
2) Begin using the foam roller to work on the muscles first (in other words above/below the tendon). The tendon is what attaches the muscle to bone. The goal here is to start getting slack into the muscles without aggravating the injury itself. No tennis ball work or mobilizations. The order should be foam roll the muscle above/below the tendon -> stretch -> rest + ice.
3) Begin using the foam roller over the tendon to tolerance. The order should be foam roll the muscles above/below the tendon-> over the tendon -> stretch -> rest + ice.
4) Begin using cross friction. Remember, you will want to work perpendicular to the the tendon (use the picture below; the tendon is green, you want to be working in the direction of the white dotted lines). Not sure on cross friction? Review here. Start with light pressure at one end of the tendon and work your way all the way down it. Repeat as needed (and as tolerated) with increased pressure. If it’s too painful- wait and try again the next day. The order should be foam roll the muscles above/below the tendon -> over the tendon-> cross friction -> stretch -> rest + ice.
5) As the tendon heals, we can really start to go after the muscles using the mobilization techniques. The order should be foam roll the muscles above/below the tendon -> over the tendon-> cross friction -> mobilizations -> stretch -> RICE.
How long do you need to R.I.C.E for??? Until it’s 100% gone.
Here’s what it looks like for tennis elbow. Use the guidelines above.
Step 4: Strengthening
We’ve broken the exercises down into three levels based on pain levels. This stuff should NOT hurt. If it does, go back a level or ease up on the resistance. Only progress as pain free.
What you’ll need: 1) resistance tubing or 2) dumbbells.
Optional equipment: 1) a stability ball. As you start to get stronger with these exercises this will allow you to add that total body component to really pull it all together.
Video’s for each level are here. Please note, in the PDF download you will find details for reps and difficulty progression, as well as, benchmarks you should meet before progressing to the next level. The number one thing to remember is that these exercises should be pain free. If you’re getting discomfort, go back a level. You can’t force this injury to heal, but you certainly can make it worse if you over do it.
Hope that helps, and fire away with any questions in the comments section!
1) Capobianco, Dr. Steven and van den Dries, Greg. (2009). Power Taping, 2nd Edition, Rock Tape Inc, Los Gatos, CA.
2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.
3) Hyde, Thomas and Gengenbach, Marianne. (2007). Conservative Management of Sports Injuries, 2nd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.
4) Kase, Kenzo, Wallis, Jim, and Kase, Tsuyoshi. (2003). Clinical Therapeutic Applications of the Kinesio Taping Method.
5) Muscolino, Joseph. (2009). The Muscle and Bone Palpation Manual. Mosby, Inc, St. Louis, MO.