Do you suffer from chronic elbow pain? It is common to refer to pain on the outside of the elbow as “tennis elbow,” and is often deemed to be tendinitis, even though it is not always a tendon problem. Research has demonstrated that painful tendons do not actually become inflamed, but rather their cellular structure breaks down over time. More accurately, we now refer to chronic tendon pathology as a tendinopathy, rather than tendinitis. This serves as just one reason why treatments focused on inflammation have not been successful, resulting in persistent pain. In fact, if you strain a tendon during a sport or activity it should be substantially better without any treatment after 4-6 weeks, provided that you avoid any aggravating activities. If it remains persistently painful and/or weak after a period of relative rest, there are likely other unidentified issues contributing to the ongoing pain. In fact, it might not even be a primary elbow problem. Tennis swings are complex movements that involve multiple joints working together to produce a powerful and accurate swing. Limitations in mobility and coordination in the thoracic spine, shoulder girdle and hips may be causing compensatory excessive loads around the elbow.
Additionally, techniques for different strokes can also be a contributing factor to persistent elbow pain. Specifically the “modern forehand” involves an increased amount of racquet lag and a shorter backswing. It is possible that this may not be the right choice for you based on your current levels of mobility and strength. Screening by a physical therapist familiar with tennis techniques can help identify specific physical impairments that may reveal whether or not it’s worth pursuing this type of swing. Furthermore they can offer modifications as necessary and prescribe exercises to optimize your mobility and strength for more efficient dynamic function.
Maybe it’s not a tendon problem.
It is not uncommon for physical therapists to identify joint restrictions at the elbow or wrist as the precipitating factor(s) of lateral elbow pain. Manual therapy techniques can resolve these entrapments and relieve pain.
Consider the cervical (neck) component.
The relationship between neck dysfunction and tennis elbow was first described in the 1960’s, with notable improvements in elbow pain following manual therapy treatment to the neck. Despite this long recognized connection, the neck is often overlooked with chronic elbow pain treatment protocols. If you have had any previous neck injuries or pain in the past, it is important to screen this region as a potential contributing factor to your lateral elbow pain.
A quick self-screen, simply involves turning your head toward the side of pain and then tipping it back over your shoulder. If there is pain or limitation, then a more thorough assessment of your neck by a physical therapist would be necessary as part of your elbow treatment.
Could it be a radial nerve entrapment?
Sometimes lateral elbow pain can arise from nerve irritation. Specifically, the radial nerve that runs along the outside of the elbow can become entrapped at a number of different places including the radiocapitellar joint, spiral groove, arcade of Frohse, tendon of the extensor carpi radialis brevis (ECRB), or at the radial tunnel (Buchanan https://www.ncbi.nlm.nih.gov/books/NBK431097/). Your physical therapist can assess whether you have adverse neural tension in the radial nerve, locate the particular site of entrapment, and provide the necessary treatment to alleviate this problem.
Is the grip size of your racquet right for you?
The grip size of your racquet significantly influences the impact forces transmitted to your forearm muscles. When grip size is incorrect, the grip force increases, leading to excessive force transmission to your elbow (Rossi, Vigouroux et al. 2014). To assess the optimal grip size of a racquet, measure from the tip of the ring finger to the bottom palmar crease. This distance should therefore be the grip size of your racquet. A cushion grip can also reduce slippage of the racquet, requiring less grip force. You can also try reducing the tension in your racquet strings and avoid using old tennis balls that are poorly inflated as these variables can cause greater strain on your forearm muscles.
Try eccentric training.
Despite the name, this is not some oddball form of exercise, but rather a particular phase of a normal muscle contraction. It refers to the lengthening phase of a muscle contraction when you are lowering a weight, rather than lifting the weight. Using eccentric training for tendon pathologies has been a part of physical therapy since the 1970’s. The appropriate dosage for this type of training has been refined over the decades. This motion is performed relatively slowly so that the tendon has enough time under tension to allow for the injured fibers to be activated. A common error is to perform this motion too rapidly and then fail to properly apply tension to the injured portion. The weight should be as heavy as you can tolerate without pain and also be properly controlled during the movement. Some dosage options include:
- Perform eccentric wrist extension and/or supination (the rotation of the forearm and hand so that the palm faces forward or upward.)
- Isometric holds (muscular action in which tension is developed without movement of the joint) of 10 seconds for 2 repetitions to reduce symptoms.
- Eccentrically lower the weight taking 7-10 seconds to slowly lower the weight. Return the weight to the start position with the opposite hand.
- Train 2x per day with at least 6 hours between training sessions.
Conclusion.
Tennis elbow can be a challenging condition, but with the right physical therapy interventions you can find relief and regain functionality. It is essential to consult with a qualified physical therapist, who has a training background in manual therapy and rehabilitative exercise, for a personalized treatment plan tailored to your specific needs. MTI has five clinic locations in King and Snohomish Counties in the Seattle area. We provide one-to-one care with a licensed physical therapist who has advanced training in manual therapy and/or sports therapy.
By addressing pain, improving strength, restoring flexibility and mobility, as well as modifying techniques appropriately, and adopting preventative measures, you can get back to the tennis court and other activities you love pain free! Schedule an appointment with an MTI physical therapy clinic to get started today!
Jim Rivard, PT, DMT, MOMT, OCS, SCS, FAAOMPT is one of MTI Physical Therapy’s Owners and Founders and sees patients at MTI Physical Therapy’s First Hill clinic. Jim is a Board Certified physical therapist in both Sports and Orthopedics, regularly working with youth athletes, semi-professional and professional athletes. He serves as the Program Director for MTI Physical Therapy’s Sports Residency. He has over 35 years of clinical practice and publication, as well as teaching nationally and internationally and rehabilitative exercise and manual therapy. His best tennis days were his high school and collegiate years but he talks a good game.
Scott Olson, PT, MOMT, FAAOMPT is one of MTI Physical Therapy’s Owners and Founders and sees patients at MTI Physical Therapy’s Bellevue clinic. Scott is a Fellow in the American Academy of Orthopedic Manual Physical Therapists. He has been practicing PT since 1986 and has been involved with both national and international teaching in the discipline of manual therapy. A tennis player since childhood, Scott is familiar with these types of injuries and routinely sees tennis players in the clinic. He loves helping his patients safely return to not only the tennis court, but to everyday life. If not crushing his business partner Jim on the tennis court, he can be found on the mountain bike trail or in his kayak on an alpine lake somewhere in the beautiful Pacific Northwest.
Micha
el Okada,PT, DPT, OMT, FAAOMPT is a staff therapist at MTI Physical Therapy in Bellevue. Like Jim and Scott, Michael is a Fellow in the American Academy of Orthopedic Manual Physical Therapists. He received his doctoral degree in PT from Pacific University in Hillsboro, OR and his Manual Therapy residency and fellowship training through the Ola Grimsby Institute. Outside of his physical therapy practice, he enjoys playing tennis (as a former collegiate player, he is more than capable of mopping up the court with Jim and Scott), golfing, hiking, running, playing guitar and visiting friends and family in his native Hawai’i.
Tags: physicaltherapist, healthandwellness, physicaltherapy, Tennis, tenniselbow, elbow pain, tennis elbow, sports physical therapy
