What is Tennis Elbow/Lateral Epicondylosis?
You might have had a pain in the elbow and wondered what was causing it. One possibility is lateral epicondylosis, or what is commonly referred to as “tennis elbow.” Even if you are not a tennis fan, the condition can affect you while at work, in the yard, or in the comfort of your home. The condition can last anywhere from 3-6 months. The good news is that with a well-designed physical therapy program, this time may be shortened.
Muscles attach to bones through tendons. The transition area of muscles and tendons, and tendons to bones experience higher levels of tension than the muscle belly. Sometimes the demand at these areas is too much for the tendon to handle. A high volume of use (E.g. typing, repetitive lifting) and/or lifting an object even once that is too heavy can overwhelm the tendon. Imagine a rope used to repeatedly lift a box. Over time that rope will break as the fibers wear out. Alternatively, that rope will break if it’s made to only lift a 50 lb box, but is used to lift a 100 lb box.
For many years this condition was incorrectly labeled as a form of tendinitis. Tendinitis is an inflammatory condition in the tendon. Recent research has not found this to be true. Rather, the collagen fibers that make the tendon become abnormal and eventually breakdown. You may not experience pain until the tendon has reached this later stage. For this reason, it is important to seek treatment when symptoms are first present; and continue a home program given by the physical therapist even when pain-free.
Forms of Treatment
Some commonly prescribed treatments for lateral epicondylosis are actually detrimental to healing. This article will go through which treatments are recommended. Treatments that are harmful to full recovery will also be discussed.
Physical Therapy: Exercises
The best treatment is appropriate exercises to stimulate tendon healing. Your physical therapist may mention the concept of “modified tension.” Tendons are composed of collagen fibers. During movement, tension through these collagen fibers sends a signal to the body to make new, stronger fibers. The amount of collagen tension is important. Too little tension (I.e. complete inactivity of the tendon) and the collagen fibers break down. Too much tension, the collagen fibers also breaks down due to an inability to handle the load. In both situations, the tendon is weaker. A physical therapist will be able to modify your exercises to achieve the right amount of tension to stimulate tendon healing.
How the tension is applied through exercise matters, as well. An in-depth discussion of concentric and eccentric loading of muscles is beyond the scope of this article. But, in general, recent research supports the use of eccentric loading for better collagen healing. Eccentric loading is when the muscle lengthens while under a load such as a dumbbell. Your physical therapist will prescribe the correct exercises for you.
Heat or Ice?
A question frequently asked is whether heat or ice is better for this type of condition. The majority of the time ice is best. The sensation of heat does feel good; and may decrease muscle guarding. However, heating collagen actually weakens it. Weak collagen is the opposite of what you need to recover. Most people ice their injuries for much longer than is beneficial. This is good news if you are not a big fan of ice! 5 minutes maximum is all you normally need unless your ice pack is wrapped in thick layers. Use a pillow case instead if this is the case. Depending on the severity of pain, you might need to ice anywhere from 3 times a day to every hour while awake. Your skin should not be red when you remove the ice pack. If it is-decrease the application time in the future. Ice is beneficial for pain control. Pain control occurs by numbing the nerves temporarily and reducing muscle guarding.
Non-steroidal Anti-Inflammatory Drugs (NSAID’s)
NSAID’s are commonly prescribed for many health conditions. Examples of NSAID’s include ibuprofen, aspirin, and naproxen sodium. NSAID’s, in general, are not helpful since this is not an inflammatory condition. The only case where NSAID’s could be helpful is in reducing pain to allow for early movement. As we previously discussed, modified movement is the best approach to becoming pain-free.
Cortisone injections are not recommended unless the elbow has not improved with physical therapy, and the pain remains severe. The reason is due to more than just an aversion to needles being jabbed into painful joints. The tendon needs to make new, stronger fibers to resolve this condition. Corticosteroids prevent the making of these new, stronger fibers. The medication can decrease pain. However, with the absence of pain, there is also a higher risk of overdoing your activity level.
Wrist Braces and Elbow Straps
Wrist braces and elbow straps are used to rest the painful tendon to allow healing. Preventing movement for long periods of time, however, is detrimental to tendon healing. As you have now learned-tendons need non-painful, repetitive movement to stimulate healing and increase strength. A brace or strap may be appropriate when having to perform tasks that will increase pain (E.g. shoveling snow, construction work, and extended periods of computer work). But, a long period of use is not recommended. Speak with your physical therapist regarding what is the appropriate amount of use for you.
Tennis elbow/lateral epicondylosis is not strictly a sports-related injury. If you believe that you have this condition, see your physician as soon as possible in order to be referred to physical therapy. Modified exercises are the best form of treatment. Other commonly prescribed treatments can actually make your condition worse. Fully resolving the pain may take 3-6 months. However, that time can be dramatically lessened with the right rehabilitation program. Your physical therapist will also be able to teach you how to manage your condition while on the road to recovery.
-Heidi Edwards, PT, MPT, OCS, COMT, CSCS