Tennis Elbow Not Getting Better? This Could Be Why.

Tennis elbow is a condition that can happen to anyone and proper management is key to treat it.

What is Tennis Elbow?

Lateral epicondylalgia, commonly known as “Tennis Elbow”, refers to elbow pain located at the outer aspect of the elbow.

Tennis elbow is when the outside part of your elbow becomes painful and irritated because the muscles that help you grip and lift things are overworked. This can occur due to repetitive movements, sudden increase in activity and can be completely unrelated to tennis contrary to popular belief.

Is there more than one type of “Tennis Elbow”?

Yes, there are 2 types:

Type 1: True Tennis Elbow

True Tennis Elbow can arise as a result of tendon dysfunction. Tendon is a fibrous connective tissue that connects both muscles to bone and essential for controlling joint movement.

Type 2: False Tennis Elbow

Some other conditions listed below can masquerade as tennis elbow

• Pain at the elbow due to some irritation at the cx spine (neck) leading to referral symptoms.
• Instability at the lateral elbow due to a sprain of the ligaments there, collectively known as the lateral collateral ligament complex
• Pain at the lateral elbow could sometimes also be due to an irritation of a peripheral nerve known as the posterior interosseous nerve (PIN) syndrome.

How can I tell which type of I am having?

To differentiate between a true tennis elbow and other causes which can masquerade as tennis elbow requires a thorough examination by a skilled physiotherapist. The clinician is required to understand the mechanism of injury and also conduct a thorough assessment of surrounding structures to confirm a diagnosis of tennis elbow.

Tennis elbow can present with inflammation whereby pain is usually more constant and tenderness is present or it could have passed the inflammatory state when client presents themselves at the clinic. The management for both varies slightly.

To Rule In for True Tennis Elbow:

To rule in if it is a true tennis elbow, we need to test or check for the following signs.

1. Inflammatory

• Complaints of intermittent or constant pain started after sudden trauma or injury,
• Presence of swelling and warmth;
• Tenderness at the outer aspect of the elbow specifically located at the lateral epicondyle
• Pain worsens with a load into wrist extension (wrist extensors) and resisted into 3rd finger extension (ECRB)

2. Non- inflammatory

• Complaints of intermittent pain after repetitive usage of the tendon
• Tenderness reported at the outer aspect of the elbow specifically located at the lateral epicondyle
• Pain elicited with repetitive loading of the tendon into wrist extension (wrist extensors) and resisted into 3rd finger extension (ECRB)

Basically, false tennis elbow mimics pain at the outer aspect of the elbow and could be attributing to;

3. Cervical Radiculopathy (Cervical referred pain) 

The cervical spine can refer to pain down to the outer aspect of the elbow (at both C5 and C6 nerve root). Which may be mistaken as Tennis elbow.

4. Ligamentous Instability

Ligaments located at the outer aspect of the elbow called the Lateral collateral ligament and Annular ligament. Which stabilise the elbow joint that basically loose and cause increased movement to the elbow joint.

Therefore, this can also lead to pain at the outer aspect of the elbow.

5. Intra-articular pathology (elbow joint movement dysfunction)

In essence, joints are an interaction of two bones and the joints at the elbow; consist of the radioulnar joint, humeroulnar and radiohumeral joint.

6. Posterior Interosseous Nerve Entrapment where the Nerve is pinched by surrounding structures of the Elbow

The posterior interosseous nerve that lies close to the elbow can be compressed by tight muscles at the outer aspect of the elbow. When it is irritated, it can contribute to pain at the outer aspect of the elbow.

Therefore, it is important to differentiate which type of tennis elbow because treatments are different among them.

To Rule Out for False Tennis elbow

To rule out for a false tennis elbow we need to check the following signs or symptoms

1. Cervical Radiculopathy (Cervical referred pain)

Firstly, an assessment of the neck spine is carried out to see if there is any referral of pain to the elbow.

2. Ligamentous Instability

Secondly, assess the ligaments with tests to check if there is an increase in laxity and stability that causes pain around the elbow but not at the tendon at the lateral epicondyle.

3. Intra-articular Pathology (Elbow Joint Movement Dysfunction)

Thirdly, assess the movement of the elbow joint like the radioulnar joint, humeroulnar and radiohumeral joint to see if there is any increased stiffness that may contribute to the outer aspect of the elbow.

What are the specific treatments that would help my type of Tennis Elbow?

1) True Tennis Elbow

a. Non- inflammatory Type Tennis Elbow

The treatments include rest, applying an ice pack, adding compression and lastly rehabilitation to stretch and strengthen the tendons involved (R.I.C.E.R). Other treatment methods can include ultrasound therapy, as well as sports taping to reduce swelling or offload the tendon.

b. Non- inflammatory Type Tennis Elbow

Here, rehabilitation is targeted towards gradual loading of the affected tendon as a tendon is only as strong as the load that is placed on it. Hence it is important that we teach the tendon to withstand the load that is demanded of it in our daily life. This requires a delicate gradual loading program which is best done together with your physiotherapist as loading it too much and too fast can lead to counterproductive results.

2) False Tennis Elbow

Treatments for false Tennis Elbow will depend on the source of the problem. For example, if the elbow pain is referred from the neck, it is important to target the neck. Therefore, it is important to differentiate the type of Tennis Elbow with a thorough assessment before the right treatment can be given for a speedy recovery.

In summary, this video below gives a good explanation of what are tendons and what happens in tendonitis (inflammation of the tendon).

Experiencing elbow or wrist pain? Click here to find out more about physiotherapy for elbow or wrist pain relief and how Core Concepts manage effective pain relief.