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Tennis Elbow Not Getting Better? This Could Be Why

Tennis elbow is a condition that can happen to anyone who repeatedly uses their elbow, wrist, and hands in their daily activities for work or leisure.  Your tennis elbow could be healing ineffectively as you may be treating the wrong type of tennis elbow.

What is Tennis Elbow?

Lateral epicondylalgia, commonly known as “Tennis Elbow”, refers to pain located at the outer aspect of the elbow. There are many structures at the elbow that can contribute to pain on the outer part of the elbow. Hence, it is important to find out specifically where the pain is coming from so that the right treatment can be applied.

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

Yes, there are many types of Tennis Elbow. They are mainly categorised into 2 types;

True Tennis Elbow

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

False Tennis Elbow

False Tennis Elbow can be further categorised into;

  • Cervical radiculopathy (Cervical referred pain)
  • Ligamentous instability (Ligament laxity)
  • Intra-articular pathology (Elbow joint movement dysfunction)
  • Posterior interosseous nerve entrapment (Nerve is pinched by surrounding structures of the elbow)

How can I tell which type of Tennis Elbow I am having?

True Tennis Elbow is caused by two types of tendon dysfunction: Inflammatory or non-inflammatory. Normal healing of soft tissue like tendon takes 72 hours to eight weeks to recover. In most cases, true tennis elbow which does not heal after 6 to 8 weeks is due to non-inflammatory issue. However, 80% of the cases does not recover as the tendon matrix has been compromised by inappropriate loading such as the overuse of the tendon. This may lead to early wear and tear of the tendon matrix.

True and False tennis elbow is usually recognised by ruling in and out certain factors as follows.

Rule in for True Tennis Elbow

Inflammatory

  • Complains 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 load into wrist extension (wrist extensors) and resisted into 3rd finger extension (ECRB)

Non- inflammatory

  • Complaint 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)

False tennis elbow mimics pain at the outer aspect of the elbow. False tennis elbows could be attributed to;

  • Cervical radiculopathy (Cervical referred pain) 

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

  • Ligamentous instability

Ligaments located at the outer aspect of the elbow called Lateral collateral ligament and Annular ligament which help to stabilise the elbow joint can be loose and cause increase movement to the elbow joint. This can also lead to pain at the outer aspect of the elbow.

  • Intra-articular pathology (elbow joint movement dysfunction)

Joints which are interaction of two bones and the joints at the elbow consists of radioulnar joint, humeroulnar and radiohumeral joint.

  • Posterior interosseous nerve entrapment where the nerve is pinched by surrounding structures of the elbow

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.

Rule out for False Tennis elbow

  • Cervical radiculopathy (Cervical referred pain)

Assessment of the neck spine is carried out to see if there is any referral of pain to the elbow.

  • Ligamentous instability

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

  • Intra-articular pathology (Elbow joint movement dysfunction)

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

  • Posterior interosseous nerve entrapment where the nerve is pinched by surrounding structures of the elbow

Assess if there is any tenderness of the Posterior interosseous nerve and feel the muscles around the area that may contribute to the nerve referring to the outer aspect of the elbow.

It is important to differentiate which type of Tennis Elbow you are experiencing because treatments will differ accordingly.

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

True Tennis Elbow

  • Inflammatory

Treatments for inflammatory true Tennis Elbow are targeted to reduce inflammation. The treatments include rest, applying 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, and sports taping to reduce swelling or offload the tendon.

  • Non- inflammatory

The rehabilitation is targeted to stretch or massage the tendon if it is tight and to strengthen the tendons to allow more efficient loading of the tendons. This will prepare the tendons to withstand load during functional activities such as carrying weight without discomfort.

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.

Hence, it is important to differentiate the type of Tennis Elbow with thorough assessment before the right treatment can be given for a speedy recovery.

 

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