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Endurance Athlete Consulting covers a broad range of topics regarding human performance in sport, sport related injuries, and rehabilitation. If there is something specific you would like to inquire about, please feel free to email me at: bradsenska@yahoo.com.

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Monday, May 2, 2016

Treating Tennis Elbow (Lateral Epicondylitis) & Golfers Elbow (Medial Epicondylitis)

Tennis elbow and Golfers elbow are right up there with plantar fasciitis as far as the amount of difficulty to resolve especially when you don't have the proper knowledge and patience to treat these injuries appropriately.  

First, lets start with a little bit of anatomy regarding the two pathologies.  Tennis elbow is when the tendons on the outside of the elbow at the bony prominence become irritated and inflamed.  This usually happens from repetitive use weakening wrist/finger extensor muscles.  Golfers elbow affects the tendons on the medial elbow or the inside of the elbow at the bony prominence.  Again, the tendons here become inflamed from repetitive use and weak wrist/finger flexing muscles. In either case these can become quite painful.  The two different terms of tendonitis are quite obvious.  Golfers elbow is termed so because this pathology is common with golfers.  It is the same with tennis elbow.  Tennis elbow is common with persons that play tennis on a regular basis.  

Typically it's not just one specific tendon that becomes inflamed with either pathology.  Rather the "common extensor tendon mass" or the "common tendon flexor mass" are affected.  The extensor tendon mass is relevant to tennis elbow.  The common tendon flexor mass is relevant to golfers elbow.  Both pathologies are related to excessive gripping along with flexing the wrist or extending the wrist.  I think the table below will help give a better picture of the two but similar pathologies.

Tennis Elbow
  • Occurs on the outside or lateral aspect of the elbow on the bony prominence
  • Symptoms are caused by excessive and repetitive gripping with extension of the wrist or bending the wrist backwards
  • Symptoms are also brought on by weak extensor muscles of the hand and of the upper arm
  • Can involve multiple tendons which can be referred to as the common extensor tendon mass



 Golfers Elbow

  • Occurs on the medial aspect or inside of the elbow on the bony prominence
  • Symptoms are brought on by repetitive gripping and flexing or bending forward of the wrist
  • Symptoms are often the result of weak gripping muscles and weak muscles in the upper arm
  • Can involve multiple tendons which can be referred to as the common flexor tendon mass



Symptoms

Symptoms with Tennis or Golfers elbow are typically the same.  They usually present in the same manner.  Initial symptoms at first can be a medium to sharp ache or stinging pain on the outside or inside of the elbow.  The area initially affected is usually a very small area.  If left untreated and symptoms progress, pain can be present with bending or extending the elbow upon initial movement.  Pain can also be present when gripping or holding an object that may be slightly heavy.  When symptoms worsen, gripping and holding something even of light weight can be quite painful. Often, when the muscle groups warm up with an activity the symptoms can reduce a moderate amount at which time symptoms will not feel so problematic.  However, after use has stopped and the elbow has been in a resting position for a while, initial movement can be quite painful again.  During the early stages of the symptoms, they are very isolated to a very small spot on the lateral or medial aspect of the elbow.  Again, if symptoms are not treated, this small area becomes larger and can refer down the arm towards the hand.  These symptoms can be a dull to very strong aching or burning pain.  Depending on how severe the symptoms are, the area may have symptoms of numbness or loss of sensation.  This is due to swelling at the elbow which can cause pressure on the nerves affecting the forearm.  When pressure is applied on the nerves, this results in the numbness or loss of sensation.  Some symptoms may also be present just above the bony prominence of the elbow.  As symptoms progress, pain at night time can be very intense and can wake a person.  Keeping the elbow bent during the night can increase the intensity of the symptoms, i.e. sleeping with your arm above or behind your head, sleeping on your stomach with your hands under the pillow, etc.  Keeping the elbow bent for a prolonged period can significantly reduce the blood flow and circulation to the involved area causing an increase of the inflammation process and worsening of symptoms.  The involved area can appear swollen, puffy, red, and there may be a skin temperature increase over the tendon insertion area or the common flexor/extensor tendon mass.  When left untreated altogether, the tendon can become so deteriorated that it can tear from the bone or tear from the muscle belly.  This usually requires surgery to repair. 

Treatment

To begin I'm going to give you a progressive list of treatments that will help resolve Tennis or Golfers elbow.  It's very important to know that patience and consistency with avoiding exacerbation of symptoms is going to be extremely important.  Many people are often referred to physical therapy to have treatment.  Some people will have steroid injections by a doctor to help reduce the inflammation and symptoms.  During the time that the injection is working, this is the best time to appropriately treat the tendonitis so that when the injection wears off your symptoms are resolved.  Ok, so here we go:

  • Use an over the counter anti-inflammatory medication and rest the arm
  • Using ice with the anti-inflammatory and rest is also recommended.  When icing your elbow it's important to avoid icing for too long.  When the ice is being applied directly to the skin via  a plastic bag, the recommended time for icing is 10 minutes and no longer.  This is so you do not cause a nerve palsy of the radial or ulnar nerve at the elbow.  These nerves are very superficial and can be damaged by icing too long with the ice directly on the skin.  If you are icing and are using a towel or some other layer between the ice and your skin, icing may be performed longer.  The rule of thumb to abide by when icing is:  let the ice go through the stages of aching and burning.  Once the ice becomes tolerable it's time to remove the ice.
  • Stretching of the involved muscles and tissue can be performed with the above steps
  • Cross Friction Massage can be done after being properly instructed with this procedure by an appropriate healthcare provider.  Icing can be performed following the cross friction massage
  • Treatment by a competent physical therapist is recommended.  There are modalities that the PT can use which will help speed recovery of the tendonitis.  These modalities include the following:
    • Ultrasound while using the appropriate settings
    • Iontophoresis
    • Phonophoresis
    • Electrical stimulation while using the appropriate settings
    • Thermal modalities
    • ASTYM - Augmented Soft Tissue Mobilization.  This is an extremely effective treatment when performed properly and at the appropriate intervals.  ASTYM can be combined with other modalities, passive and active, to help reduce the pain and inflammation.  Not all physical therapists are credentialed with ASTYM.
    • The introduction of passive and active therapeutic exercises should be introduced at the appropriate time.
    • Using a elbow strap can also be very effective.  However, I am very picky about which strap should be used.  I do not recommend the strap with the air cushion.  This type is very ineffective.  The strap that I recommend is the Bauerfind Epipoint Elbow strap.  Bauerfind makes very effective and high end braces, wraps, and splints for various injuries.  There is one draw back with Bauerfind.  Their products can be expensive.  The plus to this is, you know that they will work and that they will last a ver long time.  They are of excellent quality.
    • Using a compressive elbow sleeve or elbow strap at night can be very effective.  The sleeve or strap will prevent you from bending your elbow to a point in which can increase inflammation and decrease circulation.  This may take some getting used to early on but the benefits are very good.
When treating Tennis elbow or Golfer's elbow, a combination of the above treatments are usually performed simultaneously.  This ensures better healing and a shorter recovery time.  Therefore seeking out a physical therapist that treats these injuries can mean the difference between a nice progressive successful recovery vs. going under the knife to debride damaged tissue and re-attach the tendons followed by a slow and drawn out recovery with possible loss of function.

As usual, if you have any questions or concerns, please feel free to email me at:  bradsenska@yahoo.com

Happy Sporting!!


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