By Musculoskeletal Physiotherapist |
Two conditions that I am very commonly asked advice for from the gym going population are tennis and golfer’s elbow, medically termed lateral epicondylitis and medial epicondylitis, respectively.
The primary complaint for this condition seems to be pain over either the medial or the lateral side of the elbow, which can be achy or burning in nature, and can either be diffusely spread or over a very specific point.
The onset of these conditions is usually seen in accordance with a rapid increase in the level of upper body activity undertaken in a client’s life, for example starting a new job which involves lots of repetitive arm motions, or starting a new gym routine with more emphasis on upper body work. These conditions can range from a nuisance to a huge hindrance and has even led some of my clients to give up their gym programme or job to allow it to settle down.
Before we can understand how to prevent and treat epicondylitis, we need to understand what it is and how it comes about.
What is medial epicondylitis?
Lateral and medial epicondylitis are primarily tendon problems to do with the muscle groups that operate not the elbow but the wrists.
We will refer to these tendon issues as tendinopathies from here on in, as this term encompasses several stages that an unhealthy tendon may go through.
Epicondylitis is actually a rather misleading name, as ‘-itis’ generally refers to inflammation; we now know that in tendinopathies, inflammation is rarely present. There has been a push recently for clinicians to start to refer to these elbow issues as ‘epicondylalgia’ as this term speaks more vaguely about the issue with the tendon, but we won’t go into physio politics here.
Lateral epicondylitis, or tennis elbow, is a problem with the extensor tendons of the wrist. These are responsible for bringing the back of your hand up towards your forearm.
Medial epicondylitis, or golfer’s elbow, is a very similar condition but is primarily a problem with the flexor tendons of the wrist, responsible for bringing your palm towards your forearm.
Medial epicondylitis will also sometimes affect Pronator Teres, a muscle that turns your palm downwards. So why do we feel pain at the elbow if this is a wrist problem? That has to do with the anatomy of your forearm and the attachments of these muscles – the wrist flexors have a ‘common flexor origin’ (CFO) which is the bony point on the medial side of the forearm where they all attach to. It is this tendon that is usually affected in medial epicondylitis.
Likewise, the wrist extensors have a common extensor origin (CEO) which is, you guessed it, on the lateral bony point at the elbow. This is why in these tendinopathies we feel such tenderness right on the bony points of the elbow and (usually) not down in the wrist.
All tendinopathies have three possible stages which were very nicely outlined by Cook & Purdam (2009), which can be thought of more as a continuum than as distinct pathologies.
The first stage is termed the reactive stage, and in a healthy tendon this is usually a temporary change. It is characterised by an increase in water content to the tendon matrix which occurs in response to overload, leading to a thicker tendon, reduced stress and increased stiffness.
If a tendon is not allowed sufficient recovery (think repetitive tasks, day in, day out) then the tendon may progress into the ‘dysrepair’ stage. This represents tendon matrix breakdown, with some possible ingrowth of blood vessels and nerves which further interrupts the useful collagen that makes up a healthy tendon (Magnusson et al., 2010).
The final stage is called a degenerative tendinopathy which occurs when a tendon is overloaded over a long period of time. The collagen becomes structurally disorganised and there are increased levels of vascularity and nerve ingrowth into the tendon.
In this stage, the tendon may become thickened in appearance and the risk of tendon rupture is increased.
Tennis/Golfer’s Elbow Treatment
So if you think you might be developing a tendinopathy around your elbow, firstly don’t panic!
Once identified, conservative treatment is usually quite effective at reducing symptoms and correct management strategies can help prevent recurrence.
The first thing to do in order to treat a tendinopathy is to try and determine what stage of the process you might be in. The management strategies for the stages of tendinopathy differ quite a bit, so you are at risk of making the problem worse if you pick the wrong one.
Reactive and Early Dysrepair
If your elbow pain is relatively new, chances are this is the plan you need to follow. We usually treat an early tendinopathy with isometric exercise and activity modification if at all possible. This basically means finding the activity that aggravates your elbow and finding a different way of doing it.
Remember: tendons may have a delayed response to an activity, so even if you do something that is pain-free at the time, you may still be aggravating it and that is why the tendon may be sore the following day.
Sometimes 5-10 days may be enough to allow a tendinopathy to settle, so if lots of bench pressing is aggravating your medial epicondylitis, try using dumbbells or a machine for 10 days to see if that makes a difference.
Treatment | Isometric exercise
In terms of isometric exercise, for medial epicondylitis, cover your affected palm with your other hand and try to curl your palm up towards you at the wrist, while preventing any movement with your other hand.
Hold this contraction for 5-30 seconds and then relax. Repeat until you feel an ache in the working muscle, several times each day.
For lateral epicondylitis, the technique is similar but instead cover the back of your affected hand with your other hand and try to bring the dorsum of your hand up towards you while preventing any actual movement.
Not working? Try these stretches!
If isometric exercise isn’t improving matters, with caution I will recommend a stretch for these conditions. These are shown in the pictures below:
Hold each for 20-30 seconds, several times a day.
These can also be used as very effective prevention strategies and I will often recommend these to clients to adopt between sets in the gym.
Late disrepair/Degenerative tendon treatment
I will start by saying for this stage of a tendinopathy, one thing I do not recommend to patients is the use of anti-inflammatories like Ibuprofen. This is firstly because we now know that there is little inflammation present in these conditions, and secondly because Ibuprofen can actually inhibit collagen repair (Tsai et al., 2004), which is what we are ultimately trying to achieve!
✓ If you feel you need medicine to help with your tendon pain, always consult your doc or pharmacist before starting a medicinal regime and try simple measures like ice and rest first.
The main treatment approach I use for this stage of a tendinopathy is called eccentric exercise.
The strategy for lateral epicondylitis is shown in the picture on the right (if you have medial epicondylitis, simply turn your hand up the other way).
✓ Eccentric exercise involves a slow, controlled lengthening contraction. Use your other hand to help with the concentric (curling up) phase.
✓ I like to prescribe 5 second lowering phases for each rep, but the effective number of reps and sets for each individual varies greatly so this one will take a bit of trial and error.
Take Home Messages
✓ Medial and lateral epicondylitis are primarily wrist problems rather than elbow problems.
✓ It is the tendons affected, and identifying which stage of the tendinopathy continuum you are in will greatly aid treatment.
✓ Address early tendinopathies with rest, isometric exercise and stretching, but address later tendinopathies with eccentric exercise.