Tennis Elbow – Get A Grip Of Elbow Pain

tennis elbowGetting a decent grip on things is the major issue with tennis elbow. Elbow pain is one of those annoying musculoskeletal problems that plague us as we get older and seem to just become part of who we are.

As time goes on the list increases of all the things you’ve “got wrong with you” and if you remember back to when you were in your twenties you had none of them at all.

When it’s acute it’s a real bitch. Ever had an acute tendonitis, the type which comes on strongly after you’ve overdone something? If you have you’ll remember it as I remember the pain in the extensor tendon of my right thumb. At night I held it up in the air because putting it down anywhere resulted in such severe pain.

It was a day or so before I put it into a splint, rather an oversight for a physiotherapist who’s supposed to know how to manage these things. It did settle down completely because it was an “-itis”, an acute inflammation in  response to high physical stresses.

Most tennis elbow symptoms are much less acute and many episodes never have an initial, highly painful episode, just grumbling from the onset.

What is Tennis Elbow?

Tennis elbow is an overuse syndrome and perhaps the most common. This means we get tennis elbow because we do too much of one thing for too long. We’re designed to do a large variety of things not very often, not one thing a lot of times such as in repetitive work with our hands.

Although tennis elbow may start off with an “-itis” as in acute tendonitis, once we’ve had it for a while there seems to be no ongoing inflammation so we need to give it a different name to be accurate.

Now tennis elbow has got a whole armful of names. Lateral epicondylitis, elbow tendonitis, lateral epicondyle tendinopathy, lateral elbow tendinopathy, lateral epicondylalgia and more. Although the accepted medical name now is lateral epicondyle tendinopathy (LET), it’s still referred to as tennis elbow by pretty much everyone as it’s so easy and descriptive.

anatomy of tennis elbowLateral epicondyle tendinopathy means an “-opathy” or change in structure for the worse, occurring in the tendon(s) on the outside of the elbow at the bony prominence called the epicondyle.

Medial epicondyle tendinopathy (golfer’s elbow) means the same thing but occurring on the inside of the elbow.

Tennis elbow involves most commonly the tendon of the muscle known as extensor carpi radialis brevis, the extensor of the wrist (carpi) on the outside (radialis) which is the shorter (brevis) one. This implies there is a “longus” as well, which there is. Two other muscles, extensor digitorum and extensor carpi ulnaris, may also be affected.

Pathology of Tennis Elbow

Tendons “insert” into our bones, it’s the way that muscles anchor themselves to bone so they can pull or push as required. Just before this insertion point into the bone tendons have a zone which is very poor in blood supply and this may make them more likely to suffer degenerative changes in this area. The commonest area for this problem is around 1-2cm from the insertion of the tendon of a muscle known as extensor carpi radialis bravis (see below).

When the affected area is examined under the microscope there are typically no signs of inflammation but an excess of blood vessels, increased numbers of fibroblasts (these make collagen which tendons are made of) and disorganisation of the collagen structure of the area with small tears.

Tennis Elbow Symptoms

The definition doesn’t cover the most important thing to us though, the elbow pain. Tennis elbow gives pain where the forearm extensor muscles originate at the lateral epicondyle, brought on by gripping and repetitive manual work. This can radiate down the forearm.

Who Gets Tennis Elbow?

Tennis (and golfer’s) elbow are commonest in men and women over 40 years of age, with no particular difference between the sexes. Its occurrence peaks between 40 and 50 years of age, with an overall occurrence of from 1-3% of the population. The pain mostly comes on slowly in a sneaky fashion although people can usually remember overdoing some activity recently.

The pain worsens with forearm activity, often around a day to three days after the aggravating event and improves with rest.

In your 40s your tendons have all changed significantly since you were 20 even though they work perfectly well most of the time. However if you overdo things you can inflame a tendon and if you really overdo it violently the tendon can rupture, although this is uncommon.

Achilles tendon rupture is well known in squash players older than 40 years and this reflects the age related reduction in strength which occurs in us all.

Risk Factors for Tennis Elbow

While the underlying pathology and treatment of this condition are not clear, it has been linked with a number of risk factors. These include:

  • Handling loads over 20kg more than 10 times a day
  • Handling tools of over 1kg,
  • Repetitive movements of the arm and hand for over 2 hours a day
  • Lifting the arms up in front of the body
  • Hands which have to be in a bent or twisted position
  • Doing precision movements

(From a paper by van Rijn and other authors, see below).

In normal life this means that anything we do with our hands at a higher level than normal in terms of force and repetition can bring on tennis elbow.

The Prognosis for Tennis Elbow (how it’s going to go)

Most episodes settle down if you don’t continue to re-stress the area by doing more of the aggravating activity, but at one year after onset 20% of people still have their pain symptoms.

Tennis Elbow Treatment

This is where things get tricky. Not only is there no clearly accepted understanding of what goes on in the tendons, there’s no clear leader in which therapy to choose. Benign neglect, where you forget about it and try not to stir it up too much, may be as good as anything.

Treatments include:

  • Benign neglect or watchful waiting
  • Strapping
  • Orthoses such as braces and wrist splints (improves grip and pain in 2-6 weeks after onset, wrist brace may be better)
  • Corticosteroid injections (reduce pain in the short term but little long term effect)
  • Drugs (non-steroidals such as ibuprofen may have helpful short term effects but little else)
  • Deep transverse frictions (no benefit has been shown so far)
  • Ultrasound (some small effects)
  • Acupuncture (no benefit has been shown so far, some short term help perhaps)
  • Laser (no benefit has been shown so far)
  • Exercise and stretching (may be useful)
  • Extracorporeal shock wave therapy (no benefit has been shown so far)
  • Pulsed electromagnetic therapy
  • Autologous blood injections (some evidence of help with injection of your blood into the area of tendon thought have poor blood supply)
  • Platelet rich plasma injections (show some promise of help in cases resistant to simpler therapies)
  • Surgery (removal  of the abnormal tendon tissue may be effective in difficult cases)

And so on. Pretty much anything we can do to someone has been tried – electrical energy, sound, light, force, activity, blood, drugs and cutting people open.

When you get this list of therapies, which is probably not exhaustive, you know that no-one has a clue how to treat the condition effectively. Or that a bunch of different approaches may have some benefits at different stages of the condition.

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My Tennis Elbows

I’ve had tennis elbow for some years and I think it’s partly because I’ve done a lot of weight training. I have small bones and narrow limbs and I’m not built for strength. When I was 21 I was six foot one (183cm) and 152 pounds (68kg).

The pains in my elbows have come and gone and nowadays I mostly manage them by avoidance, in other words by not doing things which might stir them up. I’m not sure this is a good strategy so I have decided to do something about it, to attack my tennis elbows and see if I can fix them.

They were bad, at least the left was bad enough to hurt in many hand activities and to reduce my grip strength, never very great, to about a third of normal levels. And giving the obligatory firm handshake with my right hand to any man I meet has been painful over the last few years.

My brother, who works hard manually, said it would settle down after a year or so, that it would come and go, and he was right. Now they are a lot better and give me little problem in normal life. But I reckon if I did something vigorous with my hands it might return and I get sudden tweaks of pain when I do certain things.

Being a physio I’m more attracted to the exercise options of the possible treatments, so I decided to do an experiment on my own tennis elbow. What if I improved my grip strength massively? Could I do that? Would that help my elbow pain or just make me stronger?

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Tim Ferriss and Pavel

So I was listening to this Tim Ferriss podcast and he was interviewing Pavel Tsatsouline,  an ex-Soviet strength trainer who has graduated from training Russian special forces to being a consultant to the US equivalent.

There is a culture of maleness which worships power such as grip strength and the ability to dead lift. I’ve never subscribed to this, or had the physique to exhibit it, but it gave me the idea. Perhaps I could train my forearms to be stronger and less painful.

The Captains of Crush®

captains of crushPavel introduced me to the Captains of Crush®, grip-strengtheners but not as we know them. You can buy poor imitations at sports shops across the country but the Captains are another thing altogether.

So I bought the weakest set, called the Guide, the lowest and most wussy resistance. A review on their site suggests this one is for girls or for just using two fingers!

I reckoned my grip was well below average and I was right, the lowest strength was the one to start with. They were £24.95, which may show I have somewhat more money than sense, but a solid product arrived through my letterbox.

They’re compact and heavy with sharply knurled handles which abrade your hands as you squeeze them but I reckon I’ll get used to that as I toughen up. The emphasis in training is to do good quality reps so you close the handles together completely.

The interesting thing about the Captains of Crush® is that they are calibrated to specific closing strengths and you can progress up the ladder of resistance as you become stronger. Strong men can become officially certified as being able to close the more powerful models, with only a few men in the world able to demonstrably close the No. 4 gripper.

So I’m starting with strengthening my grip because I like the idea and my grip has become weak over the years. It’s an easy thing to do, uses a cool bit of equipment and takes very little time. I’m sure my grip will get stronger as I progress through a few grippers of increasing resistance but I’m interested to see if my elbow pain changes much.

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power gripThe Grip

If you’re paying attention you may ask the question “What have the grippers got to do with tennis elbow which involves the extensor muscles, the opposite ones to the flexors which provide grip power?”. Yes it’s a good question but strong gripping involves co-contraction, the simultaneous contraction of the flexor and extensor muscle groups. Without the extensors the grip cannot get good strength from the flexor muscles alone.

Let’s try some experiments.

Lie your arm along the arm of the sofa with your hand resting on the surface. It’s likely your wrist is in slight flexion, i.e. is angled down a little. Now grip. What happened? Your wrist instantly moved up into extension and your knuckles are now pointing up into the air. This is the power position for grip and any other wrist position reduces grip power.

Now for a second experiment. Have your elbow bent at 90 degrees and flex your wrist as far as it can easily go, just letting it flop will do it. Now grip while keeping your wrist bent. How weak was that! Very weak indeed with the grip at a significant mechanical disadvantage when the wrist is in flexion, or bend.

In the power position the wrist extensors and flexors are not providing the power, they are holding the wrist in the best position for gripping and thereby allowing the finger flexor muscles to do their power work holding on to something.

The wrist flexors have been measured as 62% stronger than the extensors. So the strength of the wrist extensors and their ability to maintain the wrist position with sufficient power and endurance will dictate grip power and time. The extensors are a smaller and weaker muscle group than the flexors so they may be the limiting factor, weakening early and letting the power position fail. This will then let the grip fail. So it’s important to have strong extensors which can keep up a contraction for as long as you want to maintain your grip.

In normal life, or even in weight training, it may not be necessary to train the extensors directly, they may get enough work with all the gripping of normal objects or the weight bars.

Types of Grip

There are many aspects of grip but the major types are hook, power, key and pinch or precision grip. They each involve a different combination of joint position and a different mix of muscular efforts. Our ability to use our hands in such flexible ways distinguishes us from our primate cousins the chimpanzees, gorillas and orang-utans.

Hook Grip

A common grip we are familiar with, we use it for carrying bags for instance. In weight training we use this grip a lot as we hang on to the bars in pulling exercises such as chinning and rowing. This grip method is mostly performed by the superficial and deep finger flexor muscles.

Power Grip

This grip only works on something small enough for the hand to get right round it and form a loose fist, such as a rope, ball or thin bar. Or your hand if you’re unlucky. The whole range of wrist flexors and extensors is working here with the finger flexors.

Key Grip

key-gripHold a key and insert it into a lock and you’re using the key grip. This grip is very important not just for keys but for holding things like magazines, newspapers and mobile phones.

In his grip the the index finger and thumb are in slight flexion at each joint and the grip is being maintained by the thumb flexors against the resistance of the index finger abductor (the muscle which moves the finger away from the palm sideways).

Pinch or Precision Grip

Our hands are amazingly designed to do large range and powerful activities and then fine,  precision movements such as playing the guitar or making a model. Our thumbs are arranged so the pad can move round to meet the pads of the index and middle finger in the precision grip. With this grip we can pick up  pins, pieces of paper and manipulate small objects like winding a watch.

With the grippers I’m training the power grip. Training the other types of grip is uncommon and probably not necessary unless you have a loss of power or specific requirements. Such as playing a very tough guitar!

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My Training Programme at the moment

Every other day.

hand grip strengthenerI warm up with some gripping and ungripping of my hands for a few minutes. Then I do three sets of six reps with the Guide Gripper, which has a closing resistance of 60lbs force.

I’ll increase the reps by one every week until I’ve reached 12 then I’ll move on to the next strength gripper up. Since then my forearms have felt a little different, as if they have done some work, so it’s had an effect at least.

Once I have tested improving my forearm gripping power I’ll have to decide what to do next if my pain isn’t much better. I might then move on to eccentric exercises, the type of exercise most favoured for tendinopathy.

I’ll update this blog with my progress, such as measuring my grip strength if I can find a local device, as I go through an attempted rehab programme for this difficult condition.

There’s a lot we don’t know about managing tennis elbow in its different forms and severity, have you got any useful stories and tips you could pass on? If so please leave a comment, I read everything that comes in.

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References

Associations between work-related factors and specific disorders at the elbow: a systematic literature review. Rogier M. van Rijn and others, Rheumatology, 2009.

A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. L Bisset and others, British Journal of Sport Medicine 2005; 39:411-422.

The management of tennis elbow. J Orchard, A Kountouris, BMJ 2011;342.

Common overuse tendon problems: A review and recommendations for treatment. JJ Wilson and TM Best, 2005, American Family Physician website at www.aafp.org/afp

An exercise programme for the management of lateral elbow tendinopathy. D Stasinopoulous, K Stasinopoulous, MI Johnson. British Journal of Sports Medicine, 2005;39:944-947.

Medscape “Lateral epicondylitis” (you may need to register to get the best info from this site)

 

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