Tennis Elbow – What is the Best Approach?

In reading this commentary, I am perplexed that the use of eccentric exercise was not highlighted as a more successful treatment option. Eccentrics have been shown to: 1) increase the proliferation of type 1 collagen fibers, 2) increaes tendon stiffness, and 3) decrease the formation of neovessels within the tendon. Current research supporting an eccentric protocol for tennis elbow can be found on the Theraband Academy website. This form of treatment has been very successful clinically, and at a low cost to the patient and the healthcare system.
Sincerely,
Drew Jenk

Nice article Ben. This is a challenging diagnosis for us to treat due to the lack of good evidence. I look forward to reading the results of classification approach to treating lateral epicondylitis. There was a decent article by Cleland (I think in JOSPT) a few years back that looked at treating lateral epicondylitis with cervical mobilization/thrusts with moderate evidence to support. Bowling, Erhard and Delitto also put together a nice treatment classification article to approach tx of LBP in the 90s and it sounds like the authors are attempting to do the same with lateral epicondylitis. Keep up the good work brother.
-Joe Brence

Ben,

Overall a very well written and thorough blog post though I’m surprised there is no mention of the recent JSES article by Tim Tyler and colleagues about the efficacy of eccentric training using a flex bar. The study was actually stopped because the experimental group was doing so much better than the control group that they ended up having the control subjects go on the same program. This article should be included in your discussion. Otherwise rock solid!

One other note…the Tyler Twist as shown on the theraband website and YouTube videos should be approached with caution as the noninvolved arm is clearly falling into a shoulder impingement position, which is nearly identical to a Hawkins Kennedy maneuver. This is plain and simple poor attention to detail and I use that as an example of exactly how not to do the exercise. I nearly had a heart attack when I saw that for the first time!!!

Good core strength and scapular stability give the elbow a stable base on which to move, reducing the necessity of the body to compensate and create the tendonitis in the first place. As a PT and tennis player, when I have had tendonitis in the elbow, medial or lateral, stretching and scapular stability exercises were essential to recovery, along with reduction of playing time.

Nice comment. I would also like to highlight the fact that tennis elbow is very rare among competitive tennis players because they activate their wrists extensors (mainly the ECRB and EDC) for a shorter period of time relative to recreational players and they have superior timing which minimizes the biomechanical stresses on these two aforementioned muscles which have a poor biomechanical design to start. What stretches do you do in particular???

Hey, good article for the most part Ben, but didn’t mention intramuscular (dry) needling as a legitimate complimentary / alternative therapy. There’s some good evidence coming in to support it, and I can tell you clinically it works! Check out Meta / Cochrane review from Rheumatology (2004) out of McMaster med school in Ontario-5 of 6 studies supported it vs a control.
Thanks.
Damon

Soft tissue mobilization before muscle lengthening is important to enhance the stretch effect. Definitely pec major, minor , upper trapezius, and biceps. Also stretching to the wrist flexors AND extensors, while the scapula is actively fixed into adduction and downward rotation. PNF scapular patterns help facilitate good scapular stability and rhythm. I especially like contract relax, hold relax and combination of isotonics

How about some consistency in the labeling? With the exception of an acute exacerbation, we now know that this is not really an “itis” but a tendonosis due to the lack of inflammatory cells and the degenerated nature of the muscle fibers. I also whole heartedly agree with Drew’s post.

However, there was no mention that this condition is ultimately a self-limiting condition. The primary treatment emphasis must be on patient education, activity modification, symptom management and prevention. You can inject, rub, mobilize, laser, ionto, stretch, strengthen, wave your magic wand and you and your patient will ultimately have limited success unless they are aware of how and why they suffer from this condition in the first place and are willing to make some meaningful changes in their movement patterns. It’s funny how few studies there are on actual patient education. Without that, are we really “fixing” anything?

Hi fellow PTs,
Thanks for the responses to my initial article on tennis elbow. I’m glad it made for some excellent responses.

I think the title of my post was perhaps a little misleading, and perhaps my intention of the post was misunderstood?

I should have called the article: “Tennis elbow: the long-term results of PT versus corticosteroid injection.” I simply wanted to highlight the pitfalls of the short-term solution to improving one’s symptoms with an injection

The purpose of the post was not to mention every single evidence-based technique available when treating tennis elbow, but to give credence to one technique (a MWM), and why it has shown better results than a quick-fix solution we see everyday.

It has been documented quite well that eccentrics are helpful when treating tennis elbow. Tyler et al (2010) in their recent article in J Shoulder Elbow Surg found that “All outcome measures for chronic lateral epicondylosis were markedly improved with the addition of an eccentric wrist extensor exercise to standard physical therapy.”

Croisier et al (2007) give further credence to the theory supporting eccentric training in their article titled “An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy.”

In their study, the authors found:

Compared to the non-strengthening control group, the following observations were made in the eccentrically trained group:
(1) a significantly more marked reduction of pain intensity, mainly after one month of treatment; (2) an absence of strength deficit on the involved side through bilateral comparison for the forearm supinator and wrist extensor muscles; (3) an improvement of the tendon image as demonstrated by decreasing thickness and a recovered homogenous tendon structure; and (4) a more marked improvement in disability status during occupational, spare time and sports activities.

Malliaras et al (2008) expertly mention though, that although eccentric programs have been proven to be effective, “the outcome of eccentric training, including whether training is painful and the duration of eccentric training” needs to be further elucidated.

Clearly, we know that eccentrics work for tennis elbow. Equally as important, we know that this exercise program is cost effective for patients. Perhaps a trial comparing the Tyler Therabar to the Vincenzino MWM over a long term period, would give us a definitive answer as to what is the best PT solution to treat that pain on the outside of our elbow?

With respect to dry needling, postural work, biomechanical change and scapular stability….Yep I agree. Go for it!

References:

1) Tyler T, Thomas G, Nicholas S, McHugh M. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. Journal Of Shoulder And Elbow Surgery.2010;19(6):917-922.

2) Malliaras P, Maffulli N, Garau G. Eccentric training programmes in the management of lateral elbow tendinopathy. Disability & Rehabilitation.2008;30(20-22):1590-1596.

3) Croisier J, Foidart-Dessalle M, Tinant F, Crielaard J, Forthomme B. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. British Journal of Sports Medicine. 2007;41(4):269-275.