Chiropractic manipulative adjustments are proving superior to other treatment protocols for tennis elbow.

By Kenneth C. Thomas BS, MS, DC, CCSP

“Tennis elbow” is the common name for the painful condition lateral epicondylitis (LE), possibly caused by overuse of the forearm resulting in elbow pain.¹ To no surprise, tennis and other racquet sports can be a culprit in its development.

However, a variety of other activities or sports can also cause this painful condition. Painters, plumbers, carpenters, and others who frequently and repetitively employ their forearm extensor muscles to grip objects are prone to developing tennis elbow.

Keep in mind the phrase lateral lateral epicondylitis is a slight misnomer, as the condition is not entirely inflammatory in nature, but rather degenerative by way of micro-tearing between the common extensor tendon and periosteum of the lateral epicondyle of the humerus.^1,2,8 In some literature, this same condition is identified as lateral epicondylalgia.³

The following discussion will define the parameters of the condition, and offer general procedures for detecting, diagnosing, and treating LE with conservative and natural therapies. Additionally, a possible means of preventing the condition from developing is proposed.

Chances are, most people complain of pain on the outside (lateral) portion of their forearm near or at the elbow. While there are many causes of forearm or elbow pain, LE will stand out and is relatively easy to distinguish from other conditions. With observation and a concentrated upper extremity examination of the elbow, you may identify the exact location of the pain and during which motions the pain is reproduced. With someone suffering from LE, the common extensor tendon of the forearm will present as either painful or dysfunctional, or both.^4-6

Tendon involvement

The four muscles sharing the common extensor tendon origin site at the lateral epicondyle include the extensor carpi radialis brevis (ECRB), extensor carpi radialis longus, extensor digitorum, and extensor carpi ulnaris; more of a deep muscle, the supinator muscle also originates at the lateral epicondyle.

The specific tendon involved with LE is the ECRB, which acts to stabilize the wrist when the elbow is straight. Despite its small origin, it transmits large forces through its tendon during the repetitive grasping of objects.

The repeated biomechanical motion of a tennis groundstroke is an example of the type of motion that can lead to the gradual wearing of the muscle at its origin. In some instances, the sheer stress of all movements of the forearm gradually causes micro-tearing of the tendon, resulting in the buildup of scar tissue and thickening of the tendon.^7,8

The extensor digiti minimi, responsible for extension of the little finger (fifthphalanx) and some extension of the wrist, originates at a small anterior portion of the lateral epicondyle of the humerus. Its action allows the flicking motion of the wrist that is associated with the swinging of a racquet.

Etiology of LE

The etiology of the condition as described in the literature suggests it arises from repetitive overuse, strenuous activity requiring speed, repetitive eccentric contraction of the forearm muscles, and the controlled lengthening of the wrist extensor muscle group. Non-inflammatory, chronic degenerative changes of the common extensor tendon are identified in surgical pathology specimens.⁸

Without delving too deeply into the energetics of muscular activity, it is pertinent to note that the energy needed to contract even small skeletal muscles containing thousands of muscle fibers is enormous. In a continually contracting muscle, the fibers require specific nutrients and oxygen to sustain continued use.

Perhaps the lack of a nutrient supply to the muscle is why available literature discussing this injury identifies overuse as a common indicator.⁸ The form of overuse most indicated stems from repetitive hand movements, especially excessive deviation of the wrist from its neutral position into extension, or high levels of physical strain to the wrist as described above.^10-12

Mental chronometry, the response time in perceptual-motor tasks, is a possible factor for LE.¹³ This points to the nervous system and its transmission of information from the brain to the motor activity of a given body part.

Subjective findings

• The pain experienced with tennis elbow may have begun as the result of an abrupt injury to the elbow, but more commonly is described as developing over time.
• The pain is about 1 to 2 centimeters down from the bony area at the outside of the elbow, at the lateral epicondyle of the humerus.
• Weakness in the wrist causes difficulty with simple tasks such as turning a doorknob, shaking hands, or pouring a glass of water.
• There is pain on the outside of the elbow when trying to straighten the fingers against resistance.
• Morning stiffness is felt in the forearm and around the elbow.

Objective analysis

• The symptoms for this injury are similar to entrapment of the radial nerve, which is a possible cause for a presenting condition of the elbow.
• It is important to examine the neck as well, as elbow pain may be a referring symptom from vertebral subluxation or other problems in the cervical region, specifically at the level of C5, C6, and C7.
• Observe the patient perform the natural ranges of motion of the wrist and elbow to determine any limitations as well as which motions, if any, cause apprehension or reproduction of the reported pain.
• Examine for pain on the outside of the elbow when the hand is bent back in wrist extension against resistance.
• Palpation just below the lateral epicondyle on the outside of the elbow to identify point tenderness at the origin of the common extensor tendon.

Diagnosis

Although diagnostic imaging is not considered an essential procedure for diagnosing LE, it may be considered if a more serious pathology is suspected. With LE, an MRI will reveal common extensor tendon thickening at the lateral epicondyle.^11,14

Several other tests moderately useful for diagnosing LE include:

• Patient-rated forearm evaluation questionnaire
• Pain-free grip strength
• Resisted wrist extension (Mill’s Test)¹⁵
• Pressure pain threshold
• Tenderness to palpation at the lateral epicondyle

Note that palpation a finger’s breadth distal to the lateral epicondyle revealing tenderness, although accepted as a reliable and valid procedure, is based on traditional indication rather than scientific investigation.

Treatment

In light of one surgeon’s review of non-therapeutic modalities being “unproven at best,”¹ the efficacy of conservative treatment has not distinctly been demonstrated, even through rigorous clinical trials. However, in several randomized controlled trials (RCTs) improvements in the LE conditions were noted.

Of the trials conducted, mobilization and chiropractic manipulative adjustments to the wrist proved statistically superior to other treatment protocols, including the combined use of ultrasound, friction message, exercise and stretching, and corticosteroid injections.^1,3 Perhaps due to wrist segmental dysfunction where the extensor muscle group inserts at the metacarpals and proximal phalanges, the biomechanics of normal muscle function are altered by LE.^17-20

Although controversial in the most recent reviews of orthotic wraps and bracing, a top-rated treatment for LE is the “Dynamic Extensor Brace,”²¹ which holds the wrist in its extended position and reduces the electromyographic activity of the wrist extensor muscle group during gripping activity.

Exercise and stretching as an intervention show that eccentric contraction exercises are more effective than contract-relax stretching exercises for complete recovery of the condition.^18-20 Stretching of the

extensor muscle group also ameliorates the condition to some degree.²⁰

Light elastic taping techniques are advocated for chronic musculoskeletal conditions such as lateral epicondylalgia. Although little evidence exists supporting the effects of taping techniques on musculoskeletal pain, the few studies conducted demonstrate its efficacy.¹⁷

Perhaps because light elastic taping is effective in providing support to muscle function as well as improving circulation and oxygen supply to the surrounding area where applied, it allows muscles and tendons to repair more quickly.⁹ A preliminary study has demonstrated an ameliorative effect of a taping technique for LE, which suggests that it can be considered in the management of this condition.⁹

Conservative therapies that were rated low on efficacy included ultrasound and low-level laser.^22-25

Because laser therapy and light elastic taping techniques are relatively new therapeutic modalities, there are few studies regarding their implementation. This lack of evidence-based research is likely why they are not considered the most effective treatments.²⁷

Prevention

Factors related to playing sports, such as experience, ability, technique, and the use of appropriately sized equipment, may all be considered for preventing LE.¹⁶

Other preventative measures to consider include:

• Remaining in overall good physical condition.
• Reducing the time spent doing the activity that caused the condition to develop.
• Increasing the strength of the muscles surrounding the joint to provide stability to the elbow.
• Strengthening the muscles of the forearm (pronator quadratus, pronator teres, and supinator), the upper arm (biceps, triceps, deltoid), and the shoulder and upper back (trapezius).
• Maintaining proper biomechanics during activity.
• Maintaining proper joint positioning.²⁶
• Ensuring a healthy nutrient supply to the body through diet and supplementation that assists the body with natural function and repair processes.

Insufficient dietary nutrient intake can contribute to the deterioration of any of the body’s parts. Thus, diet is a factor when considering the presentation of any ailment involving muscles, ligaments, and tendons. The benefits of nutritional supplementation generally support the body in its natural functions. Nutrients for supporting tendons may include pea vine juice, manganese, calcium, carbamide, flavonoids, and phosphorous.

In addition, B and C vitamins all aid the body’s natural anti-inflammatory response. B complex vitamins and amino acids assist the natural repair process of connective tissue, and enzyme CoQ-10 assists with oxygen delivery to muscles and tendons.

Kenneth Thomas, DC, CCSP, vice president of academics at Parker College of Chiropractic. He is a respected expert in chiropractic and lectures extensively on exercise and the treatment of sports injuries, current trends in healthcare, and the wellness lifestyle. He is a board member of FICS and a certified chiropractic sports physician who has worked with many Olympic and professional athletes.

References

¹Boyer MI, Hastings H. Lateral tennis elbow: Is there any science out there? J Shoulder Elbow Surg. 1999;8(5):481-491.

²Struijs PA, Damen PJ, Bakker EW, et al. Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study. Phys Ther. 2003;83(7):608-616.

³Cleland JA, Whitman JM, Fritz JM. Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis. J Orthop Sports Phys Ther. 2004;34(11):713-722.

⁴Newcomer KL, Martinez-Silvestrini JA, Schaefer MP, Gay RE, Arendt KW. Sensitivity of the Patient-rated Forearm Evaluation Questionnaire in lateral epicondylitis. [ITAL]J Hand Ther.[/ITAL] 2005;18(4):400-406.

⁵Overend TJ, Wuori-Fearn JL, Kramer JF, MacDermid JC. Reliability of a patient-rated forearm evaluation questionnaire for patients with lateral epicondylitis. J Hand Ther. 1999;12(1):31-37.

⁶Leung HB, Yen CH, Tse PY. Reliability of Hong Kong Chinese version of the Patient-rated Forearm Evaluation Questionnaire for lateral epicondylitis. Hong Kong Med J. 2004;10(3):172-177.

⁷ What is tennis elbow? BBC Sport Academy. http://news.bbc.co.uk/sportacademy/hi/sa/treatment_room/features/newsid_3818000/3818931.stm

⁸ Boyer MI, Hastings H. Lateral tennis elbow: Is there any science out there? J Shoulder Elbow Surg. 1999;8(5):481-491.

⁹Vicenzino B, Brooksbank J, Minto J, Offord S, Paungmali A. Initial Effects of Elbow Taping on Pain-Free Grip Strength and Pressure Pain Threshold. J Orthop Sports Phys Ther. 2003;33(7):400-407.

¹⁰Mackay D, Rangan A, Hide G, Hughes T, Latimer J. The objective diagnosis of early tennis elbow by magnetic resonance imaging. Occup Med (Lond). 2003;53(5):309-312.

¹¹Martin CE, Schweitzer ME. MR imaging of epicondylitis. Skeletal Radiol. 1998;27(3):133-138.

¹² Newcomer KL, Martinez-Silvestrini JA, Schaefer MP, Gay RE, Arendt KW. Sensitivity of the Patient-rated Forearm Evaluation Questionnaire in lateral epicondylitis. J Hand Ther. 2005;18(4):400-406.

¹³Jensen, AR. (2006). Clocking the mind: Mental chronometry and individual differences. Amsterdam: Elsevier.

¹⁴Mackay D, Rangan A, Hide G, Hughes T, Latimer J. The objective diagnosis of early tennis elbow by magnetic resonance imaging. Occup Med (Lond). 2003;53(5):309-312.

¹⁵Smidt N, van der Windt DA, Assendelft WJ, et al. Interobserver reproducibility of the assessment of severity of complaints, grip strength, and pressure pain threshold in patients with lateral epicondylitis. Arch Phys Med Rehabil. 2002;83(8):1145-1150.

¹⁶Tennis Elbow: MayoClinic.com. Mayo Clinic Medical Information and Tools for Healthy Living. MayoClinic.com. 15 Oct. 2008. Web. 10 Oct. 2010.

¹⁷Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005;39(7):411-422.

¹⁸Martinez-Silvestrini JA, Newcomer KL, Gay RE, et al. Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening. J Hand Ther. 2005;18(4):411-9, quiz.

¹⁹Svernlov B, Adolfsson L. Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia. Scand J Med Sci Sports. 2001;11(6):328-334.

²⁰Solveborn SA. Radial epicondylalgia (‘tennis elbow’): treatment with stretching or forearm band. A prospective study with long-term follow-up including range-of-motion measurements. Scand J Med Sci Sports. 1997;7(4):229-237.

²¹Faes M, van den AB, de Lint JA, Kooloos JG, Hopman MT. Dynamic extensor brace for lateral epicondylitis. Clin Orthop Relat Res.2006;442:149-157.

²²Stasinopoulos DI, Johnson MI. Effectiveness of low-level laser therapy for lateral elbow tendinopathy. Photomed Laser Surg. 2005;23(4):425-430.

²³Binder A, Hodge G, Greenwood AM, Hazleman BL, Page Thomas DP. Is therapeutic ultrasound effective in treating soft tissue lesions? BMJ (Clin Res Ed). 1985;290(6467):512-514.

²⁴van der Windt DA, van der Heijden GJ, van den Berg SG, et al. Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain. 1999;81(3):257-271.

²⁵D’Vaz AP, Ostor AJ, Speed CA, et al. Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial. Rheumatology (Oxford). 2006;45(5):566-570.

²⁶Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939.

²⁷ Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. Jul 2005;39(7):411-22; discussion 411-22.