Dr. Kristal Nelson PT
Board Certified Sports PT
You know how frustrating and debilitating “tennis elbow” can be. Much of the frustration stems from misinformation and myths that are passed through the internet and other sources. I also think the medical community has let us down in explaining what this problem is and how to best carry out treatment. This is the first of a two-part series on tennis elbow.
Tennis elbow is pain that is fairly sharp and radiates from your elbow into your forearm/wrist with gripping. It can also be an achy and stiff feeling – especially after playing. Tennis elbow is correctly called lateral epicondylagia (which means painful elbow). Frequently and incorrectly it is called lateral epicondylitis (-itis meaning inflammation). More on this later.
On the tennis court, you likely feel tennis elbow pain at ball impact on forehand, on the slice, with mis-hits on the frame, and definitely when playing the net. It can progress from pain during/after playing to everyday tasks like picking up a gallon of milk or shaking hands.
My name is Kristal Nelson and I am a USTA 4.0 player. I am a board-certified sports physical therapist and more importantly I suffered from tennis elbow last year so I feel your pain. There is hope to save your spring season once you wade through all of the myths. Here are a few things you may hear:
While all of these suggestions may give you some pain relief, once you learn what is actually going on with the tissue, you will better understand what you need to do to solve your tennis elbow.
We, in the medical community, have known for 30 years that tendon problems are rarely inflammatory but we continue to call it tendonitis and recommend inflammatory solutions. In a recent study, “10 of 11 readily available sports medicine texts specifically recommend NSAIDS for treating painful conditions like Achilles and patellar tendonitis despite the lack of biological rationale or clinical evidence for this approach.” RICE (rest, ice, compression, and elevation) are also common instructions for tendonitis.
If it is not tendonitis, then what is it?
The term you should be hearing more frequently is tendonosis. This is a critical distinction because you can’t bring an inflammatory solution to a degenerative problem. Those treatments may decrease the pain but will not heal a degenerative tendon, in fact the rest component can make it worse.
Look at the difference between these images of a healthy tendon and one with tendonosis.
Note the parallel organized structure of the healthy tendon vs. the disorganized nature of the tendon with tendonosis – it looks like strands of a rope that are frayed. The goal of treating a degenerative tendon like this is one is to make the fibers become more aligned and organized. The only way that is proven to do that is to load it. Again, not only will the RICE/advil method not change the fiber alignment but the rest component will make the alignment worse (see Myth #2).
What? How is rest not good?? When a tendon gets stronger, rather than increasing in size, it increases in stiffness. Evidence tells us only 3 weeks of “rest” causes a dramatic decrease in the tendon stiffness. Therefore, rest is absolutely counterproductive. During recovery, we know you must load the tendon to improve alignment and stiffness, but can any type of load effectively rehab the tendon? No. The load must include the full range of motion and somewhat slow – more like a weightlifting speed. The tennis stroke is a ballistic or plyometric motion that is rapid and does not require full range of motion. I will get more specific about how to load in part 2 but for now I will say it is possible to play with pain while recovering (if tolerable) provided you are doing the appropriate recovery. If you play without the right recovery, the problem will likely worsen potentially to the point where more invasive action must be taken. The name of the game is Recovery not Rest!
You see them everywhere but how effective are they? There is no evidence to suggest the brace is an effective solution of tennis elbow. Why? Because it does not change the tendon alignment or stiffness. However, similar to ice, it can help you get through a match because it changes the force production on the tendon. If you use one, make sure it is located over the extensor tendon group just below the elbow (not on the muscle belly) and the pressure point pad should only be ¾ inch. I could not find one with that width so I cut the pad down in the one I bought. You can wear on court but also for daily tasks to reduce pain. Once the pain is gone, ditch the brace.
I will call this a partial myth. I agree rackets and strings can be a part of the problem or a part of the solution. Softer strings and a heavier racket can help dissipate the force/vibration to the tendon. Check with your pro or stringer about what technology you should try. During recovery, you can change to a softer string then change back to your preferred tendon once recovery is complete. Remember, the underlying issue still remains with the tendon and its inability to tolerate the force. At an adult age, there is likely some level of degenerative contribution so when there is tennis elbow, assume tendon recovery should be a part of the plan.
One caveat, if you have changed your strings or racket within a few weeks of pain onset, you may have overloaded the tendon creating a rare tendonitis. If this is the case, change back and see if the pain resolves within a few days using RICE. If pain resolves, then great but if it doesn’t consider it a tendonosis.
So there it is…. The busted myths of tennis elbow. Look for part 2 in April issue of the WWTA newsletter to learn what works to solve elbow tendonosis. If you have any questions, you can reach me at firstname.lastname@example.org.