Tennis Elbow

Anatomy and Injury

Tennis elbow (lateral epicondylitis) is an irritation of the outer layer of the bony lateral epicondyle (bone on the outside of the elbow) as well as of the common extensor tendon, specifically the extensor carpi radialis brevis.^1-4  This injury is typically due to repetitive use of the muscles of the common extensor tendon that extend the wrist (bend it backwards) and that help stabilize the wrist during gripping motions.  Specifically for climbing, it can also occur through repeated finger flexion and gripping movements such as with face climbing, finger jams, the use of ice tools, and rope maintenance.  This is due to the wrist extensor muscles working to keep the wrist in a neutral position as the fingers are flexing.^5,6         Tendon overuse injuries (especially when they have been around for 3+ months) are now more accurately called tendinosis, or in this case epicondylosis, rather than the previous label of tendinitis, or in this case epicondylitis, due to studies that have been done on the cells and tissues.  Instead of inflammatory cells, which would be found for tendinitis, the problem has been seen as a disorganization of the tendon tissues.  The disorganized tissues resemble a clump of cooked spaghetti on a dinner plate as opposed to healthy tissues organized in a parallel fashion like uncooked spaghetti noodles in a bag.  All of this is important because the treatment changes from targeting inflammation, which may not be present, to targeting the tissue disorganization.^2,4,7-13

This is a very painful disorder that is felt with any gripping or grasping motions as well as with resisted wrist or middle finger extension and passive wrist flexion.  The pain is felt on the lateral epicondyle (outside of the elbow) and can radiate pain down the back of the forearm.  Grip strength is also typically decreased.^7,8,14-16

Prevention

The keys to preventing this injury are:
1. Warming up properly:  For climbing specifically, roughly 120 moves or 4 routes/8-12 boulder problems of easy climbing is recommended before attempting climbing near your maximum level of climbing difficulty.^17,18.  

2. Gradually ramping up training:  Has the climbing, or other related activity, increased significantly from normal frequency or difficulty?

3. Maintaining good flexibility by stretching the muscles that are being used:  Static stretching after climbing (or repetitive gripping motions) is the best time.  Hold the stretch for 30 seconds for 2-3 repetitions, 2-3 times throughout the day.

4. Trigger Points/Myofascial restrictions:  Check for any trigger points (spots that feel tight or tender) at the end of the climbing day or after any activities requiring repetitive gripping/grasping motions.   Hold direct pressure on those spots for 2-3+ minutes.  Below are some options but feel for other spots in the surrounding area.

5. Body awareness:  Is there any pain on the outside of the elbow during or after climbing or after any activities requiring repetitive gripping/grasping motions?  If so, consider modifying your activities so as not to continue to aggravate the injury.

Treatment

Much time and frustration will be saved, not to mention pain, by addressing the above symptoms as soon as possible.  A challenging aspect of tendon injuries is that they typically take longer to heal than muscle injuries.¹⁹  Due to the decreased blood supply to tendons in comparison to muscle and bone, tendons receive less “contractors and workers” to repair the damaged area.  This is a reason to not let this get out of hand and to cultivate awareness of any activities throughout your day that may be contributing to the symptoms.  A massage therapist once told me that switching from a squeeze bottle to a pump for her massage lotion/oils almost immediately cleared up a long bout of her tennis elbow symptoms.  Its amazing how seemingly minuscule activities can produce huge effects when they’re repeated a hundred times or more per day.

There have been 40 or so treatments studied for this injury!^8,14,15  A few of the treatments that have shown the best results, are the most common, and can be performed at home will be discussed and described.  In the initial phase of healing, it is important to avoid making the injury worse.  This means listening to the signals the body is sending (pain) and allowing the natural inflammatory process to do its job of removing dead tissue, repairing damaged tissue, and laying down new tissue.  Crosier, Foidart-Dessalle, et al state that creating increased pain has been noted to slow healing progress with this injury.  They further note, “Our position is that pain must be interpreted as an alarm signal and that if the injurious effects of the repetitive motion continue, tendinous suffering may persist or even worsen.”²⁰  On the other end of the spectrum, not using the arm at all, or immobilization, has been shown to decrease the healing progress as well, because it slows new tissue formation.²⁰  Listening to the body and using pain as a guide will increase the ability to find the balance.  The first goal is to maintain range of motion in the elbow and wrist.

Some of the treatments that have been successful with this injury are:
1. Static stretching of the wrist extensors: ^1,8,21  This stretching helps the new tissue being laid down during the healing process to line up in the proper way to allow the elbow joint to move without restrictions.  Hold the stretch for 30 seconds for 2-3 repetitions, 2-3 times throughout the day.

2. Myofascial release: ⁴  (see “trigger points/myofascial restrictions” section above) Although the common extensor tendon and muscles coming from those tendons were specifically targeted in the research, it may help to also check for trigger points of the muscles of the common extensor tendon, extensor carpi radialis longus, triceps brachii, brachioradialis, supinator, and supraspinatus. Trigger points in these muscles can refer pain to the outer elbow.  The goal is to find any area that feels tight or tender and to hold direct pressure on those spots for 2-3+ minutes.

3. Eccentric strengthening of the wrist extensors:  It is suggested to start this after the acute phase (10 to 14 days) when the damaged tissue has been removed and the new tissue has been laid down. ^1,8,15,20,22   With eccentric strengthening, as opposed to concentric strengthening, the muscle is actively contracting while it is lengthening. This type of strengthening is thought to increase tendon strength and, due to the muscle lengthening aspect, help the new tissue fibers that are being laid down during the healing process to line up properly.  Furthermore, the type of collagen found in healthy tendon (Type 1 collagen) has been found to increase and excessive tendon thickness found to decrease with eccentric strengthening.^3,8,10,23,24

Concentric strengthening of a muscle is actively contracting the muscle while it is shortening.  This type of strengthening has been shown to be beneficial as well ^3,7,8 however, the lengthening or stretching aspect does not occur as with eccentric strengthening.  Furthermore, eccentric contractions have been found to produce more force while requiring less oxygen and energy than concentric contractions and therefore will produce increased strength of the tendon with less waste products as opposed to concentric strengthening.^11,25

4.  Other:  Various types of joint mobilizations/manipulations and taping have been suggested, some of which may be performed at home:^9,16,26  Healthcare practitioners such as physical therapists, chiropractors, and osteopaths can evaluate the injury and provide instruction for these services, if appropriate.  Furthermore, other areas (shoulder, neck, etc) can contribute to elbow symptoms, which can be evaluated by a physical therapist or other practitioner familiar with optimal alignment and movement strategy evaluations.

An interesting note with this injury is that it typically resolves on its own within one year’s time.  Furthermore, although corticosteroid injections significantly decrease symptoms initially (the first 6 weeks or so), symptoms have been found to actually worsen and recurrence rates are higher compared to no treatment at all from 12 to 52 weeks.^26,27

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here.  My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

References:

1. Wen DY, Schultz BJ, Schaal B, Graham ST, Kim BS. Eccentric strengthening for chronic lateral epicondylosis: a prospective randomized study. Sports Health. 2011 Nov;3(6):500-3.
2. Nagrale AV, Herd CR, Ganvir S, Ramteke G. Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: a randomized clinical trial. J Man Manip Ther. 2009;17(3):171-8.
3. Raman J, MacDermid JC, Grewal R. Effectiveness of different methods of resistance exercises in lateral epicondylosis–a systematic review. J Hand Ther. 2012 Jan-Mar;25(1):5-25.
4. Ajimsha MS, Chithra S, Thulasyammal RP. Effectiveness of myofascial release in the management of lateral epicondylitis in computer professionals. Arch Phys Med Rehabil. 2012 Apr;93(4):604-9. doi: 10.1016/j.apmr.2011.10.012. Epub 2012 Jan 10.
5. Rooks MD. Rock climbing injuries. Sports Med. 1997 Apr;23(4):261-70.
6. Moore K, Dalley A. Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, 1999. p. 746.
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17. Schweizer A. Sport climbing from a medical point of view. Swiss Med Wkly. 2012;142:w13688.
18. Hockhoelzer T, Schoeffl. One Move Too Many… Druckerei Sonnenschein, Ebenhausen, 2003. p. 109.
19. Holtzhausen LM, Noakes TD. Elbow, forearm, wrist, and hand injuries among sport rock climbers. Clin J Sport Med. 1996 Jul;6(3):196-203.
20. Croisier JL, Foidart-Dessalle M, Tinant F, Crielaard JM, Forthomme B. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br J Sports Med. 2007 Apr;41(4):269-75. Epub 2007 Jan 15.
21. Hoogvliet P, Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med. 2013 Nov;47(17):1112-9.
22. Tyler TF, Thomas GC, Nicholas SJ, McHugh MP. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. J. Shoulder Elbow Surg. 2010; 19:917Y22.
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27. Smidt N, Van Der Windt DA, Assendelft WJ, Deville WL, Korthals-De Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002; 359:657–62.