Tennis Elbow - Is it all in the name?

02 January 2018

What is Tennis elbow? Is it a misnomer? Clinical defined as Lateral Epicondylopathy (LE), you may have been told that this condition is a clinical pain problem that only affects competitors or athletes who play tennis. However, what I am about to suggest to you, is that Tennis Elbow defines a much broader spectrum of the clinical population. You don’t need to play tennis to have Tennis Elbow! In fact, there are many conditions which take responsibility of a name which doesn't quite reflect the heterogenous population.

Many people present with LE, having been told or made to believe that acute inflammation of the tendon is the key driver for their perceived pain and stiffness. However, it is important you are informed that histological studies reflect an absence of inflammatory cells within the Extensor carpi radialis brevis tendon (ECRB)! Tennis elbow is not an acute inflammatory condition! Hence, you might have realized why topical agents do very little to relief your symptoms. LE is a degenerative condition that is marked by Collagen disruption, tendon thickening, increased vascularity,  and mucoid degeneration on histopathological studies.

Why do some people get LE and others don’t? It may be that functional impairments in neck motor control combined with the predisposition to mechanical neck insult and a genetic predisposition to central sensitization, are all contributors in the onset and perpetuation of the condition.

In the history or presence of an underlying neck problem, symptoms of LE can become greatly manifested by making the elbow more vulnerable to repeated errors in task handling. These repeated errors over time can ultimately lead to a chronic inflammatory process to the ECRB, where its tendon component meets the bone at the lateral elbow.

You would be wondering as to how addressing the neck would help with a diagnosis of LE? Those with LE do have associated neck and thoracic pain, suggesting impairments in sensory - motor control of the neck. In fact, 70% of those with LE have a history of concurrent neck and upper back pain. Impairments in the coordination of the neck, relative to the shoulder and wrist during task handling, are risk factors in the underlying pathogenesis of LE. It was also found that spinal manipulative therapy to the cervical spine is an effective treatment in those with LE. Cervical (neck) manipulation does have an immediate analgesic effect at the elbow and this is believed to be a result from improved descending pain inhibition.

It has been shown that those with LE have:

- Widespread and lowered pain thresholds in other areas
-  increased sensitivity to the unaffected elbow
- Upregulated representation of poor elbow control represented in the brain
- Abnormalities in reflex control of blood flow to the area
- Failure of descending pain inhibition

From the above, it is obvious that the nature of this condition is not a quick fix. Addressing the neck and its relationship to the upper extremity has a more potent affect on LE than treating the elbow alone! Hands on therapy and rehabilitation primarily focused around the elbow will do very little to positively progress your function. Platelet rich plasma, prolotherapy and steroid injections are not fully supported by research and it seems that this is because LE is multifaceted. Pain, symptoms and dysfunction of the lateral elbow are not directly isolated to the tendon, but by the conveyance and representation of the tendon  in the brain, brainstem and spinal cord.

With regards to the latest research in LE, Chiropractic and a specific integrated systems approach can play a large positive role in the treatment and management of the condition.

1. Fernández-Carnero, J., Cleland, J. A., & Arbizu, R. L. T. (2011). Examination of Motor and Hypoalgesic Effects of Cervical vs Thoracic Spine Manipulation in Patients With Lateral Epicondylalgia: A Clinical Trial.Journal of manipulative and physiological therapeutics, 34(7), 432–440.

2. Ashe, M. C., McCauley, T., & Khan, K. M. (2004). Tendinopathies in the upper extremity: a  paradigm shift. Journal of Hand Therapy, 17(3), 329–334.

3. Berglund, K. M., Persson, B. H., & Denison, E. (2008). Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. Man Ther, 13(4), 295–299.

4 Herd, C. R., & Meserve, B. B. (2009). A Systematic Review of the Effectiveness of Manipulative Therapy in Treating Lateral Epicondylalgia. Journal of Manual & Manipulative Therapy, 16(4), 1–14.

5. Fernández-Carnero, J., Fernández-de-las- Peñas, C.& Cleland, J. A. (2008). Immediate hypoalgesic and motor effects after a single cervical spine manipulation in subjects with lateral epicondylalgia. Journal of manipulative and physiological therapeutics, 31(9), 675–681.

6. Hsu, S. H., Moen, T. C., Levine, W. N., & Ahmad, C. S. (2012). Physical Examination of the Athlete's Elbow. The American journal of sports medicine, 40(3), 699–708.

7. Lim, E. C. W., Sterling, M., Pedler, A., Coombes, B. K., & Vicenzino, B. (2012). Evidence of spinal cord hyperexcitability as measured with nociceptive flexion reflex (NFR) threshold in chronic lateral epicondylalgia with or without a positive neurodynamic test. The Journal of Pain, 13(7), 676–684.

8. Ruiz-Ruiz, B., Fernández-de-las-Peñas, C., Ortega-Santiago, R., Arendt-Nielsen, L., & Madeleine, P. (2011). Topographical Pressure and Thermal Pain Sensitivity Mapping in Patients With Unilateral Lateral Epicondylalgia. The Journal of Pain, 12(10), 1040–1048.

9. Vicenzino, B., Cleland, J. A., & Bisset, L. (2007). Joint manipulation in the management of lateral epicondylalgia: a clinical commentary. The Journal of Manual & Manipulative Therapy, 15(1), 50–56.

10. Waugh, E. J. (2005). Lateral epicondylalgia or epicondylitis: what's in a name? The Journal of Orthopaedic and Sports Physical Therapy, 35(4), 200–202.