Introduction

Physical Therapy in Pittsburgh for Elbow

Welcome to Greater Pittsburgh Physical Therapy & Sports Medicine's patient resource about Tennis Elbow (Lateral Epicondylitis).

Lateral epicondylitis, commonly known as tennis elbow, is not limited to tennis players. The backhand swing in tennis can strain the muscles and tendons of the elbow in a way that leads to tennis elbow. But many other types of repetitive activities can also lead to tennis elbow: painting with a brush or roller, running a chain saw, and using many types of hand tools. Any activities that repeatedly stress the same forearm muscles can cause symptoms of tennis elbow.

This article will help you understand:

what parts of the elbow are affected
the causes of tennis elbow
ways to make the pain go away

Anatomy

What parts of the elbow are affected?

Tennis elbow causes pain that starts on the outside bump of the elbow, the lateral epicondyle. The forearm muscles that bend the wrist back (the extensors) attach on the lateral epicondyle and are connected by a single tendon. Tendons connect muscles to bone.

Lateral Epicondyle

Tendons are made up of strands of a material called collagen. The collagen strands are lined up in bundles next to each other.

Collagen

Because the collagen strands in tendons are lined up, tendons have high tensile strength. This means they can withstand high forces that pull on both ends of the tendon. When muscles work, they pull on one end of the tendon. The other end of the tendon pulls on the bone, causing the bone to move.

When you bend your wrist back or grip with your hand, the wrist extensor muscles contract. The contracting muscles pull on the extensor tendon. The forces that pull on these tendons can build when you grip things, hit a tennis ball in a backhand swing in tennis, or do other similar actions.

Elbow Anatomy Introduction

Causes

Why did I develop tennis elbow?

Overuse of the muscles and tendons of the forearm and elbow are the most common reason people develop tennis elbow. Repeating some types of activities over and over again can put too much strain on the elbow tendons. These activities are not necessarily high-level sports competition. Hammering nails, picking up heavy buckets, or pruning shrubs can all cause the pain of tennis elbow.

In an acute injury, the body undergoes an inflammatory response. Special inflammatory cells make their way to the injured tissues to help them heal. Conditions that involve inflammation are indicated by -itis on the end of the word. For example, inflammation in a tendon is called tendonitis. Inflammation around the lateral epicondyle is called lateral epicondylitis.

However, tennis elbow often does not involve inflammation. Rather, the problem is within the cells of the tendon. Doctors call this condition tendonosis. In tendonosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers.

Instead of inflammatory cells, the body produces a type of cells called fibroblasts. When this happens, the collagen loses its strength. It becomes fragile and can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue.

No one really knows exactly what causes tendonosis. Some doctors think that the forearm tendon develops small tears with too much activity. The tears try to heal, but constant strain and overuse keep re-injuring the tendon. After a while, the tendons stop trying to heal. The scar tissue never has a chance to fully heal, leaving the injured areas weakened and painful.

Scar Tissue

Symptoms

What does tennis elbow feel like?

The main symptom of tennis elbow is tenderness and pain that starts at the lateral epicondyle of the elbow. The pain may spread down the forearm. It may go as far as the back of the middle and ring fingers. The forearm muscles may also feel tight and sore.

The pain usually gets worse when you bend your wrist backward, turn your palm upward, or hold something with a stiff wrist or straightened elbow. Grasping items also makes the pain worse. Just reaching into the refrigerator to get a carton of milk can cause pain. Sometimes the elbow feels stiff and won't straighten out completely.

Diagnosis

How can my health care provider be sure I have tennis elbow?

When you visit Greater Pittsburgh Physical Therapy & Sports Medicine, our therapist will first take a detailed medical history. You will need to answer questions about your pain, how your pain affects you, your regular activities, and past injuries to your elbow.

The physical exam is often most helpful in diagnosing tennis elbow. Our Physical Therapist may position your wrist and arm so you feel a stretch in the forearm muscles and tendons. This is usually painful with tennis elbow. There are also other tests for wrist and forearm strength that we can used to detect tennis elbow.

Tennis elbow symptoms are very similar to a condition called radial tunnel syndrome, a condition caused by pressure on the radial nerve as it crosses the elbow. If your pain does not respond to treatments for tennis elbow, your doctor may suggest tests to rule out problems with the radial nerve.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at Greater Pittsburgh Physical Therapy & Sports Medicine have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

The key to nonsurgical treatment is to keep the collagen in your tendon from breaking down further. Our goal is to help the tendon heal.

When you begin your Physical Therapy, our Physical Therapist at Greater Pittsburgh Physical Therapy & Sports Medicine will give you tips on how to rest your elbow and how to do your activities without putting extra strain on your elbow. We may apply tape to take some of the load off the elbow muscles and tendons. Our Physical Therapist may advise that you wear an elbow strap that wraps around your upper forearm in a way that relieves the pressure on the tendon attachment.

We may apply ice and electrical stimulation to ease pain and improve healing of the tendon. Our Physical Therapy sessions may also include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine, prescribed by your doctor, into the sore area. This treatment is especially helpful for patients who can't tolerate injections. Our Physical Therapist will also instruct you in exercises used to gradually stretch and strengthen the forearm muscles.

Because tendonosis is often linked to overuse, we will work with you to reduce repeated strains on your elbow. When symptoms come from a particular sport or work activity, our Physical Therapist will observe your style and motion with the activity. We may provide tips about how to perform the movement so your elbow is protected. We can also check your sports equipment and work tools and suggest how to alter them to keep your elbow safe.

Although recovery time varies for each patient, in cases where the tendon is inflamed, your Greater Pittsburgh Physical Therapy & Sports Medicine rehabilitation program is usually only needed for four to six weeks. When symptoms are from tendonosis, you can expect healing to take longer, usually up to three months. If your tendonosis is severe, it may take at least six months for complete healing.

Post-surgical Rehabilitation

Rehabilitation takes much longer after surgery. Immediately after surgery, your elbow is placed in a removable splint that keeps your elbow bent at a 90-degree angle. Your first few Physical Therapy sessions at Greater Pittsburgh Physical Therapy & Sports Medicine may involve ice and electrical stimulation treatments to help control pain and swelling from the surgery. Our Physical Therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

We will gradually have you work into more active stretching and strengthening exercises. You just need to be careful to avoid doing too much, too quickly. We generally begin active therapy about two weeks after surgery. Our Physical Therapist may begin with light isometric strengthening exercises. These exercises work the muscles of the forearm without straining the healing tissues. You will also use your own muscle power in active range-of-motion exercises.

At about six weeks, we will have you begin more active strengthening. As you progress, our Physical Therapist will teach you exercises to strengthen and stabilize the muscles and joints of the wrist, elbow, and shoulder. You will also do exercises to improve fine motor control and dexterity of the hand. Some of the exercises you'll do are designed get your hand working in ways that are similar to your work tasks and sport activities. Other exercises will work your elbow in ways that are similar to your work tasks and sport activities. Our Physical Therapist will help you find ways to do your tasks that don't put too much stress on your elbow.

Although each patient recovers at a different rate, you may need to attend your Physical Therapy sessions for two to three months. It could take four to six months to get back to high-level sports and work activities. Before your therapy sessions end, our Physical Therapist will teach you a number of ways to avoid future problems.

When recovery is well under way, your regular visits to Greater Pittsburgh Physical Therapy & Sports Medicine will end. Although we will continue to be a resource, you will eventually be in charge of doing your exercises as part of an ongoing home program.

Greater Pittsburgh Physical Therapy & Sports Medicine provides services for Physical Therapy in Pittsburgh.

Physician Review

Your doctor may order X-rays of your elbow. The X-rays mostly help your doctor rule out other problems with the elbow joint. The X-ray may show if there are calcium deposits on the lateral epicondyle at the connection of the extensor tendon.

Tennis elbow symptoms are very similar to a condition called radial tunnel syndrome. This condition is caused by pressure on the radial nerve as it crosses the elbow. If your pain does not respond to treatments for tennis elbow, your doctor may suggest tests to rule out problems with the radial nerve.

When the diagnosis is not clear, your doctor may order other special tests. A magnetic resonance imaging (MRI) scan is a special imaging test that uses magnetic waves to create pictures of the elbow in slices. The MRI scan shows tendons as well as bones.

Ultrasound tests use high-frequency sound waves to generate an image of the tissues below the skin. As the small ultrasound device is rubbed over the sore area, an image appears on a screen. This type of test can sometimes show problems with collagen degeneration.

If the problem is caused by acute inflammation, anti-inflammatory medications such as ibuprofen may give you some relief. If inflammation doesn't go away, your doctor may inject the elbow with cortisone. Cortisone is a powerful anti-inflammatory medication. Its benefits are temporary, but they can last for a period of weeks to several months.

Your doctor may suggest using ultrasound to guide a needle into the sore area. The ultrasound gives a clear picture of areas in the tendon that contain scar tissue. Poking holes in the tendon breaks up scar tissue and gets the tendon to bleed. Bleeding in the tendon helps stimulate the healing response.

Shock wave therapy is a newer form of nonsurgical treatment. It uses a machine to generate shock wave pulses to the sore area. Patients generally receive the treatment once each week for up to three weeks. It is not known exactly why it works for tennis elbow, but recent studies indicate that this form of treatment can help ease pain, while improving range of motion and function.

Surgery

Sometimes nonsurgical treatment fails to stop the pain or help patients regain use of the elbow. In these cases, surgery may be necessary.

Tendon Debridement

When problems are caused by tendonosis, surgeons may choose to take out (debride) only the affected tissues within the tendon. In these cases, the surgeon cleans up the tendon, removing only the damaged tissue.

Tendon Release

A commonly used surgery for tennis elbow is called a lateral epicondyle release. This surgery takes tension off the extensor tendon. The surgeon begins by making an incision along the arm over the lateral epicondyle. Soft tissues are gently moved aside so the surgeon can see the point where the extensor tendon attaches on the lateral epicondyle.

The extensor tendon is then cut where it connects to the lateral epicondyle. The surgeon splits the tendon and takes out any extra scar tissue. Any bone spurs found on the lateral epicondyle are removed. (Bone spurs are pointed bumps that can grow on the surface of the bones.) Some surgeons suture the loose end of the tendon to the nearby fascia tissue. (Fascia tissue covers the muscles and organs throughout your body.) The skin is then stitched together.

This surgery can usually be done on an outpatient basis, which means that you don't have to stay overnight in the hospital. It can be done using a general anesthetic or a regional anesthetic. A general anesthetic puts you to sleep. A regional anesthetic blocks only certain nerves for several hours. For surgery on the elbow, you would most likely get an axillary block to numb your arm.

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