Lateral Epicondylitis - Part 1

Editor's Note: Please wait for all images to download before attempting to print this article.

Lateral Epicondylitis affects only one to two percent of the entire population, and it often spontaneously resolves itself in eight to 13 months. For this reason, most trainers and therapists waste little time educating themselves about the subtleties of this overuse syndrome. This is not helped by the lack of sound scientific rationale that, according to Boyer and Hastings, “has led to a therapeutic nihilism with respect to non-operative management of this condition."

Why Does It Matter? 

Lateral Epicondylitis is the most common overuse syndrome of the elbow. It presents primarily in individuals ages 30 to 60 years of age and affects up to 50 percent of all tennis players within that age range. Since the shift in western culture toward increased computer use and longer work hours, overuse syndromes like Lateral Epicondylitis have been associated with increasing worker compensation costs. Finally, lateral epicondylitis is being seen as an increasing problem among athletes and gym goers alike.

If you as a trainer look carefully at the demographic that puts food on your table, you’ll notice that your clientele probably includes more than a few tennis playing, desk working, weight lifting athletes who just happen to be between the ages of 35 and 60. Now, can you start to see the relevance?

The point is, as trainers, we need to look closer at an issue that has little or no reliable science behind it and educate ourselves about the proper way to address the problem, refer out to experts and provide effective post rehabilitative treatment that will prevent reoccurrence and focus on the entire problem, not just the symptoms.

Why Should I Refer Out Over a Little Elbow Pain?

As much as we love to problem solve and be all things to our clients, good trainers know when to refer out. I always believe in erring on the side of caution when it comes to injuries, and Lateral Epicondylitis is no exception. What could appear as a simple case of Lateral Epicondylitis may also have more serious neurological implications. For example, in 1972 Roles and Maudsley noted an association between “resistant tennis elbow” and posterior interosseous nerve entrapment (PION). Not only can a client have both issues at once, but recent studies have also shown a 93 percent relationship between the extensor carpi radialis brevis (ECRB) muscle (the culprit in lateral epicondylitis) and PION, suggesting that one problem can actually lead to the other.

The issue is, if a trainer doesn’t refer out and instead makes an assumption about the condition of his/her client, presuming it’s Lateral Epicondylitis, it begins a basic stretch/strengthening protocol while neural entrapment exists. The condition will worsen, and the exact opposite of the desired result will occur.

After the client has been thoroughly assessed and diagnosed by a therapist, s/he will most likely be given a generic list of forearm exercises that can be performed at home and with you during a session. These exercises will help to provide eventual relief of the symptoms (i.e., elbow pain), but in many cases, there are other issues that need to be addressed in order to possibly increase the rate of healing and reduce the chance of reoccurrence. 

Issue 1: Posture

How does poor posture affect the elbow joint? Well, in an EMG study of computer operating office workers, they found that in a slumped posture with foreword head carriage, the tension in the wrist extensors rose approximately 25 percent. If gently tapping on a keyboard with faulty posture had such a dramatic effect, can you imagine what lifting weights would do?

Also, remember that when the ECRB muscle is performing movements at the wrist joint with the forearm in pronation, it is at its maximum length. Now apply this concept to someone who has an upper crossed syndrome. They are in a constant state of internal rotation at the shoulder joint, and their forearms are almost always pronated. So, when they attempt to lift anything substantial, their ECRB is already fully lengthened and therefore subject to excessive shear. It’s clear that poor posture negatively affects the elbow joint, primarily because it increases the forces that act on it. This can prolong repair and make reoccurrence a definite possibility. Correction of these chronic postural misalignments will significantly reduce the biomechanical stress during use of the arm and help prevent musculotendinous overload at the elbow.

Issue 2: Shoulder Flexibility

How does a deficit at the shoulder affect the elbow? Remember the concept of the kinetic chain. In any chain of muscles that act together to produce force and or movement, a deficit in a specific muscle can cause the entire chain to break down. This can be applied to flexibility limitations at the shoulder. The main problem that accompanies flexibility deficits in shoulder rotation and leads to elbow problems is compensation. Whenever a muscle or group of muscles must compensate for the shortcomings of another, the forces and stress to those muscles will most likely increase.

Issue 3:  Rotator Cuff Strength

Why strengthen the shoulder? Isn’t forearm extensor strengthening sufficient? Strengthening of the rotator cuff and scapular stabilizing muscles - in addition to the wrist extensors - is very important. Any weakness in this kinetic chain can cause Lateral Epicondylitis. It is imperative that trainers look beyond the isolationist perspectives of bodybuilding 101 and begin to view the body using a more integrated, overall approach. For example, if there is no scapular stability, posture will suffer. If the rotator cuff fatigues, the wrist extensors will often compensate. Both of these situations result in increased forces at the elbow joint and can eventually lead to Lateral Epicondylitis or a reoccurrence of it. 

Issue 4:  Poor Mechanics and Overall Core Insufficiency

How does integrated training with a core focus help to prevent elbow stress? Poor overall conditioning can lead to fatigue and improper body mechanics. This is not to say that everyone who is in poor shape will eventually receive the gift of a sore elbow. However, this is a consideration for a client who has had Lateral Epicondylitis and is looking to you to help with prevention of reoccurrence. Poor body mechanics need to be eliminated, and proper core conditioning will no doubt complement a necessary postural correction protocol.

As you can see, there is much more to this issue than meets the eye. There are several serious considerations that must be a part of any trainer’s thought process when dealing with Lateral Epicondylitis, and hopefully I've addressed most of the important “trainer specific” issues that can help to increase your knowledge regarding this topic and adequately prepare you if the problem ever presents itself. The following is a functional post rehabilitation program to help prevent the reoccurrence of lateral picondylitis.

Functional Post-Rehabilitative Protocol

Goal: To use corrective exercise, postural stretching and functional post-rehabilitative strength training to prevent reoccurrence of lateral epicondylitis.

Phase 1: Posture and Joint ROM

As mentioned earlier, poor postural position can dramatically increase the forces that act on the elbow joint. If a postural correction protocol is not implemented first, the benefits of the other exercises will be overshadowed by chronic exacerbation of the existing problem.

Postural Protocol: Upper Crossed Syndrome Correction

Exercise 1: Supine Assisted Stretch of Long Head of Biceps Brachii

• Goal: To increase ROM of the shoulder joint in extension and to create overall shoulder mobility while avoiding instability.
• Procedure: Client lies supine on table with upper arm hanging off the table. Trainer stabilizes the joint (if weak) with one hand and gently eases the shoulder into extension by applying pressure to the radius or wrist with the other hand. Trainer finds the barrier point and instructs the client to breathe deeply. Then trainer can choose method of stretch. I recommend the contract/relax method as taught by Dr. Dianne Woodruff.

Exercise 2: Supine Assisted Stretch of Pectoralis Major - Both Sternal and Clavicular Fibres

• Goal: To counteract internal rotation of the humerus and to decrease pressure on the sterno-clavicular joint while reducing inter scapular inhibition.
• Procedure: Client lies supine on table with upper arm hanging off the table. Trainer stabilizes the joint (if weak) with one hand and gently stretches the pectoral fibers by applying pressure to the wrist with the other hand. This is done with the shoulder externally rotated and the humerus horizontal at 90 degrees and then 135 degrees (as shown).

Exercise 3: Pectoralis Major Stretch in the Doorframe - Unilateral or Bilateral

• Goal: To counteract internal rotation of the humerus, to reduce pressure on the sterno-clavicular joint and to teach clients a self stretching technique.
• Procedure: Bend arms to a 45 degree ankle at the elbow and parallel to the floor. Walk into the door space and let arms and hands rest on the edge of the doorframe. Lean in but always maintain neutral spinal alignment. Adjust the line of pull on the pecs by sliding the hands up the wall and out another eight to 10 inches. Hold for 30 seconds. *Some clients will prefer unilateral stretching of the pecs, which is usually the case in those with longer levers.

Exercise 4A: Upper Trapezius and Levator Scapulae Stretches

• Goal: To stretch tonic upper trap and levator scapulae prior to strengthening phasic lower traps and rhomboids.
• Procedure: Upper trap - Keep your chin level with your trachea and side flex your neck while sliding the opposite hand down the opposite leg. Levator Scapula - Rotate your head as far as you can go in one direction without pain or strain. Drop your chin down towards your distal clavicle and hold for 30 seconds.

Exercise 4B: Kneeling Scapular Depression and Adduction Using Tubing.

Progression	Standing

• Goal: To strengthen mid and lower trap as well as rhomboids.

Exercise 5A: Cervical Extensor Stretch with Ball

• Goal: To stretch cervical extensors prior to cervical flexor strengthening.
• Procedure: Stand straight with a neutral spine approximately one and a half to two feet from the wall. Place a 55cm stability ball behind the head with the contact point touching the occipital bone. Gently apply pressure to the ball and hold for 30 seconds.

Exercise 5B: Prone Cobra Progressions

Standard with Dowel Rod	With 2LB Blue Ball on Head	Prone Swimmers

• Goals:
  1. To strengthen phasic muscles: rhomboids, serratus anterior, middle and lower trapezius. To strengthen para-spinals, gluteals and abdominal muscles.
  2. To strengthen all of the aforementioned muscles as well as providing tone to the cervical flexors of the neck.
• Procedure: Lie flat on the ground in a prone position. Externally rotate the shoulders and attempt to turn the thumbs “up.” Draw the umbilicus in toward the spine and contract the glutes. Lift the chest and upper torso off the ground while maintaining a neutral spine. Keep contact with the dowel at the skull, thoracic spine and coccyx.

Exercise 6: Supine Thoracic Extension Stretch with Deep Breathing on Stabiliy Ball 

• Goal: To stretch upper abdominals and intercostals prior to thoracic extensor strengthening.
• Procedure: Lie supine on the stability ball with mid thoracic spine contacting the apex of the ball. With the arms extended, begin a series of inhale, hold and exhale repetitions.

Exercise 7A: Thoracic Extension Against the Wall with Dowel Rod

• Goal: To improve thoracic extension while maintaining neutral lumbar spine alignment.
• Procedure: The client stands with heels, coccyx and occipital bone contacting the wall. The client flexes the shoulder to 180 degrees without losing neutral spinal position.

Exercise 7B (no picture): Overhead Olympic Squat or Squat Presses with Dowel Rod

When 180 degrees of shoulder flexion and a flat thoracic curve are achieved without excessive lumbar lordosis, the client may then progress to the Overhead Olympic Squat or Squat Presses with Dowel Rod and then dumbbells or bar. 

• Goal: To integrate proper thoracic ROM into a variety of multi joint exercises.

The next article in this series will cover Phase 2: Rotator Cuff Strength, and Phase 3: Improving Core Stability and Endurance While Strengthening Wrist and Elbow Flexors and Extensors.

Photography by Dr. Jeff Goodman and Enza Gitto.

References:

1. APTEI: Advanced Physical Therapy Institute. Lateral Epicondylitis or Neural? 14 Jan. 2004. http://www.aptei.com/library/viewReport.jsp?report=191
2. American Society for Surgery of the Hand. Lateral Epicondylitis or “Tennis Elbow.” 2001. http://www.hand-surg.org/Content/NavigationMenu/Patients_and_Public/Lateral_Epicondyl..htm
3. Boyer MI, Hastings H  2nd. Lateral tennis elbow: “Is there any science out there?” J Shoulder Elbow Surgery. 1999 Sep-Oct;8(5):481-91.[Pub Med].
4. Briggs CA, Elliot BG. Lateral Epicondylitis. A review of structures associated with tennis elbow. Anatomy Clinic. 1985;7(3):149-53.[Pub Med].
5. CASM-ACMS. Treatment-resistant tennis elbow: The radial tunnel syndrome. April 2000 http://www.casm-acms.org/Newsletter/Newsletter%20Frames/Apr01text.htm
6. Christensen, K. Help for the Injured Elbow. Dynamic Chiropractic. 24 Sept. 2003. Vol 21, Issue 20.  http://www.chiroweb.com/archives/21/20/05.html
7. Dilorenzo E, Parkes J 2^nd, Chmelar R. The Importance of Shoulder and Cervical Dysfunction in the Etiology and Treatment of Athletic Elbow Injuries. JOSPT. 1990 Mar;11:(9): 402-409.
8. Disabella VN. Lateral Epicondylitis.  26 Oct. 2004 http://www.emedicine.com/sports/topic59.htm
9. Dowler E, Kappes B, Fenaughty A, Pemberton G. Effects of Neutral Posture on Muscle Tension During Computer Use. International Journal of Occupational Safety and Ergonomics. 2001; 7(1): 61-78.
10. Kamien M. A rational management of tennis elbow. Sports Med. 1990 Mar;9(3):173-91.[Pub Med].
11. Laulan J, Daaboul J, Fassio E, Favard L. The relation of the short radial extensor muscle of the wrist with the deep branch division of the radial nerve. Its significance in the physiopathology of elbow pain. Ann Chir Main Memb Super. 1994;13(%):366-72.[Pub Med].
12. Solveborn SA. Tennis elbow is usually caused by other than tennis. The earlier the treatment the better; spontaneous remission occurs often within 8-13 months. Lasarettet I Ystad. Abstract. [Pub Med].
13. Canada Veterans Affairs Entitlement Eligibility Guidelines: Chronic Epicondylitis. http://www.vac-acc.gc.ca/providers/sub.cfm?source=eguidelines/chronepicon
14. Woodruff, D. Postural Muscle Assessment and Stretching Techniques. Body-in-Motion. Oakville, Ontario. 2003.