The pain is in the elbow, but the problem in tennis elbow involves muscles that control the hand. Place the palm of your palm and forearm flat on a table and lift the back of your hand upwards. The muscles which control this motion run from the lateral side of the elbow to multiple points in the wrist and fingertips. These extensors do much more than just lift the hand. They play a critical role in gripping, turning the hand, and can marginally assist the bending of your elbow. To perform these tasks simultaneously, these muscles undergo a tremendous amount of controlled lengthening and shortening at varying speeds. With overuse this can predispose the attachment sites at the lateral elbow to varying degrees of tendon failure. The problem can be long lasting and is now considered not so much an inflammatory process, but one of degeneration in the tendon. The ability to use the hand is greatly impacted and the experience of pain can be debilitating. This can cause changes in the nervous system that lead to chronic pain. Physical therapy treatment of tennis elbow emphasizes graded exposure to strength and desired activities. The first task is to get to a point where there is no pain at rest. This can be facilitated by using a combination of modalities, manual therapy and modifying activity. A suggestion that may help decrease the requirement of the forearm extensor muscles is to grasp objects with the palm up. Education on tendon healing and how to avoid chronic pain is important to this initial phase. The second part is to establish an appropriate amount of exercise/activity for the upper extremities. The third is to create a graded load progression applied to the extensor tendons and a very specific re-entry plan for pain-free return to desired activities. It has been shown that a program of eccentric or the lengthening contractions of the tendons can stimulate tendon regeneration. All of this must be done at a rate that does not inflict more pain. Strength and genuine confidence in abilities need to increase in parallel, for normal function to return and for protective pain patterns to cease.
Anna Kotula, DPT