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The following article has been written by Neil Motyer. 

Managing Tennis Elbow (lateral epicondylitis)

Imagine this scenario - (it probably applies to most of us!)...

A while ago you may have hurt a muscle, or been in a stressful situation for a bit too long.  Your muscles tensed up in an automatic protective response to limit range of movement (ROM) so as to prevent further injury.  To free up your conscious mind, your sub-conscious mind took over the job of maintaining the tension (technically the central nervous system is by-passed, and the spasm is maintained by the peripheral nervous system).  Some time has passed, the injury has healed, and the need for the ROM limiting tension is no longer there.  You try to relax the muscle to stretch it, but because the sub-conscious mind is still programmed to restrict ROM, it hurts.  The sub-conscious mind wins, and another "stiff muscle" develops as we get older.  Its now time to re-program the sub-conscious mind to let go the tension, but this can be very difficult because most people don't know it needs to be done, let alone how to do it! 

Re-programming the sub-conscious mind is a bit like self hypnosis.  Before you can send a message to your sub-conscious mind to re-program it, you have to believe the message first!  You have to genuinely believe that its not going to hurt if you relax and let that muscle stretch - and that's hard to do if its got a recent history of hurting every time. 

As a therapist I think it helps to plan a treatment program if there is a scientific model that describes the problem.  Even if the model is “wrong” it still gives a logical focus for each session, and if progress is unacceptable we can always change tack.

So when someone comes for treatment for a severe chronic ache or pain like lateral epicondylitis, I like to help them find ways to stretch or move a little more than usual without pain, and make sure that they clearly notice the improvement.  This sends an important message to the sub-conscious mind.

The modality is not important – for me its heat, cross-fibre manipulation and gentle stretches – but obviously there are many alternatives! 

All this leads up to the most important point I have saved for last - consciously relax when stretching (breathing out helps) to try to release all tension and pain.  If your clients are conscious of the possibility of overstretching, they will probably subconsciously tense up, so make sure their muscles are fully supported to prevent overstretching - preferably with soft firm padding.  Also make sure that they have no unpleasant pain (sometimes a mild "stretch pain" can feel good and this is ok).  The ROM of their stretch should not cause them to exceed their pain threshold if you want to successfully re-program the sub-conscious mind into "permanently" releasing the protective spasm.

I like to use the "contract-relax" method of stretching (as described below) – it is one of the most efficient and effective methods developed to date.

Stretching and strengthening exercises can be a useful part of the rehabilitation process because controlled loading improves collagen alignment of the tendon and stimulates collagen cross-linkage formation, which improves tensile strength. It is important that the state of the muscle/tendon injury is given due consideration when prescribing the loading forces.  The exercises should focus on improving the flexibility, strength, power and endurance of the entire muscle-tendon unit.  The duration of this program would generally be at least 12 weeks. 

Before starting any specific forearm exercises it is a good idea to loosen up the neck, shoulders, upper back and chest muscles, for example with heat or massage, followed by a few stretching exercises.  After that, it is beneficial to heat the most problematic area (probably the wrist extensor muscles in the elbow region) before stretching, to improve its ability to stretch.  Heat to 39°C to 43°C – the warmer the better.  For best results I like to follow up with tissue cooling prior to stretch release on the last passive stretch.  Cooling the muscle to normal temperatures (37°C or less) before releasing the tension can be soothing and seems to allow the passive stretch to be held longer.  The cooling is also thought by some to allow the collagenous microstructure to restabilise in its new stretched length.   

Self help exercises

Exercises similar to the ones described below can form part of the treatment and can also be prescribed to be done carefully at home.  They are based on the well established principle of progressive overload to gradually improve both strength and flexibility.  As a rule of thumb, don't exceed pain-free muscle loading or stretching by more than 5%.  In other words, slowly stretch further (or push harder) until extremely slight pain is felt, then go a comfortable small margin past this point.  These pain levels should not be unpleasant.  If the injury is substantial, expect that the flexibility and strength will be low, and the appropriate amount of "overload" will also be quite small.  Progress will be slow and patience is required.

Stretching the wrist extensor group using the widely used "contract-relax" method provides the benefit of also strengthening the extensor muscles and the damaged extensor group tendon.  A typical exercise is shown in the first photograph below for a right arm injury. First gently stretch the extensor group with the method as shown below - note that the range of movement will probably be less than that shown in the photograph if there is an injury.  Notice that the hand has also been rotated so the little finger approaches horizontal - this also stretches the elbow supinator muscle which is commonly involved in tennis elbow injuries.  Hold the stretch position for about 30 seconds or 5 slow breaths.  Next (while breathing out slowly through the nose) push carefully with a very light effort for about 5 seconds with the back of the right hand against the left hand, which is held steady.  After that slowly breathe in through the nose, then breathe out slowly through the mouth and at the same time gently stretch a little further (try to relax and release any tension).  Hold for one slow breath cycle, then repeat the procedure two more times.  Unless you have overdone the stretch, you should be able to hold the last stretch position for 30 seconds or 5 slow breaths.  I like to finish off with a slow "yawn stretch" to further accentuate the stretch, using the antagonist muscles to create the additional movement (reciprocal inhibition).  Repeat the exercises twice a week.  Allow about 3 days rest between exercise sessions.

A strengthening exercise for the right wrist flexor group is shown in the next two photographs.  Push from position 1 to position 2, with the left hand providing a resistance force which allows a pain free movement.  The right hand would be typically pressing with approximately 20 to 30 percent of full strength, but this could be significantly less for more severe injuries.  The number of repetitions would also vary with the severity of the injury, but would typically be one to three sets of 6 repetitions, building to 12 repetitions, done twice a week.  Allow about 3 days rest between exercises.   Using position 1, the contract-relax method can be used as described earlier for the wrist extensor group to provide a stretching exercise for the wrist flexor group.  This exercise can be useful for carpal tunnel injuries.  A more comprehensive set of exercises for the arm and hand, and a method of doing them can be seen in an excellent book by Kit Laughlin, see reference 5 below. 

Stretch for extensor tendon Strengthening - position 1 Strengthening - position 2

Rest and protection

For me the most frustrating thing working with chronic cases is the common complaint of “taking two steps forward and one step back”, and sometimes the spin is less positive.  No-one wants to be wrapped up in cotton wool, so looking at ways to prevent aggravating injuries on the mend, from improved work practices to light duties needs to be discussed. 

All muscles and tendons, particularly those that are damaged, should be protected from excessive overload at all times.  For people with overuse injuries, periodic re-aggravation is almost unavoidable, and in many cases support systems such as braces may be appropriate.  

Effective taping for lateral epicondylitis with rigid sports tape is a challenge to say the least.  Rigid sports tape can usually only be worn for a few hours due to the obvious problems of skin irritation, and it is practically impossible to get a good support force in a reasonable range of elbow positions.  Conventional forearm straps, sometimes known as counterforce braces, can help to a degree but need to be fairly tight to work. 

A new design which I have recently developed is intended to provide a much more “user-friendly” version of the popular “anchor and tie”, which is normally done with rigid sports tape.  The design includes a patented elastic GOSTRAP where a counterforce is provided in the exact opposite direction to the wrist extensor tensile forces.  Rather than providing a counterforce indirectly via friction in immobilized tissue, this support is intended to provide a direct counterforce via an additional support strap.  Consequently the “anchor” strap doesn’t need to be as tight as in a normal counterforce brace, and the support can be worn comfortably and effectively for long periods if required.

The design boasts a number of advantages: 

  • simple and effective

  • comfortable

  • can be worn for long periods of time

  • allows relatively good joint movement

  • causes a low restriction to forearm muscle contraction

  • provides good support to damaged tissue in different joint positions

  • easily adjustable and controllable support force

  • easy to fit and remove

A recent biomechanics preliminary study of the support at one Australian University found a significant reduction in muscle activity in the protected region compared to a normal counterforce brace.  The reduction of peak loads was higher than the reduction of average loads, indicating a surge or vibration damping effect. 

Clinical tests in a small trial group showed an increase in pain free ROM of the wrist which was greater than that provided by the standard counterforce brace.

 

The design was “road tested” by Melbourne physiotherapist and leading massage educator Andrew Gallagher, who gave it the following report:

 

"I have used the Motyer Tennis Elbow Support to great effect in the management of my own elbow pain and would certainly recommend its use to my patients.  The one clear advantage I see in its design is that it attaches more security to the limb providing greater support and stability particularly when using the arm." 

 

The support is known as the “Motyer tennis elbow support”, or Gostrap, and has recently been added to the product list of the Australian distributor Sportstek.  At this stage it is only available to therapists, and is not being marketed to the public.  

Since being released several physiotherapists have shown interest in the support, and as a result it is currently undergoing independent clinical trials with an elite motorcyclist and an elite golfer.

 

 

An example of non adhesive strapping to unload the common wrist extensor tendon, using a patented elastic GOSTRAPTM.  Note the line of the elastic strap (3) follows the wrist extensor group muscle and tendon, and this means that the support from the elastic strap increases when the extensor muscle group lengthens, i.e. the elbow straightens or the forearm is pronated.  This form of strapping provides well directed support forces and can be continually used during activity or recuperative periods.  The strapping can be easily applied or removed as required.  The method is simple yet effective and is ideal for self management. 

 

For enquiries about GOSTRAPTM contact the author or visit www.gostrap.com

References

1.        Pitner JV: Mind-Body Communication. Hypno Genesis June 22, 2002

2.        Peterson L, Renstrom P: Sports Injuries – Their prevention and treatment. The Law Book Co., 1990 (pp. 12-173, 207-211)

3.        Travell J, Simons D: Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams and Wilkins, Baltimore USA, 1983 (pp. 1-156)

4.        Lewit K, Simons DG: Myofascial Pain: relief by post-isometric relaxation. Arch Phys Med Rehabil 65:452-456. 1984

5.        Laughlin, K: Overcome Neck & Back Pain, Edition 4.  Simon & Schuster, 2006 

6.        Sapega AA, Quedenfeld TC, Myoyer RA, Butler RA: Biophysical factors in range-of-motion exercise. The Physician and Sports Medicine, 9:57-65, 1981

7.        Hammer, W: On Stretching. Dynamic Chiropractic February 12, 1993, Volume 11, Issue 04

8.       McConnell J: A novel approach to pain relief pre-therapeutic exercise. J Sci Med Sport. 2000 Sep;3(3):325-34

9.       Ng GYF, Chan HL: The Immediate Effects of Tension of Counterforce Forearm Brace on Neuromuscular Performance of Wrist Extensor Muscles in Subjects With Lateral Humeral Epicondylitis. J Orthopaedic & Sports Physical Therapy, Feb 2004

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