Tennis Elbow Prevention and Treatment

The successful treatment of any injury depends not only on resolving the presenting problem but also addressing the factors which contributed to the cause of the problem. In order to do this the clinician must look towards the kinetic chain to understand where the problem might have come from.

What is the kinetic chain?

The kinetic chain referrers to a biomechanical model of movement; segments or joint of the body work as a whole to achieve motion. This chain of movement transfers forces from proximal (near to the body) to distal (away from the body). For example when kicking a football the kinetic chain of movement passes from the trunk through the hip, to the knee, onto the ankle and then is transmitted through the ball as it is struck by the foot. They say that a chain is only as strong as the weakest link, this is certainly true here. Any disruption to the kinetic chain, i.e. if one body part is not functioning normally, will mean that it places stress/strain on the other segments which will ultimately result in injury.

Consider the example of a tennis serve; an activity which uses the upper limb. The kinetic chain of the upper limb is as follows:

How can the trunk and shoulder cause problems at the elbow?

If the shoulder is not able to fully rotate inwards, then the wrist will have to compensate in order to get the racquet face to the ball at the correct moment (1), this places undue stress on the tendon which is likely to develop into injury if this pattern is repeated.  

The Kinetic Chain and Tennis Elbow

The pain around the outside of the elbow joint that is associated with lateral epicondylitis (tennis elbow) develops when there is an abnormal level of stress on the tendon of the wrist extensors which attach the forearm muscles to the lateral epicondyle of the elbow. Issues surrounding the trunk and shoulder can be the cause of this undue stress to the tendon.

Rotator Cuff and Mid Thoracic Strengthening in the Treatment of Tennis Elbow

The rotator cuff consists of the tendons of 4 different muscles: Infraspinatus, Teres minor, Supraspinatus and Subscapularis. These muscles are responsible for providing stability at the shoulder by drawing the head of the humerus (arm bone) towards the glenoid fossa (socket of the shoulder joint). They also produce rotational movements around the shoulder. When strengthening around the shoulder the articulation between the scapula, ribs and thoracic spine (middle back) cannot be forgotten. The muscles around the middle back and shoulder blade work to extend the thoracic spine, and tuck the shoulder blade in towards the rib cage. This serves to place the glenoid fossa into its optimum position for movement of the shoulder.

By stabilizing and generating force within the first two links; it is possible to improve the efficiency of the kinetic chain, thus, helping to not only remove the stressful stimulus that may have caused the elbow injury, but also to prevent further problems in the future.

References

1. Occult periarthrosis of the shoulder - A possible progenitor of tennis elbow. LaBan, MM, Iyer, R and Tamler, MS. 11, 2005, American journal of physical medicine and rehabilitation, pp. 895-898.

 

Useful Manual Therapy Techniques to Improve Shoulder Impingement Outcomes

The shoulder gives the most degrees of freedom of any joint in the body. The rotator cuff is an extremely important structure in providing a vital balance between mobility and stability. The rotator cuff consists of the tendons (a tendon is an extension of a muscle which attaches that muscle onto a bone) of 4 different muscles: Infraspinatus, Teres minor, Supraspinatus and Subscapularis. These structures are vulnerable to injury. One of the most common of all shoulder injuries is impingement.

Impingement occurs when the rotator cuff tendons get pinched in the space between the arm bone and the arch of the shoulder blade, which is known as the sub acromial space, as they pass from their muscle to their attachment at the front of the shoulder. This causes a mechanical stress to the tendon which results in swelling and/or damage. This pain is usually felt when lifting the arm up straight in front of you or out to the side as this is when the sub acromial space is at its smallest.

Rotator cuff impingement can be difficult to cure. Stretching or strengthening exercises and non steroidal anti inflammatory (NSAID's) are often prescribed as treatments for impingement. Another valuable treatment option is manual therapy. Manual therapy has been shown to improve the outcomes for rotator cuff impingement treatment ⁽¹⁾. Manual therapy helps to relieve the mechanical stress on the tendon which causes the damage and helps the damaged tendon to recover more quickly.

What is Manual Therapy?

Manual Therapy is a term used to describe a ‘hands on' treatment approach where joints, muscles ligaments and other soft tissues are mobilized or manipulated by a therapist to achieve a therapeutic benefit.  The benefits for the shoulder and rotator cuff muscles in using these techniques includes increased flexibility, increased tissue healing, improved muscle function without impingement, and a patient's increased tolerance to performing functional activities without impingement pain following treatment.

There are a range of techniques which fall into the category of manual therapy, those most commonly used for the treatment of rotator cuff impingement are:

• Soft Tissue Massage
• Friction massage
• Manipulation
• Mobilization

Soft Tissue Massage

Soft tissue massage is the systematic application of pressure and movement on the soft tissues of the body with the intention of facilitating normal range of movement.

Friction Massage

Deep  tissue friction massage is the application of a massage technique whereby superficial tissues are rubbed against deeper tissues. It is useful in assisting the body's own healing mechanisms and as such can help to speed up the healing of injured tendons.

Manipulations

Manipulation is a passive joint movement performed with the aim of increasing joint mobility. It incorporates a small amplitude quick thrust movement at the end of the available joint range.

Mobilizations

Joint mobilization involves the application of a passive force to increase joint range of motion. Mobilizations are performed up to the end of available joint range, but always within that range.

Although manual therapy has been proven to improve rotator cuff impingement recovery, it is not clear which of these manual therapy interventions is better ⁽²⁾. It would seem logical to assume that a combination of these treatments would prove to be of benefit in promoting recovery from rotator cuff impingement.

References

1. The effect of manipulation on the structures of the shoulder girdle as additional treatment for symptom rekief and for prevention of chronicity or recurrence of shouder symptoms. Bergman, GJD, Winters, JC and G, Heijden. 2002, Physical Therapy, Vol. 25, pp. 543-549.

2. Comparison of conservative treatment with and without manual physical therapy for patients wth shoulder impingement syndrome: a prospevtive, randomized clinical trial. G, Senbursa., Baltaci, G and Atay, A. 2007, Knee surgery sports traumatology and arthroscopy, pp. 915-921.