// Common injuries: Extensor tendinopathy
by Paul Wright
Pain in the lateral aspect of the elbow and forearm is a frequent complaint for patients attending physiotherapists, sports physicians and also personal trainers. Pain and discomfort in this region of the elbow can be due to referred pain from the cervical spine, nerve entrapment, various bursitis conditions, and irritation of the radiohumeral joint. However, the most common cause of lateral elbow pain, and the topic of this article, is extensor tendinopathy.
Terminology and pathologyExtensor tendinopathy has been referred to in the past as ‘tennis elbow’ due to the large incidence of this condition in both competitive and recreational tennis players. More recently this term has gone out of favour as the condition can, and often does, occur in individuals who do not play tennis.
The other term previously used for this condition was ‘lateral epicondylitis’ in reference to the previously held theory that the pain felt in the area of the lateral epicondyle (a ridge of bone on the lateral side of the humerus from which the forearm extensor muscles draw much of their bony attachment) was due to an inflammatory process.
It is now believed that there is a fundamental change in the structure of the extensor carpi radialis brevis tendon (ECRB), a few centimetres distal to its proximal attachment on the humerus, that is more closely associated with tendon degeneration than active inflammation – thus the term extensor tendinopathy or extensor tendinosis is a most accurate label for the condition. It is possible to have a combination of inflammation as well as tendon degeneration; however, with long standing elbow pain the condition is more likely to be degenerative, which explains why anti-inflammatory medications often have little or no effect on the symptoms.
Signs and symptomsTypically, extensor tendinopathy presents itself when a patient complains of lateral elbow pain one or two days after a bout of vigorous activity that incorporated repeated and powerful wrist extension. Typical examples include painting, using a screwdriver and bricklaying. In the sporting world the pain may arise following extended sessions of tennis or squash, and in the fitness industry following a change in workout program or increase in load.
The pain can be localised to the lateral epicondyle area, but is often felt down into the mid forearm. The severity of the symptoms can also vary from a mild ache with muscle contraction to a deep pain at rest, and may be severe enough to affect sleep. Factors that may contribute to the development of this condition include an increase in wrist extensor activity, change in equipment (i.e. racquet string tension and grip size), reduced recovery between sessions, external factors (hitting into the wind) and poor exercise technique in the gym.
ManagementAs with all episodes of pain, it is essential the client is examined by a physiotherapist or sports physician as soon as possible. The medical professional will evaluate the extent of the injury, determine an accurate diagnosis and chart the most appropriate management strategy to return the client to full function.
The keys to successful rehabilitation of extensor tendinopathy are a well constructed and progressive rehabilitation plan and an understanding of the importance of reducing the extensor muscle load. The primary methods used to reduce load include a minimisation of the amount of gripping activities, reduction of racquet sports, and reducing the total weekly training volume.
Local physiotherapy treatment will involve tendon massage, ultrasound, acupuncture to trigger points, regular icing, stretching, and appropriate cervical spine treatment as there is often a link between elbow pain and neck pathology.
The trainer can assist in reducing the tendon load by using open hand machine strength training equipment (i.e. seated chest press, Smith Machine Presses, and machine shoulder press) in preference to barbell and dumbbell lifts. (Note: this is one of the very few times you will hear me advocating machines over free weights). Barbells and dumbbells require the client to grip harder to stabilise the load, whereas the machine based exercises are able to be performed with a more ‘open hand’, thus reducing the load on the extensor muscles. The client may also benefit from the use of lat straps in rowing and pulldown exercises to further reduce muscle force in the extensors.
An important component of the rehabilitation process is the need for an effective strengthening program to restore pre-injury function. The majority of exercises should be performed pain free with close attention being paid to any post exercise pain, and especially increased pain the morning after a rehabilitation session – the need for appropriate strengthening must be balanced with possible aggravation of symptoms.
A useful exercise employed in the strengthening program for extensor tendinopathy is the ‘towel squeeze’ (see photo below).
This simple exercise is performed by twisting a towel as though you were wringing water out of it.
It is best commenced isometrically before moving to more aggressive concentric and eccentric contractions. Ice is usually applied after each session. The patient may then proceed to other wrist strengthening exercises such as the ‘reverse wrist curl’.
The progression of the strengthening program should always be overseen by the treating physiotherapist or sports physician, as re-injury and poor recovery are often caused by over-enthusiastic patients and premature return to exercise and sport.
Paul Wright, BAppSc (Physio) DipEd (PE)
Australian Fitness Network’s Author of the year 2006, Paul is the director of Get Active Physiotherapy and Health Services, which has clinics inside Fitness First clubs at Carlingford, Castle Hill, Dee Why and St Leonards (Sydney, NSW). He is a senior lecturer for the Australian Institute of Fitness (NSW) and a featured presenter at many national and international health and fitness conventions. Paul has also released a series of DVDs specifically for fitness leaders covering knee, shoulder, and lumbar spine injury prevention and rehabilitation, Swissball for rehabilitation, and advanced resistance training. His latest release is ‘Potentially Dangerous and Ineffective Exercises Explained’. For more information visit the Get Active web site at www.getactivephysio.com.au or call 02 9966 9464.
NETWORK • WINTER 2006 • PP51-52