Beyond the Baseline: Novel Approaches to Tennis and Golfer's Elbow
Let's dive into the specifics of two common but often misunderstood conditions - Golfer's Elbow and Tennis Elbow. Despite their sporty names, these conditions aren't exclusive to athletes and can affect anyone performing repetitive movements that strain the elbow joint.
By understanding the anatomy and biomechanics of these conditions, we can better appreciate their impact, the key structures involved, and the activities that might contribute to their occurrence. So, whether you're a healthcare professional, a curious patient, or simply interested in learning more, this information can shed light on the complex interplay of structures that keep our elbows functioning smoothly.
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Golfer's Elbow: Medial Epicondylitis
Anatomy and Biomechanics
Pain and inflammation at the inside part of the elbow (medial epicondyle)
Common flexor tendon connects forearm muscles to the medial epicondyle
Carpi radialis and pronator teres muscles involved in wrist flexion and rotation
Key Structures Affected
Common flexor tendon
Carpi radialis muscle
Pronator teres muscle
Activities and Overuse
Swinging a golf club
Strong grip actions
Repetitive wrist flexion
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Tennis Elbow: Lateral Epicondylitis
Anatomy and Biomechanics
Pain and inflammation at the outside part of the elbow (lateral epicondyle)
Common extensor tendon connects extensor muscles to the lateral epicondyle
Extensor carpi radialis brevis muscle (ECRB) involved in wrist extension and abduction
Key Structures Affected
Origin of the common extensor tendon
Extensor carpi radialis brevis muscle (ECRB)
Supinator muscle and extensor carpi radialis longus (in some cases)
Activities and Overuse
Tennis backhand stroke
Repetitive wrist extension or supination
Occupational activities or daily tasks involving overuse of extensor muscles
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Kinetic Chain Dynamics: From Shoulders to Wrist
Understanding the kinetic chain - the interconnected network of muscles, joints, and fascia from shoulders to wrist - is vital to grasp the complexities of Golfer's and Tennis Elbow.
Shoulders
The shoulder complex plays a vital role in the kinetic chain. Comprising the scapula (shoulder blade), clavicle (collarbone), and humerus (upper arm bone), it allows a wide range of motion. The rotator cuff, a group of muscles and their tendons, provide stability and facilitate shoulder movement.
In both golf and tennis, rounded shoulders (anterior posture) is a common issue. This posture can lead to strain on the rotator cuff and upper back muscles, possibly increasing stress on the elbow.
Elbow
The elbow joint involves the interaction of the humerus, radius, and ulna (forearm bones). Key structures affected in Golfer's and Tennis Elbow are the medial and lateral epicondyles of the humerus, where the forearm muscles attach.
In Golfer's Elbow, overuse of the muscles that flex the wrist and fingers can strain the medial epicondyle. In Tennis Elbow, it's the muscles involved in extending the wrist and fingers and supinating the forearm that put strain on the lateral epicondyle.
Forearm
The forearm contains a multitude of muscles involved in movements of the wrist and fingers. These muscles, encased in layers of fascia, can develop myofascial restrictions due to overuse, leading to pain and limited mobility.
Wrist
The wrist is a complex joint where the two forearm bones meet a collection of small bones. It's integral to the effective transfer of force from the body to the hand, such as when gripping a golf club or tennis racket. Imbalances in the forearm muscles can lead to wrist pain and reduced grip strength, further complicating Golfer's or Tennis Elbow.
Integrated Approach
An effective treatment approach for these conditions involves assessing and addressing the entire kinetic chain. By identifying and treating areas of restriction, weakness, and imbalance, we can help restore optimal function and prevent re-injury. This might involve soft-tissue and osseous techniques, strengthening exercises, and mobility work targeting not just the elbow, but the shoulder, forearm, and wrist as well.
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The Nervous System In Elbow Health
Alongside soft tissue restrictions, nerve entrapment is another issue that can afflict many patients. For instance, in the medial elbow, a compressive nerve syndrome known as Cubital Tunnel Syndrome may develop. This condition involves the compression of the ulnar nerve within the cubital tunnel, located on the inner side of the elbow. Ranking second only to Carpal Tunnel Syndrome, Cubital Tunnel Syndrome is one of the most common nerve compression syndromes in the upper extremity.
Interestingly, about 60% of individuals with Golfer's Elbow also experience compression of the Ulnar Nerve. These patients often report altered sensation or a numbness and tingling sensation affecting their ring and little fingers. However, it's crucial for practitioners to eliminate the possibility that the numbness originates from the neck - a condition known as cervical radiculopathy.
As for injuries to the lateral elbow (commonly referred to as Tennis Elbow), these could be coupled with radial nerve compression, otherwise known as "Radial Tunnel Syndrome." A number of patients initially diagnosed with Tennis Elbow may, in fact, be dealing with Radial Nerve Entrapment Syndrome. Therefore, for both ulnar and radial nerve entrapment cases, a thorough physical examination is critical to avoid misdiagnosis and to ensure the most effective treatment plan.
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Orthopedic, Neurological, and Vascular Assessments
An accurate and thorough diagnosis is the cornerstone of effective treatment. In the case of conditions like Golfer's and Tennis Elbow, this means conducting comprehensive orthopedic, neurological, and vascular assessments.
Orthopedic tests allow us to evaluate the musculoskeletal system, including bones, joints, and soft tissues, to identify any structural issues or restrictions.
Neurological assessments help detect any nerve-related issues, such as nerve compression syndromes, and evaluate the health of the nervous system.
Vascular assessments are essential to examine the blood flow to the area, ensuring that any circulatory issues, which could influence healing and recovery, are addressed.
Together, these assessments provide a holistic understanding of the patient's condition, enabling the creation of a personalized and effective treatment plan.
Elbow Examination - Orthopaedic Testing
This video goes through inspection and observation, palpation, Active and Passive Ranges of motion, and orthopaedic examination of the Elbow.
Upper Limb Neuro Exam
The upper limb neurological examination is part of the overall neurological examination process and is used to assess the motor and sensory neurons which supply the upper limbs. This assessment helps to detect any impairment of the nervous system.
Peripheral Vascular Examination - Key Points
A peripheral vascular examination is a valuable tool used for ruling out signs of vascular-related pathology. The detection and subsequent treatment of PVD can potentially mitigate cardiovascular and cerebrovascular complications. In this video we go over some of the common procedures we perform in daily clinical practice.
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Manual Therapy for Golfer's and Tennis Elbow
The upcoming videos showcase some of the Myofascial Release (MSR) techniques we frequently employ to treat our patients suffering from Golfer's or Tennis Elbow. These techniques encompass a mix of soft-tissue procedures and osseous (bone) manipulation. We firmly believe that effective treatment isn't just about focusing on the area of pain, in this case, the elbow. Instead, we broaden our approach to encompass the larger kinetic chain, when necessary.
This means we also address other interconnected muscles, joints, and fascia that could be contributing to the problem. By integrating the entire body into our therapeutic approach, we aim to not only alleviate symptoms but also address root causes and promote overall musculoskeletal health.
Elbow Release Protocol - Golfer's & Tennis Elbow
Each case of elbow pain should be assessed and treated as a unique dysfunction that is specific to that individual. Certain cases will only involve local structures, while other cases can involve a much larger kinetic chain. The MSR procedures I am demonstrating are very effective at addressing elbow pain.
MSR - Ulnar Nerve Release
As mentioned earlier, up to 60% of patients with Golfer’s Elbow also suffer from Ulnar Nerve Compression. (3) Patients with ulnar nerve compression often complain about sensory changes in the fourth and fifth fingers. They may also complain of trouble when opening jars, or turning doorknobs, or experience weakness when performing work that requires repetitive motion. In this video, we focus on releasing the ulnar nerve by using Motion Specific Release (MSR) procedures.
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Exercises
The subsequent videos present a selection of exercises that we commonly recommend to our patients experiencing elbow discomfort. Please note, this is merely a snapshot of the potential exercises we could suggest, and these are shared for illustrative purposes only. These exercises aim to promote strength, flexibility, and overall elbow health for those dealing with conditions like Golfer's and Tennis Elbow.
5 Minute Elbow Pain Relief
Have a sore elbow? Then try our "5 Minute Elbow Pain Relief" routine. Doing this routine several times per day can make a huge difference in eliminating your elbow pain.
Five Great Daily Shoulder Mobilization Exercises
Elbow problems often involve restrictions in the shoulder. For best results, you can perform these exercises throughout your day. These exercises can make a huge difference in your posture, especially when you have been sitting for long periods of time.
Ulnar Nerve Flossing Exercises
If you have Ulnar Nerve Entrapment Syndrome (60% of patients with golfers elbow, then you can use the exercises in this video to floss, mobilize, and release this nerve from its surrounding tissues.
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Conclusion
Understanding and addressing conditions like Golfer's and Tennis Elbow requires a comprehensive and nuanced approach. From unraveling the intricacies of the kinetic chain to diagnosing nerve entrapment syndromes, every facet plays a pivotal role in establishing an effective treatment plan. We must not only focus on the site of pain but also consider the entire interconnected system of muscles, joints, and fascia that could be contributing to the problem.
Through thorough orthopedic, neurological, and vascular assessments, along with implementing appropriate manual therapy and exercise regimens, we can offer personalized and effective strategies for our patients. As we navigate the path to recovery together, our goal is not only to alleviate symptoms but also to restore optimal function, promote overall musculoskeletal health, and prevent re-injury. This comprehensive, patient-centric approach is the bedrock of our practice and key to successfully managing conditions like Golfer's and Tennis Elbow.
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Dr. Brian Abelson - The Author
Dr. Abelson is committed to running an evidence-based practice (EBP) incorporating the most up-to-date research evidence. He combines his clinical expertise with each patient's specific values and needs to deliver effective, patient-centred, personalized care.
As the Motion Specific Release (MSR) Treatment Systems developer, Dr. Abelson operates a clinical practice in Calgary, Alberta, under Kinetic Health. He has authored ten publications and continues offering online courses and his live programs to healthcare professionals seeking to expand their knowledge and skills in treating musculoskeletal conditions. By staying current with the latest research and offering innovative treatment options, Dr. Abelson is dedicated to helping his patients achieve optimal health and wellness.
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References
Hayter, C. L., & Giuffre, B. M. (2009). Overuse and traumatic injuries of the elbow. Magnetic Resonance Imaging Clinics of North America, 17(4), 617-638.
Neal, S. L., & Fields, K. B. (2010). Peripheral nerve entrapment and injury in the upper extremity. American Family Physician, 81(2), 147-155.
Hariri, S., & McAdams, T. R. (2010). Nerve injuries about the elbow. Clinical Sports Medicine, 29(4), 655-675.
Thiele, S., Thiele, R., & Gerdesmeyer, L. (2015). Lateral epicondylitis: This is still a main indication for extracorporeal shockwave therapy. International Journal of Surgery, 24(Pt B), 165-170.
Descatha, A., Leclerc, A., Chastang, J. F., & Roquelaure, Y. (2003). Medial epicondylitis in occupational settings: prevalence, incidence and associated risk factors. Journal of occupational and environmental medicine, 45(9), 993-1001.
Huisstede, B. M., Miedema, H. S., Verhagen, A. P., Koes, B. W., & Verhaar, J. A. (2007). Multidisciplinary consensus on the terminology and classification of complaints of the arm, neck and/or shoulder. Occupational and environmental medicine, 64(5), 313-319.
Degen, R. M., Cancienne, J. M., Camp, C. L., Altchek, D. W., Dines, J. S., & Werner, B. C. (2018). Three common presenting symptoms of medial epicondylitis: pain, loss of strength, and functional disability. Journal of shoulder and elbow surgery, 27(6), 1072-1077.
Peterson, M., Butler, S., Eriksson, M., & Svärdsudd, K. (2014). A randomized controlled trial of exercise versus wait-list in chronic tennis elbow (lateral epicondylosis). Upsala journal of medical sciences, 119(4), 352-359.
Thiese, M. S., Hegmann, K. T., Kapellusch, J., Merryweather, A. S., Bao, S., Silverstein, B., ... & Garg, A. (2014). Effects of varying case definition on carpal tunnel syndrome prevalence estimates in a pooled cohort. Archives of physical medicine and rehabilitation, 95(12), 2320-2326.
Frontera, W. R., & Silver, J. K. (Eds.). (2014). Essentials of physical medicine and rehabilitation: musculoskeletal disorders, pain, and rehabilitation. Elsevier Health Sciences.
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