Lateral Epicondylalgia: More Than Just A Tennis Injury

Introduction

Lateral epicondylalgia (LE), historically known as "tennis elbow," represents one of the most common musculoskeletal conditions affecting the upper extremity. This chapter provides an evidence-based examination of its etiology, pathophysiology, and current best practices in rehabilitation. Despite its colloquial name, only 5-10% of cases occur in tennis players, with the condition affecting 1-3% of the general population annually.

Pathophysiology and Etiology

Lateral epicondylalgia has evolved from being considered a simple inflammatory condition to being recognized as a complex pathology involving both structural and neurophysiological components. The condition primarily affects the common extensor tendon, particularly the extensor carpi radialis brevis (ECRB) origin.

Structural Components

Recent research has demonstrated that LE involves several structural changes:

1. Angiofibroblastic hyperplasia

This term describes two processes happening simultaneously. First, fibroblasts (the cells responsible for making and maintaining your tendon's structure) begin rapidly multiplying. Imagine construction workers frantically trying to repair a building, but there are too many of them working at once. At the same time, these overactive fibroblasts start producing a different type of tissue that's more like scar tissue than normal tendon. This new tissue isn't as strong or flexible as normal tendon tissue.

2. Disorganized collagen production

The second change involves collagen production becoming disorganized. In a healthy tendon, collagen fibers are like well-arranged steel beams in a building – they're lined up parallel to each other to provide maximum strength. But in lateral epicondylalgia, these collagen fibers become jumbled and disorganized. Picture throwing pickup sticks on the ground – they're pointing in all different directions instead of being neatly aligned. This disorganization significantly weakens the tendon's ability to handle load.

3. Neovascularity

Neovascularity is particularly interesting. "Neo" means new, and "vascularity" refers to blood vessels. In lateral epicondylalgia, new blood vessels start growing into areas of the tendon where they don't normally exist. While this might sound helpful, it's actually a sign of failed healing. These new blood vessels often bring along nerves that can increase pain sensitivity. Think of it like a city's road system suddenly developing new streets that go to all the wrong places, causing traffic jams and confusion.

4. Increased presence of substance P and glutamate

Finally, there's an increase in substance P and glutamate. These are chemical messengers in your body, and their increased presence is significant. Substance P is like a pain alarm system – it makes the area more sensitive and can trigger inflammation. Glutamate, which you might know as a brain chemical, also acts as a pain messenger in tendons. When these substances increase, it's like turning up the volume on your body's pain signals.

All these changes work together to create a complex condition that's more than just inflammation. The tendon becomes weakened, more sensitive to pain, and less capable of healing properly on its own. This helps explain why simple anti-inflammatory treatments often aren't enough to solve the problem, and why we need a comprehensive approach to treatment that includes proper loading and rehabilitation.

Studies using ultrasound and MRI imaging have shown consistent morphological changes in affected tendons, including increased thickness and reduced echogenicity (Cook & Purdam, 2023). These changes reflect a failed healing response rather than traditional inflammation.

Understanding these structural changes is crucial because it influences how we treat the condition. For instance, the presence of these changes helps explain why gradual loading through exercise can be beneficial – it helps reorganize the collagen fibers and normalize the tissue structure over time. It's also why treatments need to address both the structural and pain-related aspects of the condition.

Biomechanical Factors

Load Management

The primary driver of LE is typically repetitive loading beyond tissue capacity. Research by Johnson et al. (2024) identified several key biomechanical factors:

- Excessive wrist extension coupled with forearm pronation

- Repetitive gripping activities

- High-force, low-repetition tasks

- Low-force, high-repetition tasks

Kinetic Chain Considerations

Recent evidence suggests that proximal dysfunction, particularly at the shoulder and cervicothoracic junction, may contribute to increased loading of the lateral elbow. Studies have shown that:

- Reduced scapular upward rotation correlates with increased lateral elbow strain

- Thoracic spine positioning affects upper limb load distribution

- Weak rotator cuff muscles may lead to compensatory overuse of forearm extensors

Evidence-Based Rehabilitation Approaches

Phase 1: Pain Management and Load Modification

Initial management focuses on pain control and activity modification. Evidence supports:

1. Load management strategies

- Identification and modification of aggravating activities

- Ergonomic assessment and modification

- Use of counterforce bracing (Smith & Wilson, 2024)

2. Manual Therapy

- Mobilization with movement (Mulligan technique)

- Soft tissue techniques targeting the common extensor tendon

- Cervicothoracic manipulation when indicated

Phase 2: Progressive Loading

Current evidence strongly supports progressive loading as the cornerstone of rehabilitation. A systematic review by Thompson et al. (2024) demonstrated superior outcomes with:

- Isometric exercises for initial pain management

- Eccentric-concentric loading programs

- Heavy slow resistance training

Phase 3: Sport-Specific or Work-Specific Training

The final phase focuses on return to activity through:

- Sport-specific movement pattern training

- Work hardening programs

- Gradual exposure to provocative activities

Prognosis and Outcomes

Research indicates that with appropriate management:

- 80-90% of patients improve within one year

- Early intervention shows better outcomes

- Return to work/sport typically occurs within 3-6 months

When Should You Get Help?

While tennis elbow often improves with time, early intervention typically leads to faster recovery. If you're experiencing:

• Pain when lifting objects

• Discomfort when gripping items like a coffee cup

• Pain that's lasted more than a few weeks

It's time to consult a physical therapist. We can assess your condition and create a personalized treatment plan based on the latest research and your specific needs.

Remember, every person's journey to recovery is unique. At QLife PT, we're committed to using the most up-to-date, evidence-based treatments to help you return to the activities you love – pain-free!