What is tennis elbow, what are the symptoms, and how do you know if you have it
This is covered ad nauseam on the internet, and if you’re reading this you’ve probably already got a good idea of the basics of tennis elbow. So I’m going to make this brief.
Tennis elbow, also referred to as lateral epicondylitis, is pain on the outside of the elbow. It is referred to tennis elbow because tennis players and other racquet sport players commonly get it.
This is not the same as golfer’s elbow. Golfer’s elbow is pain on the inside of the elbow and requires a completely different treatment.
Medial elbow pain / Golfer’s:
Lateral elbow pain / Tennis:
If you have chronic pain on the outside of the elbow while grabbing things, that’s pretty much all you need to know i.e. you have tennis elbow. If you want to get more specific, if picking up a suitcase is consistently painful on the outside of the elbow you probably have it. Getting more specific: If grabbing something with your palm facing your side and or the ground is painful on the outside of your elbow, you likely have tennis elbow.
The only further qualification needed is tennis elbow is a chronic condition. It’s something that has been hurting you for a while. Perhaps a few months or years. It is not you bruised your elbow from walking into a wall and now you have tennis elbow.
What causes tennis elbow (anatomy and movement talk)
Simple anatomy version:
Tennis elbow is caused when the muscles on the outside of the elbow become overused. That is, some of the forearm extensors are overused relative to the forearm flexors.
Simple movement version:
Tennis elbow is caused by the elbow being bent too often with the palm facing down and not enough with the palm facing up.
Getting more complicated:
There are various muscles that flex the elbow. Most notorious is the biceps brachii aka Zee Gunz.
In people with outer elbow pain the biceps becomes underused and weak. The biceps is predominantly used as an elbow flexor when the forearm is supinated (when your palm is facing upwards).
The biceps becomes weak due to a lack of elbow flexion being done with the palm facing upward and too much elbow flexion performed with the forearm pronated (when your palm is facing downward).
When the elbow is bent with the palm facing downward other elbow flexors kick in and the bicep is pretty quiet. Those other muscles we’re concerned with are the extensor carpi radialis brevis (ECRB) and extensor carpi radialis longus (ECRL). (Don’t you just love anatomy talk?)
These muscles are never talked about as elbow flexors. I’ve actually only seen one source referencing them as so. Even their names, “extensor” and “carpi” have nothing to do with “elbow” and “flexion.”
However, if you look at where these muscles start, it’s at the humerus (upper arm), not the forearm. Meaning they are capable of pulling the fingers, wrist and forearm towards the humerus (elbow flexion).
Notice the hand needs to be in a pronated position for this to happen. If the hand is supinated, the line of pull of these muscles is the back of the wrist to the back of the humerus (elbow extension). Flip the hand so it’s pronated and the line of pull becomes the back of the wrist to front of the humerus (elbow flexion).
And if you take another look at where these muscles originate in relation to the elbow, you’ll see it’s on the outside of the elbow. You know, that place you have pain.
Next: Too much wrist extension
Because the ECRB and ECRL also extend the wrist, when the forearm is pronated and these two muscles are performing elbow flexion they are often performing wrist extension concurrently.
The differences between finger extension and finger flexion
This is where things get a little more complex.
So far we’ve seen in lateral epicondylitis we are moving our elbow too much with the palm down and wrist extended. More is going on though. That more is at the hand.
For a lot of people with this condition, the act of bending the elbow with the palm down isn’t painful. (It is in some, these are the really messed up ones.) The pain doesn’t begin until that motion is performed AND something is being grabbed.
When you grab something in this fashion those overactive muscles, the ECRB and ECRL, have to work even harder to make sure the task can be performed. Either causing them to one day get pissed off from doing this so much, or, if they’re already pissed, they’re getting pissed off further. This being pissed off would manifest as pain.
Back to the hand though, the point here is the elbow is always bent in one fashion, the wrist is extended (bent back) too, AND the fingers are always grabbing (they’re flexed). The extensor digitorum (ED) is a wrist extensor and finger extensor. However, because in our condition the wrist is always being extended but the fingers are always being flexed, ED gets worked as a wrist extensor but not a finger extensor. Where does ED begin?
That ‘ol familiar place of the lateral epicondyle aka that place where you have pain.
So we have elbow flexion, forearm pronation, wrist extension, and finger flexion all happening at the same time; all causing that one issue at your elbow.
This will all be important when we get to the corrective measures. A big part of getting out of pain is to the do the opposite of what’s causing you pain.
What about the neck and cervical radiculopathy?
If you’re (really) well researched on this topic you may have read some speculation lateral epicondylitis (tennis elbow) arises from cervical radiculopathy (fancy talk for a herniated disc in the neck). Let’s address this.
The most often cited study used to bring up this issue is this one: Evaluating concomitant lateral epicondylitis and cervical radiculopathy. This study found a correlation between the two.
I’m just not sure about this study.
First off, the diagnosis method didn’t seem right. From the paper:
“The diagnosis of lateral epicondylitis was reached by documenting tenderness to palpation at the common extensor tendon 1 cm distal to the lateral epicondyle while the patient’s elbow was flexed at 90° with the forearm supinated. Pain radiating down the forearm with straightening or lifting of the arm, gripping of an object, or making a fist also contributed to the diagnosis.”
In layman’s terms: Tenderness was used as the primary diagnostic with pain during movement used as an after thought.
Using tenderness as a barometer for epicondylitis is just crappy. If you press down on anyone’s forearms there are going to be some tender spots. It’s a commonly overworked area, it’s a commonly beat up area, there are a lot of adhesion sites there, etc. That doesn’t mean there is tennis elbow though.
Tenderness is also a sign of inflammation, but tennis elbow is not an inflammatory condition. It is a chronic, degenerative condition. So much some smart people are even proposing changing the name from epicondylitis (-itis meaning inflammation) to lateral epicondylalgia (pain). (See here: Lateral Epicondylalgia or Epicondylitis: What’s in a Name?)
The fact this seems to be the primary diagnosis method doesn’t sit well with me.
Next, at least in the people I’ve seen, true tennis elbow doesn’t often have pain radiating down the forearm. It is much more localized. In fact, whenever someone says they have pain that radiates I immediately look at the neck, as this is a sign something is going on with the nerves.
For the purpose of true tennis elbow, we are much more concerned with an issue that is only at the site of the lateral epicondyle. That doesn’t mean we ignore the neck; we’re just stating priorities.
Another issue with the study is it has an absurd amount of bilateral cases relative to unilateral cases. In other studies I’ve looked at the bilateral numbers come around to 8% of all cases. This study has bilateral cases making up 82%!!! In terms of number of bilateral cases relative to unilateral cases, this study’s numbers are the opposite of others I’ve seen.
I’m not saying this means the study is wrong, but it is definitely odd. Anecdotally, bilateral cases are rare for me as well.
The study also has a significant amount of more women presenting with lateral epicondylitis than men compared to other studies. For instance, one study found a 3% difference (basically no difference) while this study found women to have a greater incidence by 15%!
(I have a hunch the diagnosis method used here was a factor in this. Women are more likely to say something is tender when touched compared to men.)
There is a another commonly cited study:
“Gunn and Milbrandt studied 50 patients with tennis elbow (lateral epicondylitis) resistant to the usual conservative treatment measures for the elbow.”
This study just sucked.
In this study those resistant to conventional elbow treatment for 4 weeks were moved on to cervical treatment.
If you’re reading this you’re probably aware the typical treatment for tennis elbow sucks ass. Furthermore, this study is basing a “usual conservative treatment” FROM 1976!!! Are you serious?!?! It is 2012 and people are still having trouble treating this condition, so we should use something from 1976???
(Note here I am not so much criticizing the original study as I am criticizing people who use this study as “hard” evidence for treating tennis elbow at the neck.)
From the study:
“The other patients who had no previously received local treatment of the elbow, were first given ultrasound (Note: Useless), friction massage (Note: Maybe beneficial, maybe not), ice (Note: Useless), and other therapy (Note: Whatever the hell this means), and when symptoms persisted after 4 weeks, treatment was directed instead to the neck.”
Steroids and immobilization were also used as treatment for some patients. Again, both useless for tennis elbow. None of these things are addressing what’s CAUSING tennis elbow. (All the movement and anatomy stuff we discussed above!)
Next, the authors gave their “other” elbow treatment four weeks to work while they gave their neck treatment apparently no finite timeline. They state after four weeks of not responding to elbow treatment the group was directed to neck treatment. First, most therapy programs are going to take at least 4 weeks, and if things are spot on, noticeable differences should definitely be attained by roughly 6 weeks. The elbow treatment wasn’t even given this long.
And, on average, patients responded to the neck treatment in about 7 weeks. That means some were given longer than 7 weeks to respond. In fact, they state that two patients did not have relief at the 18-20 week mark!
4 weeks for their “other” elbow treatment (again, whatever the hell “other” means) but up to 16 weeks for their detailed cervical treatment?(The cervical treatment is detailed in the paper.) Come the fuck on.
Another issue: The average age of patients in the study was 47. Nearly anyone this age is going to have “abnormal” radiologic findings in the neck possibly constituting a herniated disc (like those found in this study). I haven’t come across research on the neck, but it’s estimated up to 80% of people with healthy, asymptomatic lower backs have abnormal radiological findings (herniations, bulges, etc.). I think it’s safe to assume something of this nature is going on with the neck too. That is, damn near everyone this age is going to have abnormal radiologic findings (the authors even state the patients had findings “commesurate with age”) but only 1-3% of the population has tennis elbow. There is something missing here.
This study is just littered with bias. All I can reasonably ascertain from this study is it’s worth looking at the neck. That’s it.
How other segments can influence tennis elbow:
Now, onto that something missing. Again, we have tons of people who have horrible looking MRIs and such but are not in pain. We also have people who have great MRIs but are in pain. AND we have people who have crappy MRIs and are in pain. What are we missing?
How things are MOVING.
Have a great MRI and move crappy = pain.
Have a crappy MRI and move well = no pain.
Have a crappy MRI and move crappy = pain.
And that’s what important here. Improper movement at the neck, and more so the shoulder, can impact movement at the elbow. And it just so happens people who have movement issues at their shoulder, also have movement issues at their neck, and also have movement issues at their elbow.
If we take a look at the Anatomy Trains philosophy we can see this makes perfect sense as there are a ton of muscular / fascial connections from the neck down to the elbow and hand. Take a quick peak over at the Anatomy Trains website for some great photos of this connection here.
This what we need to address.
Not whether or not you have a herniated disc. Because even if you don’t have a herniated disc, your shoulder or neck can still cause faulty movement at the elbow.
So, in that vain, I agree with these studies. We should definitely look at other body segments to form a comprehensive treatment.
I’m going to show two exercises illustrating how issues at the shoulder / neck affect the elbow:
1) Watch the elbows and wrists closely in this video:
Notice how the elbows flare outside of the wrists? And then you can see the wrists are extended? Realize how this is the same position we’ve spent the first few chapters talking about? And how we want to get out of this position!
2) Watch the same thing here:
Same thing here when bringing the arms backwards. The wrists end up in an extended position.
Why this is happening:
There are three main muscles contributing to this issue. First, the trapezius is not working as well as it needs to. The trapezius helps to lift the arms, and clearly there is an issue doing this in the above videos. If you take another look at the Anatomy Trains photo from above, you can see there is a fascial connection from the trapezius (and thus the neck) to the outside of your elbow. (Where you have pain!) We need to get this muscle working better.
Next, there is excessive tightness at the internal rotators of the shoulders, the lats and pecs specifically. Because of this the person has trouble keeping their wrists and elbows in a straight line. Thus, the shoulders rotate inwards, elbows flare outward, and wrists bend backwards. All causing the elbow to move into a position where the ECRB and ECRL do more work than they normally would. After our lengthy discussion on these two muscles, this is obviously a problem.
This is all very, very common. And when it comes to the shoulder and neck this is what we’ll address in the corrective / treatment section.
To find out more information continue reading.
Curing Tennis Elbow
How to finally get rid of your elbow pain
Tired of recurring elbow pain that just won’t go away no matter what you do?
If you’re reading this you are probably at your wits end with your elbow pain. No matter what you try, whether it’s tennis elbow straps, ultrasound, cortisone shots, resting for what seems like forever, NOTHING seems to work. You still have pain when you pick up your coffee mug, or grab clothing out of the washer, or swing a bat / racquet.
About the book:
This ebook details what tennis elbow (also known as lateral epicondylitis) is, why people get it, and how to get rid of it while getting a good workout in the process. No stupid physical therapy bands required.
What you get from the book:
-A detailed explanation of why tennis elbow occurs. Which muscles are involved? Why do tennis and other racquet sport players get it more than others? Why do people who type a lot get it?
-Note: This is not some asinine explanation of “You have inflammation! And tiny tears in your elbow! Take some Advil!” This is a detailed look at the muscles involved and the exact, intricate movements that CAUSE the elbow to have potential inflammation or tears. This will not be something you’ve read before. In fact, you’ll learn why treating tennis elbow as an inflammatory condition is the wrong process. (And probably why you’re still in pain.)
-Why picking up clothes out of the washer, grabbing your cup of coffee, rotating door knobs, etc. all hurts your elbow
-You’ll learn what movements you’re doing during the day that are causing your pain and how to avoid them
-Why being overweight could derail all your rehab efforts OR why being overweight could cause your tennis elbow
-Whether cervical radiculopathy (a herniated disc) is or isn’t causing your elbow pain
-Why you need to pay attention to other body segments, like the neck and shoulder, as they can be negatively affecting the elbow
-You’ll immediately learn how to be able to pick up something without being in pain
-Why cortisone shots and Advil (ibuprofen) suck, and how they can actually make your elbow worse
-Whether tennis elbow straps are worth wearing, or if they just make you look weird
-Which wrist, finger and forearm stretches you should stop doing and which you should start doing.
-A great self-massage / soft-tissue method you can use to help immediately alleviate your pain.
-You’ll figure out how you can get back to working out without being in pain, while getting your elbow to heal. No more crappy, half-assed workouts because your elbow hurts.
-Which exercises you should stop doing and how to modify many of the exercises you’re already doing to get rid of your pain and cure your tennis elbow.
-A couple of sample workouts to help get you started. Most importantly though, you’ll learn how to eventually get yourself back to working because you’ll learn the principles of what not to do and what to do to avoid the issue ever coming back.
-For those who just want to feel better, aren’t as interested in the why behind everything, and aren’t interested in workouts, you can simply skip to chapter 7 and learn which few things you need to do everyday and be done with it
-Videos and pictures for damn near everything. Seriously, this took me fucking forever to do. You better love them.
This book is for you if:
-If interested in getting a good workout you are willing to commit a couple times per week to getting a good workout. While this book is geared towards those wanting to get rid of their tennis elbow and get a good workout in the process, the workouts are not essential to alleviating the condition. All that is required is changing how your elbow moves. The workouts will help though. It’s recommended you do them.
-If you are not interested in the workouts you must be willing to do a few exercises every day. This takes 5-10 minutes max out of your day
-You are willing to be patient. This is not a one day or one week fix. It took a while to screw your elbow up, it is going to take some time to get it healthy.
This isn’t for you if:
-You are expecting a single supplement, substance, shot, one exercise, or whatever as the end-all be-all to getting rid of your tennis elbow. If you are expecting a remedy to the effect of, “Just do this one thing” you might as well stop reading.
-You are not willing to modify your daily activities. Simply put, some basic things like how you stand, how you type, how you pick things up, etc. are going to have to change. If you’re already complaining, please leave.
-You are only going to adhere to the program for two weeks and then go back to all the stupid things you’ve been doing that caused your whole issue. Like I said, this is going to take some time. Patience is essential.
“How long will this program take until your elbow feels better?”
This always depends on the person i.e. how bad is their elbow right now, how diligent are they with the program, etc. With that said, 8 weeks is a normal amount of time for the elbow to feel damn near normal again. Considering most people cite 6 months to 2 YEARS as the average -due to “spontaneous” healing (aka we have no fucking clue why it healed)- I think 8 weeks is pretty reasonable. If you’re very good about things, you can get this done in 4-6 weeks.
Keep in mind, 8 weeks is until normalcy. You will immediately learn how to relieve your elbow during a whole host of activities. The elbow should gradually feel better each week. With 8 weeks being roughly the point at which all pain is pretty much gone.
Please keep in mind there a lot of factors influencing this. For instance, if you spend 10 hours a day typing and you are not very diligent in changing your positioning, 8 weeks is probably pushing it for you and you’ll likely need longer.
Also, you can’t do half the program, or continue doing painful things and wonder why at 8 weeks you only feel a little better.
“Do I need to go to the gym to do this program?”
It’s not essential, but it will help. As mentioned, the gym workouts are not essential to making your elbow feel better (modifications to your daily activities ARE though).
“What do I need to view the product?”
The book is in PDF form and an internet connection is needed to view all the videos.
“How do I view the videos?”
They are all on Youtube with a private link only people who get the book have access to.
“Who am I?”
Check out my testimonials and results page to see some of the people I’ve helped out with various conditions if you want to make sure I’m not just some schmuck who is full of shit.
“What if I’m not happy with the product?”
If you’re not satisfied though, just email me ( firstname.lastname@example.org ) and I’ll refund you immediately.
“How much does it cost?”
The book is 20 dollars. Considering going to a physical therapist would consist of probably at least 8 visits, all with at least 10 dollar co-pays, I think it’s a good deal.
Also, you don’t have to deal with some horseshit therapist dictating you pull on some bands, rub on your arm, play with yourself, and smile while you pay them 80 dollars an hour. I know people who call that “Friday night” and get more out of their money.
Here’s the table of contents for another look at what’s in the book:
Table of Contents
(If you just want to know what you need to do to get rid of your pain and are not as interested in the why behind things, skip to chapter 7.)
1) What is tennis elbow, what are the symptoms, and how do you know if you have it?
2) What causes tennis elbow? (Specific anatomy involved, specific imbalances occurring, specific movements)
3) What about the neck and cervical radiculopathy? / Why other body segments are important
4) Which daily activities can cause tennis elbow?
5) How do tennis elbow straps work? / Do they do anything but make you look weird?
6) What about cortisone shots, ibuprofen, and other anti-inflammatories?
7) Getting rid of tennis elbow
8) Things to correct in your daily life
9) Soft-tissue / Massage technique
10) Stretching technique
11) Designing an exercise and treatment program to cure tennis elbow / How to modify exercises
12) Sample exercise programs designed to get rid of tennis elbow AND get a great workout
13) How long until you start feeling better
Please feel free to email me with any questions or if I can help you in any way: email@example.com