Tennis elbow: Pain Management with Eccentric

Exercises

Pain management module

Induchoodan Ravindran Nair

ID NUMBER: 18040632

Post graduate Physiotherapy programme

20th May 2010

0

Index

S.NO. TOPIC PAGE NUMBER

1. Abstract 2

2. Introduction 3

3. Physiology of pain : Tennis elbow 3-5

4. Eccentric exercise and tennis elbow pain 6-7

5. Holistic approach to tennis elbow pain and dysfunction

8-9

6. Alternative methods for treatment 9-11

7. Discussion 12-14

8. Conclusion 14

9. References 15-17

10. Appendix 1TurnitinUK receipt

18

Abstract

1

Objective: To evaluate the pain modulation in tennis elbow and how the

eccentric exercise reduces this pain by reviewing few related studies. And

briefly analyse the current approaches for tennis elbow pain and how the

holistic approach being more beneficial.

Physiology of pain: Most of the studies are suggesting the pain is because

of the local changes in the tendon such as neovascularisation elevated levels

of substance P and Glutamate. Neurogenic inflammation is another reason for

pain.

Effect of eccentric exercise: Exercise reduces pain through promoting the

healing process locally. And it is hypothesised that endorphin release

enhances with exercise and pain regulated centrally.

Holistic approach: Exercise in addition of movement with mobilization

(MWM) and Cognitive behavioural therapy (CBT) will be helpful. CBT can deal

with psychological symptoms and MWM can reduce pain instantly and

exercise can improve strength.

Conclusion: only one study found for the long term effectiveness of eccentric

exercises and it needs better quality study to prove the effectiveness. It is

assuming that more holistic approach with exercises, MWM (corticosteroid)

and CBT can solve varieties of symptoms that suffer by the patients (pain,

dysfunction, anxiety and depression). The exact pathology behind the

condition and how the pain regulated with eccentric exercises are still

unknown.

Introduction

2

Tennis elbow is also known as lateral epicondylitis or lateral

epicondylalgia. Is a painful condition affecting lateral compartment of elbow.

Mostly it occurs at or near to the lateral epicondylar origin of wrist extensors

(Vicenzino 2003). The pain is mostly sharp and intermittent. Usually radiates

from lateral epicondyle to wrist through the extensor aspect of forearm and

aggravates with movements like pronation of forearm, wrist extension and

gripping (Geoffroy et al 1994).

Exercise programmes are considered as a most common physical

therapy treatment for tennis elbow. The main principles of eccentric exercise

are load, speed and frequency (Stasinopoulos et al 2005). Eccentric exercise

is the only physical intervention which is having some long term effects on

tendinopathy (Svernlov and Adolffson 2001). Other common interventions

such as Movement With Mobilization (MWM), corticosteroid injection and

acupuncture only got short term effects (Bisset et al 2005, Newcomer et al

2001).

Physiology of pain: Tennis elbow.

Pathophysiology of tennis elbow is always controversial in

researches. In recent study by Coombes et al (2008) suggested a new model

of pathophysiology that causes pain in tennis elbow patients. After reviewing

many articles Coombes et al (2008) suggesting that tennis elbow has three

interrelated components in its pathology. 1, A Local pathology of tendon 2,

Changes with pain system 3, Impairment of the motor system.

3

According to Coombes et al (2008) not all tennis elbow

patients have same presentation. With a thorough examination therapist can

find different levels of pathology such as local pathology, dysfunction of pain

system and impairment of motor system.

Through the microscopic studies it is found out with local tendon

pathology that, elevated number of cells and ground substance,

neovascularisation, elevated density of neurochemicals and disarranged

immature collagen. In this neovascularisation is considered as the origin of

pain in tennis elbow, along with a close relation of neural structures and

neurochemicals at the origin of extensor carpi radials brevis at lateral

epicondyle.

In a study conducted by Alfredson et al (2000) suggested that

there is an elevated levels of glutamate in extensor carpi radialis brevis

tendon which affected with tennis elbow when it compared with normal

tendon. They used microdialysis technique to compare the density of

glutamate in 8 people (4 normal and 4 chronic tennis elbow patients). They

found a four fold larger concentration of glutamate in tennis elbow patients.

This glutamate is basically functions as excitatory neurotransmitter. So

authors suggesting that this increased concentration of glutamate may be one

of the reasons for peripheral excitation of pain in tennis elbow cases.

Calcitonin gene related peptide reactive nerve fibres (CGRP) and substance

P is situated at proximal extensor carpi radials brevis tendon along with small

4

blood vessels. These neurochemicals are considered as the potent pain

modulators in nervous system. Other functions of them are, regulation of

blood circulation locally and neurogenic inflammation. When

neovascularisation occurs as a part of development of pathology there will be

an increase in number of substance P and calcitonin along with these small

vessels that is why now a days literature are giving priority for

neovascularisation as the origin of pain in tennis elbow.

Also there are no signs of inflammation in tennis elbow but there

are chances for neurogenic inflammation because it is reported that

neurogenic inflammation is mediated through active peptides (CGRP and

substance P). Density of these peptides is higher in tennis elbow cases. So

this elevated level of peptides will keep fire the impulses of pain through

unmyelinated sensory fibres to dorsal horn of spine and thus results in severe

pain (Hyperalgesia) (Kidd et al 1996 and Coombes et al 2008).

When it comes to motor impairments associated with pathology of

tennis elbow most of the studies reported a decreased gripping capacity in

comparison with normal subjects or unaffected side. This is because the

elevation of pain occurs when doing griping. During gripping, wrist extensors

act as the strong stabilizers to oppose wrist flexion this is why tennis elbow

pain is associated with gripping.

5

Eccentric exercise and tennis elbow pain

How the eccentric exercise relieves tennis elbow pain is still

remains uncertain. One of the strong hypotheses is that, eccentric exercise

stimulates mechanoreceptors inside the tenocytes and it will results in

excessive production of collagen. Repetitive lengthening and loading of

tendon with eccentric exercise will remodel the new collagen which

synthesized by tenocytes and improve healing. There by the tendon (in the

case of tennis elbow it is Extensor carpi radialis brevis) get strengthened. The

healing of the tendon results in pain relief. In other words eccentric exercise

stimulate cross linkage formation of new collagen and it will enhance the

collagen alignment, ultimately both of these will amend tensile strength of the

tendon (Stasinopoulos et al 2005).

Progressive eccentric exercises will exert a stress force at the

attachment of extensor carpi radialis brevis and this will results in an increase

in production of collagenous scar at the area of tendon insertion, thus pain will

get reduced. Production of this new fibrous tissue at the insertion

(musculotendinous unit) will give the tendon more tensile strength to with

stand the repetitive stress. Other explanations include repetitive loading and

lengthening while doing eccentric exercise also improve tensile strength and

results in hypertrophy of muscles. Eccentric exercises are better than the

concentric exercise to improve muscle strength but the former has got the

potential to damage the muscles also. By adding concentric exercises with

6

eccentric exercise reduce muscle tension during regimen and it can minimize

the damage to muscles (Finestone and Rabinovitch 2008).

Standardized eccentric exercise regimen will be adequate for

rehabilitation of all tendon disorders by reversing the pathology. The

standardization means, the load or resistance for exercise should increase

according to the symptoms of the patients present with. Eccentric exercise

should perform in a low speed in all sessions of the treatment because this

only allows proper healing of tissues (Manias and Stasinopoulos 2006).

During the eccentric exercise the blood flow to the area affected may stop and

this will force to start neovascularsation. This formation of newer blood

vessels will increase blood flow and nutrients thus healing will progress and

pain get suppressed (Stasinopoulos et al 2005).

Above evidences supporting that eccentric exercises can alleviate

pain by improving healing and ameliorate function by improving tensile

strength.

Another hypothesis which related with exercise and pain is, there is

a neurotransmitter called endorphin produced by pituitary gland and

hypothalamus which is considered as a natural pain reliever. When the

intensity of doing exercise is high endorphin get released and pain

suppressed centrally. This may create an emotional state of well being

(Weyrer and Kupfer 1994). It is very important in tennis elbow as it is reported

that there is a higher chance for the occurrence of depression and anxiety

(Alizadehkhaiyat et al 2007).

7

Holistic approach to tennis elbow pain and dysfunction

In a recent study by Bisset et al (2006) who combined exercise

with MWM based on more holistic approach to rehabilitate the patient and to

make the effects of MWM long lasting by improving muscle strength with

exercises. According to the results corticosteroid injection group was superior

to other two groups for first 6 weeks but after that there was a large number of

patients reported a recurrence of pain. physiotherapy group was superior to

wait and see group for first 6 weeks and it was better than the corticosteroid

injection group after 6 weeks till 52nd week with a statistically significant lower

number of recurrence.

The results expressed that more holistic approach to tennis

elbow with MWM and exercises is more effective than MWM alone or

corticosteroid injection when considering long term benefits.

The results of above study put forwarded a newer treatment

regimen with eccentric type of exercises that augment with MWM to reduce

tennis elbow pain instantly. Along with this Coombes et al (2009) suggested

another holistic protocol in that eccentric strengthening exercises are augment

with MWM and corticosteroid injection to make a relief of pain with in a

session of application.

It is important to address the psychological aspect of pain also.

There is a high level of incidence of depression and anxiety in tennis elbow

patients (Alizadehkhaiyat et al 2007). Including cognitive behaviour therapy

8

along with rehabilitation will be vital for regional musculoskeletal disorders

(Hanada 2003, Geffen 2003).

Alternate treatments for tennis elbow

Movement With Mobilization (MWM).

Studies are unanimous in the effectiveness of MWM for alleviating

pain in tennis elbow patients immediately after application. But it still lacks the

evidence for the long term effectiveness of MWM alone.

McLean et al (2002) conducted a pilot study with 6 subjects to find

out the optimum force level for applying MWM to create an adequate

hypoalgesic effect. They observed 15-18% of improvement in pain free grip

strength.

Paungmali et al (2003 and 2004) conducted two trials and got 29%

and 47% of improvement in pain free grip strength respectively. One of those

studies they observed MWM has a sympatho excitatory effect also but there is

no explanation available about the relation between sympatho excitatory

effect and pain reduction.

A systematic review of clinical trials on physical modalities by Bisset et

al (2005) suggested that MWM has got the potential alleviate pain but only

short term studies are available for the effectiveness. In long term studies

MWM was give with some other interventions such as exercise (Bisset et al

2006) so it is difficult to say that the effect is coming with the use of MWM.

There are different arguments on effectiveness of MWM in pain

management of different musculoskeletal disorders. One of the strongest

hypotheses is that, the MWM can correct the positional fault that occurred at

9

the joint and there by it can reduce the pain (Mulligan 1999). Kavanagh 1999

conducted a study on patients with ankle sprain reported that MWM is able to

correct the positional fault associated with ankle sprain in inferior tibiofibular

joint. But the study did not measure the pain levels of the patients. There are

no studies available which is conducted in tennis elbow patients in relation

with positional faults and its correction.

Paungmali et al (2004) suggested that MWM on elbow inducing a non

opioid type of analgesia.

Local corticosteroid injection

Like MWM corticosteroid injection also got the ability to relieve

pain immediately. But most of the results with corticosteroids are inconsistent

with long term effects, which means after a period of 6-8 weeks of application

47/65 recurrence of pain reported by Bisset et al (2006).

Newcomer et al (2001) compared rehabilitation with corticosteroid

injection reported that rehabilitation with exercise should be the first treatment

of choice in patients with acute onset of tennis elbow when considering long

term effects because both groups (rehabilitation and injection) shown similar

improvement. Only positive thing found with injection was the immediate

effect on the pain after administration.

A systematic review done by Smidt et al (2002) suggested, with the

lack of high quality studies there is no improvement was found in tennis elbow

cases in intermediate and long term follow up but administering corticosteroid

10

is more beneficial than physiotherapy and wait and see approach for first 2-6

weeks.

Arthroscopic release

This is an effective treatment for lateral epicondylalgia and is

better than the open procedures. Average unrestricted work can be start after

6 days of procedure (Owens et al 2002). No studies were found which

compared arthroscopic procedures and with physical interventions.

Usually divides the extensor carpi radialis brevis tendon and

releases it and decorticate the lateral epicondyle this reduces further stress on

lateral epicondyle and the tendon. Thus patient will get a pain relief.

Cognitive behavioural therapy (CBT)

Along with physiotherapy CBT is important for the holistic approach

towards tennis elbow as it deal with psychological problems. CBT based on

diverting patient’s attention from the symptoms and modifying the beliefs and

thoughts about the symptom (Hanada 2003, Geffen 2003).

11

Discussion

Croisier et al (2007) in recent controlled trial noted that isokinetic

eccentric exercises are beneficial for chronic tennis elbow patients to relieve

pain and improve function. But the study only had shown the short term

benefits of eccentric exercise (9 weeks). They conducted a wide range of

outcome measures with VAS for pain, muscle strength analysis and

ultrasonographic examination. Interestingly, both rehabilitation group(passive

modalities like TENS, deep friction massage, ultrasound and stretching) and

eccentric exercise group shown similar improvement in ultrasonographic

examination. That is, with in the treatment period the affected tendon almost

reached its normal thickness. But eccentric exercise group had shown

significant improvement in pain score assessment and muscle strength

analysis.

As it is mentioned earlier, Coombes et al (2009) put forwarded

a new regimen to augment the effects of exercise with addition of MWM and

corticosteroid injection. But it may not be that cost effective approach as it is

already proven that patients will get an instant relief from pain with MWM and

corticosteroid (McLean et al 2002, Paungmali et al 2003, Assendelft et al

1996). So it assuming that there is no need to apply both of this interventions

for the same effect. Through the strengthening, remodelling and healing

eccentric exercise can relieve pain and dysfunction but not as fast as MWM

and corticosteroid (Woodley et al 2007).

12

Arthroscopic release can reduce pain in tennis elbow and

improve function but it was reported by Owens et al (2001) that, patient can

be return to non restricted work after 6 days. This is also questionable

because this type of restriction is not yet reported in any article which dealt

with physiotherapy interventions such as MWM or exercises. Holistic

approach with corticosteroid and exercise or MWM and exercise may not

restrict the patient from daily activities.

A microdialysis study on extensor carpi radialis brevis by

Alfredson et al (2000) proving that there are no inflammatory changes found

with the tendon. If there is any inflammation in tennis elbow the concentration

of prostaglandin E2 should be high. When they compared normal tendon with

tennis elbow affected tendon the density of prostaglandin E2 was similar.

According to this result they suggest that it is not necessary to prescribe

NSAID s for tennis elbow. It is better to prescribe corticosteroid for pain relief.

Only one study reported eccentric exercise will increase pain on

lateral epicondyle and it will cause withdrawal of subjects from the study. This

is the only adverse reaction noted with eccentric exercise in tennis elbow

(Martinez-Silvestrini et al 2005).

Only one study is available with long term follow up which used

eccentric exercise as treatment regimen. Svernlov and Adolffsson (2001)

compared conventional stretching with eccentric exercise took a follow up

after 12 months. The results were in favour of eccentric exercise. This is the

13

only study with longer term follow up. Further studies with proper

randomisation, adequate power and long term follow up need to ascertain the

effectiveness of eccentric exercise for tennis elbow (Woodley et al 2007).

Conclusion

For short term benefits it is good to administer local

corticosteroid injection. The effect will last for 2-6 weeks. When considering

longer term benefits it is better to go for physiotherapy (more holistic with

MWM and exercise or corticosteroid and exercise along with psychological

support using CBT). Physiotherapy for tennis elbow will be more beneficial

than wait and see approach (Barr et al 2009).

14

References

ALFREDSON, Hakan et al. (2000). In vivo investigation of ECRB tendons with microdialysis technique- no signs of inflammation but high amounts of glutamate in tennis elbow. Acta orthop scand, 71(5), 475-79.

ALIZADEHKHAIYAT, Omid et al. (2007). Pain, functional disability and psychologic status in tennis elbow. The clinical journal of pain, 23(6),482-489.

ASSENDELFT, Willem JJ et al. (1996). Corticosteroid injections for lateral epicondylitis: a systematic overview. British journal of general practice,46, 209-216.

BARR, Steven, CERISOLA, Frances L and BLANCHARD, Victoria (2009). Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: A systematic review. Physiotherapy,95(4), 251-65.

BISSET, Leanne et al. (2005). A systematic review and meta analysis of clinical trials on physical interventions for lateral epicondylalgia. British journal of sports medicine, 39, 411-422.

BISSET, Leanne et al. (2006). Mobilisation with movement and exercise, corticosteroid injection or wait and see for tennis elbow: randomised trial. BMJ, 1-6.

COOMBES, Brooke K, BISSET, Leanne, and VICENZINO, Bill (2008). A new integrative model of lateral epicondylalgia. British journal of sports medicine,43, 252-58.

COOMBES, Brooke K et al. (2009). Optimising corticosteroid injection for lateral epicondylalgia with addition of physiotherapy: a protocol for a randomized control trial with placebo comparison. BMC musculoskeletal disorders, 10 (76), 1-11.

CROISIER, Jean-Louis et al. (2007). An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. British journal of sports medicine,41, 269-275.

FINESTONE, Hillel M and RABINOVITCH, Deborah L (2008). Tennis elbow no more. Canadian family physician, 54, 1115-6.

GEFFEN, Saul J (2003). Rehabilitation principles for treating chronic musculoskeletal injuries. MJA Practice essentials, 178(3), 238-242.

GEOFFROY, Pierre, YAFFE, Mark J and ROHAN, Ivan (1994). Diagnosing and treating lateral epicondylitis. Canadian family physician, 40, 73-78.

15

HANADA, Edwin Y (2003). Efficacy of rehabilitative therapy in regional musculoskeletal conditions. Best practice and research clinical rheumatology, 17(1), 151-166.

KAVANAGH J (1999). Is there a positional fault at the inferior tibio fibular joint in patients with acute or chronic ankle sprains compared to normals? Manual therapy, 4,19-24.

KIDD, Bruce L, MORRIS, Vanessa H and URBAN, Laszlo (1996). Pathophysiology of joint pain. Annals of the rheumatic diseases, 55, 276-283.

MANIAS P and STASINOPOULOS D (2006). A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy. British journal of sports medicine, 40, 81-85.

MARTINEZ-SILVESTRINI, Julio A et al. (2005). Chronic lateral epicondylitis: Comparative effectiveness of a home exercise programme including stretching alone versus stretching supplemented with eccentric or concentric strengthening. J HAND THER., 18, 411-420.

McLEAN, Sionnadh et al. (2002). A pilot study of the manual force levels required to produce manipulation induced Hypoalgesia. Clinical biomechanics, 17, 304-8.

MULLIGAN, Brian R (1999). Manual therapy “NAGS”, “SNAGS”, “MWM” s etc. 4th ed., Hutcheson Bowman and Stewart Ltd.

NEWCOMER, Karen et al. (2001). Corticosteroid injection in early treatment of lateral epicondylitis. Clinical journal of sports medicine, 11,214-222.

OWENS, Brett D, MURPHY, Kevin P, and KUKLO, Timothy R (2001). Arthroscopic release for lateral epicondylitis. The journal of arthroscopic and related surgery,17(3),582-87.

PAUNGMALI, Aatit et al. (2003). Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Physical therapy, 83(4), 374-83.

PAUNGMALI, Aatit et al. (2004). Naloxone fails to antagonize initial hypoalgesic effect of a manual therapy treatment for lateral epicondylalgia. Journal of manipulative and physiological therapeutics, 27(3),180-185.

SMIDT, Nynke et al.(2002). Corticosteroid injections for lateral epicondylitis: A systematic review. Pain, 96(1-2), 23-40.

16

STASINOPOULOS D, STASINOPOULOS K and JOHNSON MI (2005). An exercise programme for the management of lateral elbow tendinopathy. . British journal of sports medicine,39,944-947.

SVERNLOV B and ADOLFSON L (2001). Non operative treatment regime including eccentric training for lateral humeral epicondylalgia. Scandinavian journal of medicine and science in sports,11,328-334.

VICENZINO, Bill (2003). Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. Manual therapy, 8(2),66-79.

WEYERER S and KUPFER B (1994). Physical exercise and psychological health. Sports medicine,17,108-16.

WOODLEY, Brett L, NEWSHAM-WEST, Richard J, and BAXTER, David G (2007). Chronic tendinopathy: Effectiveness of eccentric exercise. British journal of sports medicine,41,188-198.

17

Appendix 1 TurnitinUK receipt

jisc_help@turnitin.com

 to Induchoodan.Ra.

show details 16:04 (8 hours ago)

Hello Induchoodan Ravindrannair,

This receipt acknowledges that TurnitinUK received your paper.Below you will find the receipt information regarding your paper submission:Paper ID: 6929107Author: Induchoodan RavindrannairPaper Title: tennis elbow: pain management with eccentric exercise.Assignment Title: pain managementE-mail: Induchoodan.Ravindran-Nair@student.shu.ac.uk

18