Ask a Physio: Chronic tennis elbow

“I’ve had tennis elbow for a long time now (over 6 months). I’ve tried all the usual stretches, exercises and massage that had been recommended, but it’s still not going away. Do you have any other suggestions?”

This is actually a fairly common type of question – I’ve had ‘x’ for a long time and it’s not getting better. Half the time it’s because people haven’t sought any treatment (and unfortunately not all problems will go away on their own). The other half of the time, people have had some treatment, but the problem isn’t progressing as they would like.

The first question to ask is are the expectations realistic? If you’ve had a severe injury, it’s probably not going to get better in a week. Sometimes you just need to trust the process and take the time (and do the work). But in this case, you’ve been having treatment that sounds appropriate, and you’ve given it a very reasonable amount of time to progress.

When I do second opinions in cases like this there’s usually 3 areas I would want to look at:

  • Is this actually the correct diagnosis?
  • If it is the correct diagnosis, is the treatment the best or most correct treatment (or is anything missing?)
  • If it’s not the right diagnosis, what could be the correct diagnosis and treatment.

Is this the correct diagnosis?

If you are doing all the right treatment and management strategies for a problem and it’s not responding, the first question to ask is “Is that actually the problem?” In the same way that antibiotics won’t treat a viral infection, even though both cause a sore throat, having pain in a certain area could be due to different reasons. If you keep doing something and it’s not working, perhaps we should try something else.

For a chronic (i.e. long term) tennis elbow – Stretches, strengthening exercises and specific muscle treatments are all good treatment. If they aren’t helping, we would want to make sure that you actually have a tennis elbow problem, and not some other sort of issue that could also cause lateral elbow pain. If you’ve seen a health professional and they’ve diagnosed you, perhaps have a discussion with them about the progress and if there are any other possibilities. If you haven’t seen a health professional, and have self-diagnosed, then your first step should be to get an assessment with someone experienced and qualified to get the correct diagnosis. If the diagnosis is wrong, then often everything else we do to treat it will also be wrong. You end up going down the wrong path that may not help.

 

If it is the correct diagnosis, is the treatment the best or most correct treatment (or is anything missing?)

Assuming you do have a chronic tennis elbow condition (which is actually a tendinopathy of the common extensor origin). Is it being managed correctly and is there anything missing?

Without knowing the exact stretches and exercises you are doing; I couldn’t say for sure. But ensuring the rehabilitation is corrected loaded and dosed (how hard, how much and how often) would be important. You obviously need to be doing the right things the right amounts to get the best results. If you are doing the right exercises and the right amount, I would like to see if there is anything else to add in? For tendinopathies that aren’t responding to other treatments, Shockwave therapy has been shown to be an effective treatment option (we don’t offer this service at South Perth Physiotherapy, but our friends at Sportreat in Palmyra do offer Shockwave, and we will refer clients there if indicated). Some people might go towards cortisone injections, but they aren’t always effective for tendinopathies (and there can be an increased risk of tendon rupture if injected into the tendon). Bracing can also be a simple, cheap, and effective strategy to relieve pain for tennis elbow, if that hasn’t been trialed.

Finally, you need to make sure that you aren’t undoing all the hard work rehabilitating with the rest of your life. If you are constantly overloading the tennis elbow, aggravating it regularly, you could be undoing all the work of the treatment and rehab. Loading matters with tendon issues. If you’re overdoing it, that might be slowing down the progress (conversely underdoing it can also slow progress – it’s a real goldilocks situation)

If it’s not the right diagnosis, what could be the correct diagnosis and treatment?

For lateral elbow pain, tennis elbow would be the most common cause, so a safe bet if you were betting. But you can’t assume that’s the diagnosis, and as a health professional we should never assume, and always assess.

Other common cause of lateral elbow pain could be:

  • Referred pain from the neck.
  • Radial nerve irritation
  • Radio-humeral joint pain
  • Posterior interosseus nerve syndrome
  • Possible trauma like muscle injury, etc.

Some of these are less common but could be ruled in or out with a thorough assessment. In my experience, it’s quite common in cases of persistent tennis elbow/lateral elbow pain to experience redial nerve irritation (either as a secondary symptom, or perhaps the primary diagnosis). An experienced physio (or similar) should be able to assess and diagnose this for you.

Takeaways

If you keep doing the same thing, you’ll keep getting the same results. If the current management isn’t working, you’ll probably need to look at something else.

  1. Step one is getting an accurate diagnosis.
  2. Step two is to make sure the current management is appropriate, and a complete and total solution to the problem.
  3. Step 3 is to take a different approach if your current approach isn’t working.

If you are having ongoing issues that aren’t progressing as you would like, our team often provides second opinions for cases. If you have a question you’d like answered by a physio, please feel free to get in touch.

Julian Bowen

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