If you've had Tennis Elbow before you'll understand how frustrating it can be.
It's stubborn, persistent and often compounded by a lack of obvious triggers.
But did you know that it may be more than just isolated elbow pain? That there's an important piece of the puzzle easily missed?
From what I find clinically, this is significant enough to potentially hold the keys to a better understanding of the issue.
So I ask you this; is your Tennis Elbow actually a consequence of neck dysfunction?
I think there's enough clinical evidence to suggest it might be. So let's discuss why.
What is Tennis Elbow
For those unaware, Tennis Elbow is an overload and irritation of the wrist and forearm tendons at the elbow. Its technical name is Lateral Epicondylitis - which implies inflammation, but this isn't always the case.
Tennis Elbow Cause
Traditionally we equate the onset of Tennis Elbow pain with tasks that require repetitive gripping and twisting.
But we also link it to other tasks that expose you to high wrist and forearm load. Things like brick-laying, tiling, working a register and overhand carrying seem connected.
It's often classified as an "overuse" injury for the above reasons. We feel load plus high repetition can equal tendon dysfunction.
It can genuinely be a pain in the ass.
Interestingly, I also see a large number of office workers with Tennis Elbow. They still seem exposed to a lot of repetitive movements but without the heavy load.
In my opinion, this highlights why there's still an element of mystery associated with Tennis Elbow - load isn't always involved.
And this is where the neck becomes relevant.
Does the Neck Cause Tennis Elbow?
It can sound strange to suggest the neck is involved here but clinically I've seen enough to warrant greater attention.
It seems that in order to develop Tennis Elbow (Golfers Elbow and potentially other hand, wrist or fingers tendon issues as well), you may need to have accrued some dysfunction at the base of the neck first. I don't necessarily mean a disc bulge or pinched nerve, but mechanical dysfunction.
When performing an assessment for Tennis Elbow I'm now highly attentive to any local neck joint stiffness and related soft tissue tightness.
This is often tricky for most patients to comprehend as these symptoms generally won't stand out. You have to go hunting to find them to appreciate what's going on.
And I have some thoughts on why.
How the Neck Causes Tennis Elbow
The lateral elbow is affected by the neck in a few ways.
Dermatomes and Myotomes
Without going into too much detail, Dermatomes and Myotomes are aspects of the spinal cord that serve specific areas of sensation and muscular activity throughout the body.
Formed in the Embryonic stages of our development these neurological connections are often severely underrated when trying to understand injury and dysfunction.
In terms of Lateral Epicondylitis, the base of the neck houses connections to the lateral elbow and forearm. As a result, low neck stiffness and tightness may act like a 'kink' in a hose and affect the function of your arm.
It's very important to understand that the normal flow of function can be suppressed or altered by dysfunction further up the chain. If you kink a hose the water pressure drops off, and this may also be true for incoming and outgoing neural information.
It seems to result in functional changes like hyper, or altered sensitivity and relative weakness - reducing the elbow tendons' ability to tolerate normal and/or increased loading over time.
In short, there should be nothing wrong with you performing repetitive tasks.
After all the body is designed to thrive with use. But if the hose that supplies your tissue is 'kinked', then its threshold for dysfunction is likely to be compromised. Most likely without you realizing until it's too late.
It's a similar idea here with the Radial nerve.
The nerve and its offshoots originate from the base of your neck and the very top of your upper back. It follows a path down the back of your arm and directly passes by the lateral part of your elbow before finishing down around your thumb.
As before, any kink in the system can have downstream consequences.
It's important to note that our nervous system doesn't have a lot of inherent 'slack' in the system. Unlike our soft tissue which has more 'elasticity', our nerves are more steel cabling by design. This relative rigidity helps provide a conductive pathway for neural traffic. So it's important that our neural connections can 'floss' freely through their designated pathways.
But if there's a mechanical anchor at its origin, the nervous system can become a source of restriction and anything can become dysfunctional by association.
This is often displayed as increased neural tension.
As you can hopefully appreciate, any low neck dysfunction can have functional, mechanical and performance-related consequences for the lateral elbow.
If this neck dysfunction is left unattended, it may potentially become very hard for any symptomatic elbow treatment to work. And if it does, have we truly solved anything?
If you are like many long-term sufferers of Tennis Elbow and have gone through months of anti-inflammatories, elbow injections, pain medication, strength and conditioning exercises, Tennis elbow splints, braces, straps, and other supports, etc. all without success, then you might be missing one huge piece of the puzzle.
The Best Treatment for Tennis Elbow
In light of this, please consider the health of your neck and your work/home environment.
How do you hold your neck? Do you constantly look down when reading or using your phone? Do you recline and watch TV through your feet? Are you someone who just generally slouches?
What is your neck having to buffer day to day behind the scenes?
It may not seem like these positions and shapes can equate to a sore elbow but clinically it seems there's a connection.
By treating patients' neck dysfunction it's common to see some immediate change in elbow pain and an increase in strength and overall function.
It's as close to a Tennis Elbow cure as I think we are likely to get.
The results are there to see. I urge everyone to test it out themselves - regular folk and health professionals alike.
The Best Tennis Elbow Exercise
Take a lacrosse ball or tennis ball and lie down.
Let it gently press into the lower aspects of your neck and go looking for stiffness and tightness. It's very safe, but take the time to explore your neck and pay more attention to what you feel is relevant.
If you're in the right area it may even communicate with your symptoms.
If unsure, go and see a trusted health professional and let them do it for you.
Frequently Asked Questions
Tennis Elbow can be painful. However, the pain associated with the condition is not usually a constant pain. Instead many have intermittent pain brought on by specific movements and tasks, the most common of which involves gripping and loaded wrist movements.
Classic symptoms include an intense, duller pain with activity. It may also ache in a non-specific way.
The best treatment depends on how irritated the tendon has become. If you've caught the symptoms early a mixture of massage, relative rest and eccentric forearm strengthening may do the job. However, if it's quite irritated or more chronic you may need a brace or tape to help distribute the load and protect it. It's also important to note that freeing up the base of your neck and upper back may also help undo the potential underlying cause of Tennis Elbow making any symptomatic treatment more effective and long-lasting. Ice and anti-inflammatories should not be relied upon unless absolutely necessary due to their ability to delay healing.
In most cases it is curable. Provided there has been no chronic damage to the underlying tendons and tissue of the elbow, you should expect your Tennis Elbow to regress at some stage. If your symptoms aren't responding to regular therapy make sure you are addressing any associated neck dysfunction as well.
The prognosis for Tennis Elbow is highly specific to the individual. Many low-grade cases can be treated in 4-6 weeks if managed correctly. More involved cases can take 3-6 months (and longer) particularly if any underlying neck stiffness goes untreated and the elbow isn't given enough relative rest.
From my experience as a Physiotherapist, heat is the best option for treating Tennis Elbow. As mentioned before, ice has the capacity to delay the healing process and should only ever be used as a last resort for pain management. Heat, on the other hand, can help loosen up tight and restricted tissue and help down-regulate the nervous system leading to a reduction in pain. Both should only be considered short-term options while you work hard on improving the underlying mechanical faults responsible in the first place.
If left untreated, Tennis Elbow is highly likely to persist (or come back again at a later date). This is important to remember for two reasons:
1. Tendons need relative rest from aggravating activities to settle.
2. The underlying mechanics of the neck, shoulder, and elbow also need to be addressed to restore normal loading to the tendon.
These issues are unlikely to solve themselves unless you actively try and influence them.
On the other hand, pure rest on its own is unlikely to solve Lateral Epicondylitis. Tendons need to be used and loaded in order to remodel and strengthen. The key to treating Tennis Elbow is to continue to use it within reason while also trying to improve the way you load it.
Traditional treatment of Tennis Elbow usually includes eccentric strength exercises. Eccentric exercises focus on lengthening the tissue under load. With Lateral Epicondylitis this often looks like performing a wrist extension movement with an emphasis on slowly lowering the weight down again. This controlled lowering can help reorganize the dysfunctional tendon over time.
Similarly, I would always recommend anyone with Tennis Elbow use a Lacrosse ball or Tennis ball to mobilize their upper back and neck. Clinically there seems a strong link between stiffness in these areas and the onset of Lateral Epicondylitis.
Tennis Elbow is traditionally seen as an over-use injury. We believe that activities like using a Tennis racket can overload the elbow -creating dysfunction over time. Interestingly, we adhere to this idea despite use and tendon loading being both normal and vital for proper tendon health by definition.
Instead, we should look at the onset of Lateral Epicondylitis as the moment underlying poor mechanics could no longer tolerate the situation they found themselves in. Then it's just a matter of stepping back to see what factors set the elbow up to fail when it did.
The true underlying cause of Tennis Elbow seems to be less than perfect neck posture, an overloaded and stiff neck and upper and an increase in neural tension through the radial nerve.
In a perfect world, a Tennis Elbow brace should be worn in the short-term while you are working hard to fix things behind the scenes. Bracing (and taping) can be useful for those looking to maintain some level of function and activity in the meantime. The use of a Tennis Elbow brace long-term is only appropriate is you feel your symptoms are still gradually improving at the same time. If not, it may be time to re-assess the way you are managing your elbow,
Subtle pain and tightness on the outside of your elbow when gripping, twisting or lifting may be the first sign of Tennis Elbow. Some also experience weakened grip strength.
Surgery is an option for many persistent soft-tissue complaints, and Tennis Elbow is no different. Many consider surgery for Lateral Epicondylitis after a long period of unsuccessful treatment. The challenge here is to distinguish between a Tennis Elbow that won't respond to conservative treatment and poor conservative treatment. If you are considering surgery for your elbow, please make sure to get a second opinion just in case something has been unintentionally overlooked.
Interestingly, it's more common for those who don't play Tennis to develop Tennis Elbow than those that do. From what I see clinically, those most at risk of Tennis Elbow are bricklayers, tilers, office workers and those that work at a cash register. Professionals like these seem to have that awkward mix of poor neck postures, the development of neck stiffness and repetitive use of the forearm and elbow. Tennis players clearly experience the condition but often have a level of forearm and elbow conditioning that creates a better buffer against Lateral Epicondylitis.
Game, Set, Match
So if you are dealing with Tennis Elbow make sure you respect the health and function of your neck. Take a moment to consider your postural habits and make amends where possible.
By all means, work hard on your elbow treatments and exercises. Build on the strength and mobility of your wrist, elbow and forearm musculature, but please consider the potentially bigger picture at play here.
The bottom line is that your tissue should support you if you choose to use it. Repetition should rarely be an excuse for dysfunction on its own. It may, however, expose already less than perfect mechanics and function over time.
This can be a hard idea to reconcile considering that we often confuse feeling 'normal' with being normal, but I feel the evidence is mounting.
I urge everyone to explore this idea. There's likely something here if you're willing to look for it.
It has been a game-changer for me and my patients and something I genuinely feel needs to be explored and officially researched. Perhaps discussing this is the first step.
Are you dealing with Tennis Elbow? What are your thoughts on this?