If you play competitive sports you have felt the inevitable pains that can come with too much activity. Often these pains are felt in your tendons. In this blog I will discuss how the latest researching is guiding our treatment of lateral elbow pain, while weaving in my own experience with this injury.

Tendons transmit forces between muscle and bones. We don’t yet fully understand tendon pathology (the injury process), but research is providing greater clarity. I discussed three important points in a previous post on achilles tendonopathy, they are:

1. A tendon injury appears to be caused by a combination of high load and high stress during a stretch, shorten cycle. The shorter the cycle and the higher the force the greater the strain on the tendon. We see this in sports like squash, basketball, and running. There can be other causes for tendon pain and it is crucial for a physio to clear other potential diagnosis.
2. Exercise is the only “drug” that promotes collagen growth. The gold standard treatment for tendons is better load management. This includes physical loads, neurological loads, social and psychological loads, and lifestyle loads. Some may argue that PRP (platlet rich plasma) stimulates growth but the mechanisms of how this works are still not fully understood or proven. Although many stakeholds would like PRP to be proven it is still not advisable for tendon rehab (yes I realize every athlete does it but this does not mean it works…far from it). See here, here, and here.
3. Tissue turnover is slow compared to muscle. This can lead to a slower recovery and resolution of pain. Programs that last 12 + weeks are normal and a full resolution may take up to a year.

Like other injuries it is important to remember pain is not always a good indication of tissue damage. Hand, elbow, and shoulder pain appear to be more sensitive and provoke more pain than other body parts. Continuing to exercise is important, but appropriate pain levels must be adhered to. I often have patients poke the bear (go into some pain) but in the case of elbow pain I may suggest they stay clear of pain (as best they can).

What else could it be?

During an assessment I attempt to distinguish the type of tendon injured, the pain contributors, and factors that help or hinder healing.

1. Is it an energy storage or stabilizing tendon – elbow vs hip?
2. Is it acute or chronic – Did this happen suddenly or over time?
3. Is it degenerative or acute – how might age being affecting your tendon?
4. Is it an upper or lower limb – this distinction changes how much pain you work into.
5. Potential pain drivers from the neck and shoulder should be cleared. These areas can cause referred pain in the arm.
6. Social, psychological, and lifestyle factors can help or hinder the healing process. As the picture below describes, pain is an experience of many contributing factors. These contributors become more important as pain persists.

Different contributors to the pain experience.

For squash players (or most athletes) the most common cause of pain in the elbow is due to an in-balance of load and recovery. Quite simply, the tendon was inadequately prepared to meet the demands of the sport.

The balance between preparation and training load. With better preparation and good sleep we can train more.

The rehab process:

There are many areas to consider during rehab process but a simple place to start is to identify pitfalls in training and to measure baseline load tolerance. In my case I was probably doing a little too much solo hitting, working on similar shots each time. Although creating a story and trying to identify an exact cause, this is not always possible. We can’t always draw a direct line from one action to our cause of pain. We shouldn’t be discouraged by this it is just the nature of life.

Step 1: Back off a from the most aggravating activity. Ideally you can continue to play, the amount and type will be modified.

Step 2: Identify how to be globally stronger ad

Step 3:  Can you load the injured tendon without increasing your symptoms. In certain cases the pain resolves quickly in others it can take months. I encourage patients to stick with the plan as long as their symptoms are not worsening and they are making functional gains in both global and specific strength. In my case I was continuing to lift more weights, was on court 1-2 x per week and was tolerating specific work 2x / week. The pain was still around after 3 months but I was making functional gains and my pain was not worsening. I believed in the bodies inherent ability to heal and trusted the process.

Specific exercises include: hand to hand presses, cable resistance and/or dumbbell resistance. Research now suggest that we start with what feels best on first assessment and progress from there. Eccentrics or isometrics aren’t necessarily the place to start. Everyone will be a little unique.

General full body exercise includes: pushes, pulls (sometimes more pain provoking because of the carpi-radialis commonly the injured tendon), presses, lifts, carry, and rotations. When an athlete is able to maintain there fitness through injury they are much more successful when they return to full competition. A workout like this as an alternative to squash.  This is by no means prescriptive but it paints a picture of what rehab might look like!

More details on Reduction: What may you need to reduce: A reduction in squash and known irritable activities is often advised. It may only be a matter of changing the type of squash your are playing. More games, less games, more drills, more solo hitting, it depends. The key is to replace the reduced squash with another form or anaerobic/aerobic exercise. In the video below I show a simple ladder drill. Work to rest of 30 seconds / 30 seconds. You can vary the work to rest ratio or the ladder distance. Have fun:)

Rest periods followed by high level activity is a poor choice for rehab. A more gradual return is preferred. This approach should include relative rest, education, activity modification, and strength.

The pitfall of the rest and blast approach.

A more gradual return is preferred.

With this in mind an activity ladder and pain scale are useful constructs to guide exercise choice and load progression.

Each tendon and each person needs a unique plan but a typical exercise gradient looks something like this:

From low load to high load:) General to specific.

What does this mean?

1. Isometric (activation with no movement)
2. Slow strength ( isotonic or simple strength)
3. Dynamic / energy storage (add more movement and speed)
4. Sport specific / energy storage and release (transition to sport specific and greater speed)

Step 4: Stretching…yes I am suggesting stretching:) lateral elbow pain appears to respond well to a stretching program inconjuction with exercise therapy. So go for it – start stretching. My only advice is that the stretching is comfortable. It should feel like a warm bath around the elbow. I suggest both a stretch of the flexors and extensors of the wrist (front and back of forearm) conditions in which stretching appears to be beneficial.

With all this mind I would like to end with two important statements.

1. Adherence to a good loading program is the single best thing you can do for your tendon. This should be comprehensive of all loads – sleep, physical, mental, etc.
2. During a painful episode I encourage my clients to work harder than their periods of “perfect” health…we have to be smart but I want clients to take the challenge head on and work hard:)

Thanks for reading

Dave Carter

Great resources

1. Leanne Bisset / Vicenzo research
2. Anything by Greg Lehman
3. Anything by Adam Meakins
4. BJSM papers on patella-femoral and patellar tendonopathy