I recently conducted an experiment on elbow pain, with one of the patients of my practice. Lets call him Arnold. Arnold is a 51 year old man, recreational tennis player and cross fitter. The combination of playing tennis and intense cross fit activity saw Arnold develop both pain and weakness in his [dominant] right forearm.
Specifically, Arnold’s pain was centred mostly at the inside aspect of his elbow joint. The pain radiated about half way down the inner aspect of his forearm. He had suffered this pain in excess of three months and, at the time, his symptoms included, poor grip strength, inability to shake hands without pain, and exquisite tenderness at the inside aspect of the right elbow joint.
Tennis and Golfer’s elbow are both repetitive strain injuries that arise because of the repetitive force experienced by the common forearm flexor and extensor tendons originating at the elbow. Whilst playing tennis is a common cause, other physical activities such as crossfit, jack hammering, and even gardening can also be to blame.
Initially, rest will be the best means of elbow pain reduction. However, there are many other things one can do to accelerate their recovery. Here’s what I found worked with my approach to Arnold:
Accurate diagnosis
I made the diagnosis of medial epicondylitis, otherwise known as golfer’s elbow. I was able to do this through a thorough history take and using orthopaedic testing to confirm this diagnosis:
- Palpation assessing muscle tonicity in the forearm flexors through touch and feel.
- Handshake test: I actually noticed on greeting Arnold, with a handshake, as he came in to the office that he had poor grip strength. He almost winced as he shook my hand.
- Finger tapping: merely tapping a finger at the origin of the common flexor tendons can be extremely sensitive in golfer’s elbow patients.
- Resisted wrist flexion: a muscle test that assesses the functioning of the forearm flexor muscles.
- Arm wrestle test: inability to resist opposing force in the arm wrestle position is a strong indicator for golfer’s elbow.
I also added two extra tests to rule out tennis elbow:
- Resisted wrist extension: a muscle test that assesses the functioning of the forearm extensor muscles.
- Middle finger sign: the patient will hold their hand out with fingers fully extended and palm facing the ground. Inability to resist a downward pressure on top of the middle finger will indicate damage to the common extensor tendons of the elbow.
Equipment
Like many recreational tennis players, Arnold had no idea that the setup of his tennis rackets might be contributing to his elbow pain. There are essentially three crucial racket specifications that will influence how your body responds to hitting tennis balls.
- Weight: if it is too light, the racket will not have enough mass on collision with the ball. The shock will travel straight through your racket and into your arm.
- Grip size: if it is too big, you will strain your forearm musculature unnecessarily.
- String: the tighter your string bed and the tougher the string (eg. Kevlar), the more shock you will experience into your arm.
Treatment
Golfer’s elbow is fundamentally a problem with the tendinous portion of the forearm flexor muscles. It is however, vital to consider the surrounding structures involved with elbow pain. Simply put, this includes the elbow and wrist joints, the bellies of the forearm flexor muscles, not to mention sparing consideration for the shoulder and thoracic spine (mid back).
- Soft tissue work: I used active release technique with Arnold. This is a fantastic modality for treating tendinopathies. Essentially, it is a combination of massage and stretching applied at the same time.
Joint mobilisation/manipulation: the elbow and wrist joints demonstrated restricted motion. I was able to restore full range of motion through the use of gentle mobilisation and manipulation techniques.
Dry needling: following the above therapies, I used acupuncture needles to introduce a different stimulus to the injured muscle tissue. This is a highly effective technique for restoring vital blood supply to the damaged tendons as well as facilitating a loosening effect within the tissues.
Taping: I used some kinesio [stretchy] tape to provide some extra support to the soft tissues in between Arnolds treatments. Amongst other things, this special tape is most effective in facilitating optimal muscle firing sequence patterns in the affected areas.
Take home exercises: I prescribed Arnold some club bell exercises. Club bells are the only effective means I have found to target the forearm flexor and extensor tendons adequately. The use of normal dumb bells to target these areas, in my opinion, simply does not work. You can see my club bell in the picture above.
Arnold came to see me three times a week for just two weeks, totalling six treatments. He has told me that since this course of therapy, his symptoms have not returned. He is playing tennis and continuing with his crossfit regularly throughout the week without experiencing elbow pain. Each time I see him, he always greets me with a firm hand shake.
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