There is a lot of bad information floating around on the web regarding tennis elbow. Especially when it comes to “cures” and therapy. Many products claim to treat or cure tennis elbow, but many are ineffective and can even worsen your symptoms. They range from topical creams to straps and specialized home modality equipment. The primary symptoms that these products claim to address are pain, tightness, and weakness in your forearm.
TE can be one of the most difficult orthopedic conditions to treat, and it often takes several months to resolve. It is painful and limits your ability to grip and lift things during your daily activities.
Pain and the Gate Control Theory
Pain is usually the primary complaint that people have during an injury even when experiencing weakness, limited motion, and swelling. There are entire fields of study that focus on the causes, interpretation, and management of pain. Thousands of devices and medications claim to relieve pain and allow you to return to your normal activities.
Many of these products cite the gate control theory of pain as the basis of their effectiveness.
The proposed mechanisms of the gate control theory of pain are beyond the scope of this article, but a basic model will help you understand the rationale. This theory states that non-painful stimuli travel along your sensory nerves and get the brain faster than painful (noxious) stimuli that travel along the nociceptive (pain) nerves.
When your brain processes the non-painful stimulus, an inhibitory interneuron fires to block other stimuli including painful sensations. A practical explanation is your natural tendency to squeeze your thumb when you accidentally hit it with a hammer. The pressure and touch sensations travel to your brain faster than the pain sensation. This blocks the feeling of pain and you only sense pressure in the thumb.
When you’re suffering from acute or chronic tennis elbow, you often feel significant tightness along the lateral (outside) aspect of your forearm. The tension generally worsens when you attempt to straighten your elbow – especially with your wrist bent. Tightness can be a cause or a symptom of tennis elbow.
Your wrist extensor muscles originate on outside of your elbow and travel along the top of your forearm. The tendons pass over the wrist extending across the back of your hand and into the fingers. If these muscles become tight from overuse, they create tension at the point of origin on the lateral side of the elbow. The constant pulling as your continue to perform your daily tasks causes inflammation of the area where the muscle attaches to the bone.
Tightness can also be a symptom associated with tennis elbow caused by muscle guarding. As you experience the pain, your muscles become tense as a protective response to prevent you from moving the area and creating more pain. Muscle guarding can start a protective response, but it can perpetuate your condition if it becomes chronic.
You’ve probably noticed that your forearm and grip feel weak when you have tennis elbow. The weakness can be caused by injury to the muscle tissue (e.g., muscle strain), but it can also come from your response to the pain. When you experience pain, your body may shut down the muscles around the area to prevent further injury and to avoid continued painful movements. This response is like turning off the switch that activates muscle contraction.
Muscle guarding, as described above, is another pain response that can cause weakness. If you’re experiencing significant muscle guarding, your muscles are unable to relax causing a constant shortened state of the contractile units of the muscle, called sarcomeres. Muscular force is normally generated when the ends of the sarcomeres (Z lines) are drawn closer together and the sarcomeres become shorter. In the case of muscle guarding, the sarcomeres stay in a shortened state with minimal ability to change length so very little force can be generated.
Topical Creams & Lotions
Topical creams and lotions that claim to relieve pain have been used for decades. Most of these products do nothing more than stimulate the sensory nerves of the skin and decrease pain by the gate control theory. They often include ingredients such as menthol or camphor that cause a cooling or warming sensation. Some topical agents include non-steroidal anti-inflammatory drugs (NSAIDs) like Voltaren or Ibuprofen.
These agents can be helpful in the short-term, but the effects are temporary and there is no long-term resolution of the condition. The primary purpose of most topical products is to relieve pain so you can perform corrective exercises and your usual daily activities with less restriction. Creams and gels that contain NSAIDs, such as Voltaren, are more effective in relieving localized inflammation. When using topical agents, remember that the actual cause of the condition is not addressed and you may continue to suffer from symptoms.
Elbow Straps and Braces
Elbow straps and braces are a popular way to manage tennis elbow symptoms. However, they can be ineffective and possibly slow the healing process when the devices are poorly designed or improperly used. If you decide to try one of these products, be careful to choose one that is well made and is the appropriate type for your condition.
You’ve probably seen someone with tennis elbow wearing a single strap around the upper part of her forearm, just below the elbow. Some of these devices have a pad or cushion while others are just a strap. The rationale for elbow straps is that they redirect the force in your forearm muscles to the point of compression under strap. As you move your wrist and grip with your hand, the tension in the forearm muscles pulls against the strap instead of the muscle’s attachment to the bone.
Elbow straps function much like a guitar player’s fingers on the fret board. As the finger presses the string, the point of tension changes from the nut at the end of the guitar neck to the point of finger contact. In this analogy, the finger would be the elbow strap changing the tension on the guitar string at the nut.
Product design can influence the effectiveness and relative risk of using elbow straps. Many companies offer basic straps that wrap around your forearm and secure with Velcro. This design not only compresses the forearm muscles (the desired effect), but also compresses all of the tissue in the forearm. The force is not focused over the muscle, but rather it is dispersed around the upper forearm which may reduce the benefits of wearing this device.
Basic elbow straps may also compress the nerves and blood vessels in the forearm. This can cause tingling, numbness, or weakness in the forearm and hand. The generalized compression may also lead to reduced blood flood and slower healing time – especially in the case of muscle strains and tears.
The Aircast Pneumatic Armband and Proband BandIT are examples of elbow straps with pads that allow you to direct the force over the specific muscle area. This design reduces the amount of compression in other tissues and limits the risk for negative effects. Although this type of elbow strap might be more expensive, it can be more effective than a strap alone.
Elbow braces are also designed to reduce irritation of the injured forearm muscles, but the approach is a bit different. They immobilize the elbow to prevent motion that could put stress on the tissues. Some braces have an adjustable range of motion, while others are set in a fixed position. They often involve some type of compression similar to elbow straps. In the case of muscle tears, elbow braces can support the healing process by limiting motion and preventing further injury. However, they should only be used for a short time to prevent stiffness and formation of troublesome scar tissue.
Straps and braces can be helpful when you need to perform your daily activities, but they should not be the primary treatment method for tennis elbow. They can give temporary pain relief and briefly improve your strength. However, they should only be used for a short time to relieve symptoms and to prevent further injury.
Home Therapeutic Modalities
Therapeutic modalities are commonly used in rehabilitation clinics to relieve pain, decrease inflammation, and support tissue healing. Over the last decade, many of these treatment options have become available for home use. Some of these products are inexpensive and easy to use, but others have questionable effectiveness and can be quite costly.
Thermal Packs and Wraps
Thermal packs and wraps are one of the oldest forms of home self-treatment. These include heating pads and cold packs, but the category has expanded to include “electromagnetic” hot packs and cold packs with compression. While these modalities can be effective for temporary symptom relief, many companies use exaggerated claims to market their products.
Heating pads, like this one, have been around for many years and are often the “go to” treatment option for many musculoskeletal injuries. They are a type of superficial heat that increases surface tissue temperature and increases blood flow to the skin. The warming sensation has also been shown to reduce muscle guarding.
A relatively new type of “electromagnetic” heat wrap has entered the market. These devices claim to penetrate into deep tissues where the energy waves are converted into heat energy. The heat energy stimulates blood flow, clears toxins, and improves tissue healing. The rationale for these products is similar to diathermy, a clinical modality diathermy sometimes used by physical and occupational therapists.
Electromagnetic heat wraps have slick marketing and apparent testimonials, but they can cost as much as $200 and their clinical effectiveness has not been proven. Although heat therapy can be helpful in reducing pain and improving flexibility, caution should be used in the acute stage of tennis elbow. If you apply heat to an injury with acute inflammation, you could experience increased pain, muscle guarding, and swelling.
Cold packs are the treatment of choice for most acute injuries, especially when rapid swelling occurs. If your tennis elbow started after playing sports and doing yard work, your first thought was probably to apply a cold pack to reduce pain and swelling. This is a sound choice in the early stage. Cold packs (also called cryotherapy) reduce tissue temperature, slow local blood flow, and decrease pain intensity.
Newer cryotherapy treatment options add compression to help the cold penetrate deeper and to improve management of swelling. The compressive force squeezes the tissue and pushes the excess fluid away from the injured area. Some of these units offer static compression while others deliver sequential compression.
Static compression means that the force doesn’t change once it’s applied. In sequential compression, the wraps fill from one end to the other. For tennis elbow, the wrap would begin to fill over the forearm, then continue to fill to the middle of your upper arm. The compression can be created by the pressure from cold water or by air that is pumped into the wrap by a control unit. There is some evidence for the effectiveness of adding compression with cold for acute injuries, but the long-term difference may not justify the expense.
Thermal packs and wraps can be effective for managing pain and tightness in tennis elbow. However, their effect is usually temporary and doesn’t cure the problem. You should be careful in monitoring the temperature of hot or cold modalities to prevent additional injury.
Electrical Stimulation – TENs and NMES
Electrical stimulation has been used for decades to treat many conditions including musculoskeletal injuries, neurological conditions, and even mental illness. It has been shown to be effective for reducing pain and improving strength in musculoskeletal injuries. There are many types of electrical stimulation, but the most commonly used forms for musculoskeletal injuries are TENs and NMES.
Transcutaneous electrical nerve stimulation (TENS) is a sensory stimulation based on the gate control theory of pain. The idea is to stimulate the painful area with an electrical current that is stronger than the pain signal felt. The sensation is like a tingling massage on the skin and in the superficial muscles.
Like thermal modalities, TENS can be effective in temporarily reducing pain while you perform daily tasks. There may be brief carry over when the TENS is stopped, but there is generally no long-term symptom relief.
Neuromuscular electrical stimulation (NMES) is another form of electrotherapy, but it focuses more on recovering strength in injured muscle. While you will still feel the tingling sensation, NMES is a stronger current that can cause muscle contraction. If you’ve suffered from tennis elbow for a long time and have developed disuse atrophy, NMES can help you regain your strength. It has only been shown to be effective in increasing strength for injured muscle contrary to some product claims.
In a clinical setting, TENS and NMES are effective modalities used to reduce pain and to regain strength. However, the models sold for home use often use inferior components and are not able to deliver the appropriate current to get results. TENS is primarily for symptoms management, but it does not promote healing or cure tennis elbow. NMES can improve strength, but the stronger current can be more difficult to tolerate. As with thermal modalities, you should be careful when using TENS or NMES at home to avoid further injury.
If you’d like to give one of these a try, here is one on Amazon.
Home ultrasound units
Ultrasound is a commonly used modality for treating tendinitis and other orthopedic conditions. However, the research shows questionable effectiveness in reducing inflammation and promoting healing. While it has been shown to increase deeper tissue temperatures, this can be a bad thing if you are experiencing acute inflammation because it can worsen your symptoms.
Recently, smaller ultrasound units have become available for home use, like this one. They claim to offer the same effects of the medical grade models, but some sales copy exaggerates the benefits. Many products target tennis elbow specifically as “one of the most effective treatment options,” however, ultrasound has not been shown to be clinically effective for tennis elbow.
Home ultrasound units can cost several hundreds of dollars. They can also be very dangerous if you don’t understand the risks. The ultrasound head must keep moving slowly over the tissue to avoid burning deeper tissues including periosteum of the bone. This can be particularly dangerous in the elbow region because the bones are close to the surface of the skin. Home ultrasound units should be avoided because of the lack of proven effectiveness, expense, and risk for injury.
What Does All of This Mean?
There are many options for self-treatment of tennis elbow. Some products, such as elbow straps and topical creams, offer temporary symptom relief with little risk of further injury. They may also allow you to perform your daily activities with less pain.
Home therapeutic modalities can be beneficial in decreasing pain, reducing swelling, and improving strength. However, they have questionable effectiveness, higher cost, and greater risk for further injury. If you decide to treat your own tennis elbow, you should do your research so you can make informed choices and consult a health care provider before you begin.