Elbow pain is surprisingly common affecting around 1-3% of the Australian population every year. The most common presentation of elbow pain in tennis elbow with golfers elbow is probably a distant second. Most presentations that I see as a physiotherapist tend to fit more within the overuse category. Of course, there are still acute injuries like fractures, tendon avulsion injuries, muscle strains or ruptures, but there appear to be far less common than overuse-style injuries at the elbow.
Unsurprisingly, elbow pain can cause a lot of functional deficits in everyday life. From simple things like opening a door, picking up some plates, opening a jar, and even typing on a computer or driving. Fractures often give us mobility deficits after coming out of casting if needed, tennis elbow stops us from gripping, and our hands do so much that we need our elbow to be working well to make it all happen.
Optimising the strength of the shoulder, elbow, wrist, hand and fingers is all necessary to ensure optimal recovery from an episode of elbow pain whether it be an overuse injury or an acute injury.
Just like everything else, understanding how the pain began is step number one when we are assessing elbow pain. If you’ve had more of a gradual slower onset of symptoms we’ll be looking for something that has changed recently. Maybe your boss has asked you to write up a big report at work and so you have doubled your time typing at work, or maybe you’ve decided you are going to DIY that deck at home and so every afternoon after work you are spending time on the tools that you weren’t before. Often in these cases, something will have changed in the lead-up to symptoms starting. If we are looking at an acute injury, we really want to get a good understanding of what happened and how it happened. Most higher-grade injuries such as fractures or tendon avulsions will display significant movement losses in certain movements, and as such these should be screened for and potentially sent for further imaging if needed.
Next up are the symptoms, getting an understanding of what the pain feels like and how it responds to different movements and positions is incredibly important. For example, a radial nerve issue will present with a very different type of pain and aggravating factors than a tennis elbow would, they would also have very different aggravating factors most likely. So understanding the nature of the symptoms is a key factor in helping me differentiate between different potential diagnoses.
I also want to understand you as a person, what you do for work, for hobbies, and around the home. The hands and by extension the elbow feed into everything. Perhaps you absolutely love playing squash and the tennis elbow is stopping you, or maybe you live by yourself and adore cooking and now you can’t open your jars (I can help you while I’m there, but outside of that opening the jars won’t be much fun). All of these are common reasons people will seek treatment, understanding what drives you gives us a goal to work towards.
Last but not least is whether you have any symptoms of nerve tension or compression. Nerve pain is a relatively common source of symptoms and could be coming from either the cervical spine or more distally at the elbow itself. If you have any sensations of numbness, weakness, tingling, pins and needles, or just odd sensations, passing these on is key. As this could potentially either change our diagnosis or open up other treatment options for you that may help alleviate your symptoms faster.
Assessing elbow pain requires specific diagnostic tests and clinical reasoning following the subjective portion of the assessment to come to an accurate diagnosis. Following the subjective assessment, we will have a number of potential diagnoses we will have to work with and assess to either rule in or rule out.
For acute injuries, we are often looking for changes in range of motion in particular planes as well as certain symptoms and history following the subjective portion. There are a few specific tests that we are able to perform but in most cases, imaging is often the best avenue to explore to adequately rule these in or out.
Cases of overuse and gradual onset pain can be much more challenging from a diagnostic perspective. The symptoms and history will lead us 75% of the way there but there is still plenty of work to be done. If we are looking at either a case of tennis elbow or golfers elbow we are looking for a quite distinct area of symptoms isolated around the origin point of the wrist extensor or wrist flexor tendons respectively. Most cases of these are able to be picked up with isolated muscle contractions, tests known as isometrics. Isolated contractions of these muscles load the affected tendons and muscles and should replicate your symptoms. For tennis elbow, the two tests I utilise are Cozen’s test and resisted extension of the 3rd finger. Both of these are incredibly good at detecting cases of tennis elbow in my experience. For golfers elbow often I will perform an isolated contraction of the wrist flexors to assess for pain recreation. If these tests are turning up negative but I’m still suspicious I might utilise Polk’s test. This test can be done for either tennis elbow or golfers elbow. It requires the client to lift a 2.5kg weight with the elbow pronated or supinated depending upon which group we are assessing.
Palpation of structures for elbow pain is actually quite a good assessment tool. For acute injuries such as fractures, we are able to palpate the bony structures of the forearm as well as the elbow joint which allows us to be quite specific with our potential diagnosis. For overuse injuries, palpation can give some really useful information. Tennis elbow clients hate me touching the sore part of the elbow, same with golfers elbow clients.
As we mentioned above, nerve pain can be quite a common presentation either referring to the elbow from the cervical spine or coming directly from the elbow itself. In most cases, I will perform some neurodynamic assessments as a clearing assessment, but if I really suspect it I will be spending a good amount of time clearing the cervical spine as well and on occasion a full neurological exam. Neurodynamic assessments are designed to assess the mobility of the neural system and determine any potential areas of restriction that may be causing neural referral. Clearing the cervical spine involves the use of cervical range of motion as well as palpation and assessment of the facet joints of the cervical spine assessing for pain to touch, stiffness, or in some cases referral of symptoms.
Treating elbow pain can be a little challenging at times. Often I like to work off of the basis of treating one thing on the initial consultation, particularly if we are managing an overuse injury. Whether I choose to treat the cervical spine because I think there is a nerve component to it, or I choose to treat the wrist extensors and maybe some joint mobilisations to treat the elbow directly, more often than not I choose to treat just one to avoid things getting too complex on a follow-up. Like if you get worse, which one made you worse, and if you get better, how do I know where to put the most time of treatment into to get our best effect?
Most commonly when looking at cases of overuse injuries I’m usually performing work on the muscles surrounding the elbow joint and doing mobilisations to optimise the movement and reduce stiffness at the elbow. Soft tissue techniques like massage and dry needling can be highly effective at reducing pain and improving freedom of movement to allow you to maximise the effects of an exercise program. Joint mobilisations are often my go-to for clients who have a movement restriction such as a restriction in turning the palm upwards. We can perform isolated mobilisations or we can perform a technique such as mobilisation with movement. This is a technique that performs a joint mobilisation as you move into the range of motion that is restricted and this is then repeated and reassessed to determine whether we had a lasting improvement.
Adjunct treatments like dry needling and taping can work wonders in these cases. In fact, when I had a small case of tennis elbow two years ago, dry needling was a bit of a saviour for me. Dry needling works well at reducing muscle tone in the short term, and it can work within a few minutes and will often be less irritable than what some hands-on techniques can be. Taping is the other adjunct I commonly use. Whether it be taping to improve joint positioning, or taping to unload a muscle in a tennis elbow case, there can often be effective and lasting results from a good taping job.
Life can get a little frustrating when you have an episode of elbow pain, suddenly you realise just how integral your elbow is. Just like when you realise how great it is not to have a stuffy nose when you get a cold it’s amazing how life can be when it starts to get better. So how can we get some quick wins on the board for elbow pain? Probably the best avenue is taping or bracing in my experience. For cases of tennis elbow – you can buy a tennis elbow brace either at the chemist or through me or basically any other physio and it should have a significant effect. Otherwise, there is a multitude of ways that you can strap a tennis elbow case to improve symptoms and functions, some tapings try to affect joint alignment and position, others will work to just simply deload the wrist extensors, whilst some cases could be driven higher up by the shoulder or cervical spine could respond really well to a shoulder taping. Other presentations can also respond well to taping, often with elbow joint-based presentations responding well to medial or lateral glide taping techniques.
Dry needling is the other technique I find is a really nice quick win for these cases, particularly in cases of tennis elbow or golfers elbow. Nobody is quite too certain what the true effects of dry needling are with a lot of different researchers proposing different hypotheses, but sometimes it just works, and if it works why stop?
Our 3-week program was designed for clients who have suffered an acute injury and want to get out of pain ASAP. This package could be suitable for clients who have sustained the recent onset elbow pain most likely due to tennis elbow or golfers elbow within the last month, or a recent acute injury to the elbow that has maintained most of their range of motion.
Our 3-week program is inclusive of the following:
Package price: $770
Our 6-week program is designed for clients who have sustained a higher-grade injury and want to not only rehabilitate their injury but also address causative factors and ensure a safe return to sport. Injuries such as either a more irritable or longer-term case of tennis elbow or golfers elbow between 1 and 4 months, or a more significant joint injury that has had minor to moderate loss of range of motion.
Our 6-week program is inclusive of the following:
Package price: $1050
Our 12-week program is designed for clients who have sustained higher-grade injuries and want to address causative factors but also want to return to sport as a more complete athlete than what they were when they got injured. Injuries such as a moderate to higher irritability tennis or golfers elbow or have been present for greater than 4 months or more significant joint-based injuries that have sustained moderate or higher loss of range of motion.
Our 12-week program is inclusive of the following: