Chiropractic Care and Tennis Elbow

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Chiropractic Care and Tennis Elbow

Dr. David L. Phillips

I ran across an interesting article in the esteemed medical journal The Lancet a while ago on the subject of tennis elbow. Tennis elbow is an annoying and painful condition involving the outside aspect of the elbow. These jargonistic terms for common physical conditions can be very misleading to the average patient. Most often, if I am asked to examine someone's painful elbow and I declare the problem to be "tennis elbow", the patient very frequently responds, that they don't play tennis. The implication being that if s/he doesn't play tennis, how can it be possible to develop the condition?
This all too predictable response then requires me to explain that tennis elbow is in fact a tendonitis of the extensor muscles of the hand and wrist. It can develop from many activities involving lifting objects with one's palm facing down. For example, reaching over the front seat of your car to fetch a briefcase from the floor of the back seat is classic injury producing. The briefcase is simply too heavy to be grasped in this manner because, due to your body position, you get very little leverage from your shoulder muscles, and are forced to rely almost exclusively on the outside or extensor muscles of your elbow to do the work. This excessive pressure can cause a partial tearing of the tendinous insertions on the outside of the elbow. Most people do have these minor tears; just as so many of us have them in our shoulder muscles (rotator cuff tendonitis).
What makes one person's elbow sore, inflamed and painful, and others not, is either repetition of the stress, or lack of proper healing of the tendon, or a condition of increased tension in the extensor muscles. This latter condition of underlying tightness in the muscle delays healing by causing an aberrant and constant traction on the tear, thereby, not allowing proper healing to occur. Much like a cut is slow to heal if one continually separates the skin borders. In this case, as in the case of repetitive stress, you get partial healing, followed by partial tearing, followed by partial healing, etc. as the cycle goes on with the activities of daily life. The end-result is a scar that is jagged, uneven and one that has 'tight' sections and 'loose' sections.

A scar that has developed in this manner will cause pain and inflammation each time the muscle is used. At this point the patient complains that s/he cannot even pick up a cup of coffee or open a door without pain.

So much for the introduction to tennis elbow, now back to the Lancet (2002:359, pp 657-662) study. The authors of this article were attempting to discover which common therapy worked better for tennis elbow over the short term and the long term. The common therapies compared were corticosteroid injections (so-called cortisone shots), physiotherapy, and do nothing (i.e. rest followed by wait and see). As a side point, this article, and many others that I have read, are frequently vague as to exactly what physiotherapy treatment is administered. It's as if many medical personnel are unfamiliar with just what physiotherapists do. As if "physiotherapy" is a treatment all by itself, rather than being made up of many treatments i.e. ultrasound, traction, massage, joint mobilization, etc.
The study involved 185 patients randomly assigned to the 3 groups for 6 weeks. After 3, 6, 12, 26 and 52 weeks, a research physiotherapist who was unaware of which patient received which treatment assessed the severity of all 185 elbow complaints, their grip strength, and pressure pain threshold.

At 6 weeks, corticosteroid injections were reported to be significantly better than the other therapy options for all outcome measures. Success rates were 92% for the injections compared with 47% for physiotherapy and 32% for the wait-and-see policy. However, the recurrence rate in the injection group was high. Long-term differences between injections and physiotherapy were significantly in favour of physiotherapy. Success rates at 52 weeks were 91% for physiotherapy, and 83% for the wait-and-see group and only 69% for injections. Physiotherapy had better results than the do nothing group, however, the differences were not significant.

It really must suck to be a physiotherapist these days. Lately, I seem to be reading studies every week that examine the common treatments offered by physiotherapy and, quite frankly, they are found lacking in many cases. For example, when treating lower back conditions, both acute and subacute, most of their regular therapies are no longer recommended. These therapies include T.E.N.S., low volt and other electronic stimulation, traction, acupuncture, biofeedback, magnetic therapy, ultrasound, among others. Another study, reported in BMJ in 1998, discussing physiotherapy and shoulder pain found little scientific evidence to support the effectiveness of therapeutic interventions employed in treating this condition as well. This tennis elbow study is yet another that clearly shows physiotherapy to be little better than doing nothing.

Chiropractic care for tennis elbow is very effective and way better than doing nothing or waiting to see what happens. The secret to our success is manipulations or adjustments to the area of the spine that controls the nerve supply to the extensor tendons. This nerve supply, located in the lower neck, is the key to the healing of overly tight and internally tractioned muscles. By relieving the mechanical irritation to these nerves we can enhance recovery and speed the healing of painful tennis elbows. Once the nerve supply has been normalized, any of the usual physiotherapy treatments become far more effective, whether administered by a chiropractor, a physiotherapist or a massage therapist. If the nerve supply to the extensor muscles is not normalized, whatever therapy administered is doomed to failure as relapses are virtually inevitable.