Joint problems are often to blame for tennis elbow

Tennis elbow is the most commonly diagnosed reason for elbow pain and one of the more frequently diagnosed conditions in the upper extremity. Also termed lateral epicondylitis, tennis elbow is estimated to affect 1–3% of the adult population each year. While up to 50% of all tennis players develop symptoms resembling tennis elbow, this condition is also seen in laborers who utilize heavy tools or engage in repetitive tasks involving gripping or lifting.

The diagnosis of tennis elbow is usually made when a patient presents with pain and tenderness on the outside of the elbow. Symptoms tend to be aggravated when performing gripping activities or activities that stress the muscles on the outside of the forearm. In addition, clinicians often employ specific orthopedic tests to arrive at this diagnosis.

Tennis elbow is classically thought to be due to irritation of forearm tendons as they attach around the elbow. This explanation, however, doesn’t align with the way many patients present, even those who exhibit the aforementioned diagnostic criteria for tennis elbow.

Tendon problems, whether in the elbow, knee, shoulder or another part of the body, tend to display a particular set of criteria:

• The pain provocation is very consistent. The same activities should produce similar symptoms every time a person does them.
• The pain is very localized. You can usually cover up the area of symptoms with a quarter.
• The pain worsens when more load is applied to the tendon.
• There is no passive motion loss at the affected joint. Someone else should be able to move the joint through its full range of motion without producing pain.
• There is no pain at rest. Loading of the affected tendon is required to elicit symptoms.

While there are exceptions, if all five features are not present, a tendon is unlikely to be the source of symptoms.

Interestingly, most patients diagnosed with tennis elbow don’t fit these criteria and, therefore, don’t respond when their condition is treated as a tendon problem. Instead, the source of symptoms in many of these patients is a problem with the elbow joint itself, which frequently mimics the presentation of tennis elbow.

Providers are often unaware that the elbow joint can be the source of pain, especially when patients present with signs, symptoms, and positive tests that strongly resemble tennis elbow. This cause of pain is a paradigm shift for many in healthcare and often isn’t considered, even after failed attempts at treating the condition as a tendon problem.

The following features are commonly seen when the elbow joint is the source of symptoms in tennis elbow:

• Elbow pain due to a joint problem often presents with an obstruction to motion. For example, when symptoms worsen, bending or straightening the elbow as far as the unaffected side becomes more difficult. This finding differs from a tendon problem, which doesn’t obstruct motion.
• Elbow pain due to a joint problem may have a variable presentation, meaning certain movements or activities sometimes hurt and other times do not. This variability differs from tendon problems, which tend to be consistent in their pain production.
• The pain from a joint problem may be felt in a broad area and might even move around (e.g., it is felt on the outside of the elbow one day and the front of the elbow on another day). This symptom pattern contrasts with a tendon problem, where the pain is localized to a single spot.

If your pain displays any of these features, it’s more likely that the elbow joint is the source of your symptoms.

People diagnosed with tennis elbow are often told to wear elbow braces to relieve the load on their tendons and are prescribed exercises to build up tendon strength and function. Not surprisingly, these interventions often fail to result in a positive outcome since the source of symptoms is usually not addressed.

On the other hand, treatment for an elbow joint problem would consist of performing a precise movement found to decrease symptoms and restore range of motion. This movement is termed a patient’s directional preference, and exercising in this direction can create profound and lasting improvements in their condition. The movement eliciting this response can differ between people, even those with similar symptoms. This individuality is why proper assessment and differentiation are crucial.

If you have been diagnosed with tennis elbow and haven’t improved with treatment, the focus of intervention may have been on the wrong source. Several diagnoses, including a problem with the elbow joint, can create symptoms that resemble tennis elbow. Therefore, accurate diagnosis is essential for effective treatment and a favorable outcome.

Dr. Jordan Duncan was born and raised in Kitsap County and graduated from the University of Western States in 2011 with a Doctor of Chiropractic Degree. He practices at Silverdale Sport and Spine. He is one of a small handful of chiropractors in Washington state to be credentialed in the McKenzie Method.