Tennis elbow is just the worst; especially since most people who develop it don’t even play tennis. Which, why would you when you can play the vastly superior sport of pickleball? That’s my stance at least, and if you disagree that’s ok, you are entitled to your own opinion (even though it’s wrong). Anyhow, what can be done to address tennis elbow? Believe it or not, one of the biggest things that my fellow clinicians and I find effective for patients is treating their mid back, the thoracic spine, and their shoulder blade. Let’s talk about why.
Tennis elbow is oftentimes characterized by pain on the outside of the elbow with gripping, grabbing, carrying, or picking things up. It is historically termed “lateral epicondylitis” but is now being called “lateral epicondylalgia” or, even more simply, “lateral elbow pain”. It can be very painful and sometimes it just aches most of the day. The main area of distress is the extensor muscles of the wrist which insert to your elbow via a large common tendon. This area can become very sensitive to the touch and painful with any activity. It is not just an inflamed tendon. The reason it is so sensitive is because it has turned into a chemical issue with the tendon, in which there are inflammatory mediators in the area (which cause pain), poorly aligned collagen fibers in the tendon, poor vascularity to the region, and hypersensitivity of the nerves.1 Basically the tissue hurts like the dickens because it is a bit of a hot mess and just not healthy.
But, there is hope! Some of the standard treatments recommended for tennis elbow are stretching and strengthening of the muscles.1 This is not necessarily a bad place to start, but it is very incomplete; research would agree as the outcomes are not great for people who only use these tools. Most of the time this is when the mid and upper back, aka the thoracic spine, and the shoulder blade are the missing pieces. The thoracic spine is responsible for a lot of the rotation and back bending (extension) we have through our trunk. This rotation is vital for allowing our shoulder blade to move smoothly and creating the proper positioning for the muscles that control the shoulder blade to do their job. There is a concept in physical therapy called the joint by joint approach that teaches us each section of joints in our body is designed to be either mobile or stable. If you had two or three stable sections lined up next to each other, you would not have any motion, hence the need for this design. Similarly if you had two or three mobile sections lined up next to each other you would not have any stability. We need both! We could go through every joint in the body, but let's focus on the area of discussion. Our thoracic spine is designed to be more mobile to create the aforementioned rotation and extension needed for daily life. Our shoulder blade needs to be stable to help control the upper extremity. The shoulder joint itself needs to be more mobile so we can reach behind our heads or backs or do something like throwing a ball. Our elbow needs to be more stable from a joint perspective since there are not a lot of large muscles to hold it in place.
Before I walk through a couple scenarios, I want to explain something I will be mentioning and that is the term “motor control”. There are two main categories when something does not move well. Mobility deficits and motor control deficits. Mobility problems are when something is not moving well because it does not have the available motion. Motor control problems are when a person has the available motion but does not know how to control or use that motion. An example of this is having a person laying on their stomach on a table and asking them to reach their palm up toward the ceiling. If they can only pick their arm up 6 inches off the table but I can lift it 12 inches for them with no problem, that would be considered a motor control deficit. A lot can be written about these two things, but we will start with this explanation for now.
There are a few scenarios in which these roles of mobility and stability get switched, one being shoulder instability. If you can't rotate through your thoracic spine due to stiffness or decreased motor control, your shoulder blade has to become more mobile in order to pick up the slack. This causes our shoulder blades to lose stability and control. This is not great for the arm because the shoulder blade is the platform from which the arm operates. The arm is controlled at the shoulder first before the elbow, so when the shoulder is too mobile or has poor motor control, the elbow again has to start picking up the slack. Imagine holding a broom stick with a pencil taped to the end. You have to hold the broom stick by the end of the handle and then reach out and write your name on a piece of paper taped to a wall. Pretty tough honestly! Now imagine trying to do the same thing except you have to use a skinny pool noodle instead of a broom. The hand writing will be much sloppier with the pool noodle because it is not as stable. This is similar to what happens with our elbow when we have an unstable shoulder. Just as the hand writing becomes sloppier, the control of our arm goes down and the elbow must work harder to make up for the loss of control. This is one way people can start developing lateral elbow pain.
Instead of instability, what happens when shoulder joint stiffness is the limiting factor? When the shoulder joint itself stiffens up, it is oftentimes accompanied by limited thoracic motion and shoulder blade hypermobility. This hypermobility at the shoulder blade is to compensate for the limited motion available at the shoulder joint. Our bodies like to cheat. If they can’t get the motion they need from one joint, they will compensate with another to get the job done. As we lose mobility in the shoulder we typically lose rotation of the shoulder. This forces us to have to work harder through our elbow to make up the difference from our shoulder joint not rotating. Our elbow also rotates in two motions called pronation and supination. Many daily tasks require this rotation through the shoulder and elbow (believe it or not typing on a computer requires it!). As we lose the rotation in our shoulder, the muscles in the elbow must work harder to achieve the same outcome. Imagine a company that makes some kind of product. Let’s say the CEO of this company fires 25% of his work force. He then tells the remaining 75% they must continue making the same number of products that they made prior to him firing the other 25%. That remaining group of employees is going to have to work wayyyyy harder than they did before to get the same result. This is basically what happens with the shoulder and the elbow when the shoulder or upper back is not working well.
As you can see in both scenarios, the thoracic spine and shoulder are the main focuses of the problem, not the elbow. Now sure, the elbow is where the symptoms show up, but this is not necessarily where the problems started, and it is certainly not the only thing that needs to be focused on. It is fine and dandy to do some stretching and strengthening around the elbow, but without restoring full motion and control to the thoracic spine and shoulder, we leave the rehab process very incomplete. If you are dealing with some elbow pain and just can't seem to shake it, please come see me or a physical therapist you trust. As minor as it may seem, these problems can sometimes grow into quite the mess. The good thing is God made our bodies to heal, and together we can get you back to living life pain free!
References
Lucado AM, Day JM, Vincent JI, et al. Lateral Elbow Pain and Muscle Function Impairments. J Orthop Sports Phys Ther. 2022;52(12):CPG1-CPG111. doi:10.2519/jospt.2022.0302
