Suzie Says...Got a Hurty Elbow?
Updated: Feb 23
Got a hurty elbow? ...and here I'm talking about the outside of the elbow. You may notice it when adjusting your shock pre-load, using the controls on your bike (clutch/front brake), having a pint down the bar or getting down to some self-loving ...the list goes on!
Here’s a quick guide to preventing and treating a hurty elbow or tennis elbow (aka lateral epicondylagia - LE). It is the most common condition that people suffer from related to the elbow. In fact, my partner Kelvin has this condition brought on by a sudden increase in activity, which in his case was prepping our bikes for travel in South America. Doh!
What is the issue? What is the tendon? (Common extensor tendon).
The tendon in question is a pretty important one and is responsible for (with the muscle of course) lifting your wrist up or bending it back, like when holding your phone to text/WhatsApp, or as the name suggests, playing tennis.
The tendon is the tough bit that connects your muscle to your bone.
Basically, a lot of evidence shows that in this condition there is some local tendinopathy (hurty tendon) primarily due to tendon degeneration (old fart tendon) with or without some kind of tear. It is not a joint problem. It is often a problem of tendon 'overload' e.g. suddenly working it too damn hard.
In England for example, we are sun-starved, so when the sun does raise it's perky head we all get out and make the most of it. This often means donning the garden gloves, cracking on with the weeding/planting/clearing etc. for as long as the sun lasts. Sometimes it may be as long as a whole weekend!!! Then, hey presto, the twinges start to creep in.
Who will likely get LE?
This is a common condition in adults. I have seen it myself mainly in those people who have a history of overuse of the tendon, so people with hands-on occupations that do a lot of gripping and twisting etc. It is prevalent in those who use their arms a lot, so I feel motorcyclists fall into that category, especially if you do a lot of work on your own bike or have the shit-poor luck of getting numerous punctures and you have to sort them out yourself.
Also, if you partake in the yucky habit of puffing on cigarettes, you will also be more prone to LE.
If you are one of those office-bound people but you suddenly take up a new hobby like tennis or welly-throwing (sudden overload), you don't need much 'overload' to land yourself a bit of a problem.
Sadly, most people think that it's easy peasy to treat as the presentation is quite (ish) straightforward, but it's misleading. It's actually quite difficult to treat. The tendons do become degenerative as part of the normal aging process and it does not always equal pain, and it doesn't have to 'heal' for the pain to go down.
Symptoms of LE:
It will often come on gradually. The pain is commonly located over the outer side of your elbow, or thereabouts.
You will often get a pain with gripping, especially with repetitive activity. Gripping with your hand turned down (back of hand to ceiling) can be even worse.
Sometimes, if it's really bad the pain can spread down your arm. If you get pins and needles or numbness in your hands, especially if it's getting worse, please get it checked out properly. Sometimes you can get a bit of nerve tension as well as a tendon issue, but 'nervy' symptoms need checking! Also, if you are getting loads of neck pain, get it checked properly.
What to do:
EXERCISE IS THE BEST OPTION!
The upper limbs are different to lower limbs...it is not no pain no gain, so the exercises should NOT be painful.
A little bit of discomfort is ok i.e. if you imagine '0' is no pain and '10' is the worst pain imaginable , DO NOT go over a 3/10 at most. Please note, this is ok during and a little after exercise but it should be pain free the next morning with the arm at rest. If it's still painful in the morning (arm/wrist rested), you are doing too much.
If the pain isn't bugging the rest of your arm (radiating), not affecting your beauty sleep and you just get it with activity, then taking some rest, moderating your activity and some exercises should take care of it. Injection therapies have not been found to be superior, especially in the long-term.
If it is a new pain/condition, it may be beneficial to take 6 weeks relative rest before starting exercises, but if you have been suffering with it for over 6-8 weeks, start with the exercises gently.
Using ice can also help (covered) for 10 minutes, minimum 2 hours between applications. Be careful not to get ice burns and regularly check the skin. DO NOT use ice if you have bad sensation in the area etc.
Static holds (Isometric exercises), particularly for irritable (worse) tendinopathy (4.) - Have your elbow bent to 90 degrees / right angle. Hold a weight (about 1-2Kg). You can also hold Theraband (other end under your foot) but when travelling, something weighty is probably easier to find. Your hand should be in a normal position i.e. hand on it's side, palm facing inwards. Have the hand over the edge of the table. Hold the weight still for 30-60 seconds if you can, without pain. Work upto 3 lots of 60 second holds, with 60 seconds of rest between each hold.
If the above is ok, start making it a bit harder by turning your hand down a little (pronation in Jargon-speak). Repeat the 3 x 60 second holds. You can progress this until your palm is facing all the way down (fully pronated), back of hand to ceiling.
If all this is still ok and pain free, do the exercise with your arm a little straighter (elbow slightly extended) during the exercise. You can progress this until your elbow is fully straightened. Same repetitions.
IF YOU GET TIRED OR GET PAIN...STOP!!! Reduce the repetitions, and slowly build up as tolerated. You can build up to as many 60 second holds as you can tolerate, without pain, to then work on your endurance.
Exercises with movement (Eccentric/Concentric exercises), particularly for less irritable or degenerative tendinopathy (4.) - Have your
hand over the edge of a table, wrist straight, elbow bent and hold on to a small weight (1-2Kg), palm down (back of hand to ceiling). Slowly lift your hand up as far as comfortable over a count of about 4 seconds. Then slowly lower it as far down as comfortable over a count of about 4 seconds. Repeat this up-to 10 times, then rest. Repeat the whole lot 2-3 times with rest of 1 to 2 minutes in between each set of 10.
You can progress this by either holding a heavier weight and/or having your elbow straighter. Remember, it should not cause pain and do not try to progress too quickly.
A combination of the above exercises has recently been found to be most effective for LE (3.)
To start, only exercise once a day.
You can do taping and mobilisations to help, however I will not be writing about these here as it is best to do this with a physio's guidance. At the end of the day, exercise has been shown to be the best medicine, with or without other stuff.
QUICK HELP: From my experience you can often use a 'tennis elbow' band to help take the load off or redistribute the load on the tendon. My partner is unable to rest his arm as he is on the motorbike most days (plus he's not the best at keeping to his exercises if truth be told) , but he uses the band every day, and he definitely finds that the tendon gets irritated a lot less when he has it on. You can buy them from many sports shops or pharmacies. We found one quite easily in a Colombian 'Drogueria'.
Please remember: this is one of those stubborn arse issues that won't respond overly quickly to rehab/treatment. If it's really bad, talk to a pharmacist/Doctor about some kind of pain pills.
Use pain as a guide...you do not need scans and stuff to see if it's getting better. If your pain is reducing, you are getting better.
What NOT to do:
Do not just crack on unless you really have to...often easier said than done, but if you want it to get better, battering it on a daily basis will not help.
Keep the 'No pain, no gain' brain at bay!
Try to avoid lifting things with a straight arm and forearm/hand face down, but regardless, just ease off the heavy lifting...no offering your old granny next door help with her shopping, or picking up your partner's bike!
Don't keep stretching it. Contrary to popular belief, stretching the forearm can cause more harm than good, so this is being recommended less and less from the latest evidence...good to know!
Stop succumbing to the morning glory gentlemen...use the other hand or get someone else to help (may be wishful thinking)!
Overall, try to avoid it...as always, prevention is better than cure. Sadly, we all age, so you can't help that (if you can you will be rich and can afford a live-in physio), but try not to suddenly increase the load on your tendons. That goes for all of them, but in this case, activities with lots of gripping.
If all else fails, a shot of vodka with a coffee and sugar coated lemon will do nicely! (FYI: Not evidence based...please consume alcohol sensibly...but it is weirdly nice as I discovered on my Colombian travels)!
Sources of evidence based information include:
Physioedge podcast #044 Dr Leanne Bisset (March 2016) - Lateral Elbow Pain Part 1
Physioedge podcast #045 Dr Leanne Bisset (April 2016) - Lateral Elbow Pain Part 2
Stasinopoulos, D. & Stasinopoulos, I. (2017). Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. Journal of Hand Therapy, 30(1):13-19.
Coombes, B., Bisset, L. & Vicenzino, B. (2015). Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. Journal of Orthopaedic and Sports Physical Therapy, 45(11): 938-949.
Please note, although it can be difficult when travelling, it's often beneficial to get a physiotherapy/professional assessment where possible, especially if symptoms are persisting or worsening.
Please e-mail me at firstname.lastname@example.org for any constructive comments/feedback or questions.