Here's What ACTUALLY Causes Tennis Elbow, Diagnoses, And Treatment

Show Notes

In this episode of the Dr. JJ Thomas Podcast, we dive deep into the complexities of tennis elbow, a condition that often becomes a chronic struggle for many. I share my insights on the mechanical and neurological factors that contribute to this persistent pain, emphasizing the importance of a comprehensive approach to treatment. My goal is to help you and your patients find more effective paths to recovery, ensuring a quicker return to daily activities and overall well-being. Join me as we unravel the mysteries of tennis elbow together, fostering a deeper understanding and more caring approach to healing.

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What is The Dr. JJ Thomas Podcast?

Welcome to The Dr. JJ Thomas Podcast! Here I'll be talking all things physical therapy, raw and unplugged, giving you the unfiltered insights you've been searching for in your cash-based physical therapy business. If you're caught in the grind of the traditional model, swamped with paperwork, or feeling like you're not reaching your full potential as a physical therapist, this podcast was created just for you.

Dr. JJ Thomas: 00:00

So from a mechanical perspective, remember, an overuse injury isn't just that somebody swung a racket too many times. Yes. It is. But the consequences that come from swinging a racket too many times are breakdown in other related muscles that relate mechanically and, myotomally to that, to that area of the body. Welcome to the doctor JJ Thomas podcast.

Dr. JJ Thomas: 00:30

Hey, everybody. Welcome to the doctor JJ Thomas podcast. I'm JJ Thomas. Today, we're gonna do a clinical rounds format again. This episode is gonna be solely focused around helping you guys work with patients that have the classic not the classic, actually, have that tennis elbow.

Dr. JJ Thomas: 00:48

And what's classic about it, this lateral epicondylitis, is that I'd say it's one of the most commonly, seen injuries or, issues that PTs and patients have a hard time getting better from. So it's one of those injuries that just turns into chronic. And despite the fact that patients feel like they're doing everything they can and therapists feel like they're doing everything they can and docs are doing everything they can, it's one of those injuries that just often persists and persists and persists. And so today, we're gonna break through reasons why certain people have persistent elbow pain, especially in the lateral elbow, and how we can really investigate other underlying predisposing factors and causes. And by taking that information, we can get them better faster.

Dr. JJ Thomas: 01:39

So let's break into it. 1st, we're gonna talk about the there's 2 main musculoskeletal reasons why someone would have pain in the lateral elbow. Right? There's either a a true musculotendinous injury, tissue breakdown at that site, so somatic pain, or there's a nerve there's a nerve signal that's creating pain and an inflammatory response at that elbow as well. Those two scenarios can be broken down further to really investigate what's actually causing this person's pain and dysfunction and really help us break through how to get them past it and back to their function.

Dr. JJ Thomas: 02:18

So let's start with the first one. Let's start with the mechanical breakdown one. As a therapist, one of our most important jobs when dealing with a mechanically, induced injury is to really investigate how that injury came to be and what factors predispose them to that. We know that if it's a true mechanical inflammatory pain and injured site at the lateral elbow, at the common extensor tendons of the wrist extensors, then what we're gonna see is inflammation, tissue breakdown, a pain response. All of those things are real.

Dr. JJ Thomas: 02:52

It can be palpated. Right? We're gonna see pain with resisted extension. We are gonna see all those things for sure. But what we need to investigate further in order to get them not just to heal this area, but to heal the reason why they have the injury in the 1st place, what we have to do is really investigate what factors led them to have this breakdown injury in the first place.

Dr. JJ Thomas: 03:14

So as we know, not all tennis elbow injuries are actually in in people that actually play tennis. But let's take a tennis example for exam let's take a tennis example. If a tennis player comes to me and they say, oh my gosh, JJ, I've had this tennis elbow pain. It's unrelenting. I've had it for, you know, almost a year now.

Dr. JJ Thomas: 03:35

I've had an injection. I've seen other therapists. This is a real life scenario. This happens pretty often. And then I start asking questions like, okay.

Dr. JJ Thomas: 03:43

What was different around the time that that came on? We we have to know, environmental factors that could have contributed to this overuse injury. So did they change their racket type? Did they have their grip changed? Did they change their strings in the racket?

Dr. JJ Thomas: 03:58

All of these equipment changes are really relevant and important to really investigating and uncovering other causes that led to this tissue breakdown. Once we start to investigate those things, then we know, for instance, if they change their grip, if they they had their, racket regripped recently, then we know that potentially we're gonna take an extra look at the wrist flexors. Right? Because we changed the grip position, and now that puts increased stress on the on the elbow. How many patients have you guys had that, that come in and their lateral elbow pain, they one of the classic signs they say is, you know what really kills me is when I go to reach for my coffee cup, usually, it's the right hand, when I go to reach for my coffee cup out of the car.

Dr. JJ Thomas: 04:44

Right? They're gripping with their finger flexors. Ding. Your light bulb should go off right there. Okay.

Dr. JJ Thomas: 04:50

I really wanna make sure I'm checking the app the antagonistic side of the wrist extensors. I wanna check those wrist flexors. I think for some reason, PTs, all clinicians, often forget that the body has these general rules that can be applied to to at each joint. So think about, for example, the knee. If you had someone come to you with patellofemoral pain, you're gonna a 100% address tightnesses, weaknesses, deficits on both sides.

Dr. JJ Thomas: 05:21

Right? So if they have patellofemoral pain, you're not gonna just stretch their quads. You're not just gonna check their knee flexion range of motion. You're 100% gonna check their hamstring flexibility. And you're if there's a deficit there, you're gonna treat it.

Dr. JJ Thomas: 05:35

The lateral elbow, a mechanically driven pain at the lateral elbow is a 100% the same. So I find a lot of therapists that will treat this, and I'll I'll see and I'll hear that they're I'm massaging the heck out of this common extensor tendon. I'm massaging the entire belly and doing needling to the entire muscle belly of the wrist extensors. Great. But we have to take it a step further and make sure we're cleaning out the wrist flexors.

Dr. JJ Thomas: 06:03

One of the most commonly missed things that I see when patients come to me after failed treatment other places is that the wrist flexion range of motion is is very limited. We have to restore that in order to improve the mechanics at the elbow. So that's the first mechanical thing we need to remember. The second mechanical driver that is often, important to to rule out or uncover is a potential dysfunction at the rotator cuff. Whether or not they're tennis players, our entire society ends up having rotator cuff issues.

Dr. JJ Thomas: 06:35

Why is that? Well, I'm sitting in this couch. We're often sitting in chairs all day long. Many of us end up rounding like this. Right?

Dr. JJ Thomas: 06:44

Our rotator cuff tends to get shortened here, most of it. We're pulling into actually a protracted scapula, and our posterior cuff gets tightened down. Now in other activities, we wanna function by using a rotator cuff, and and we can do it. Also, at this position with our rotator cuff, our shoulder blade not set in the right position, our elbow is now gonna be at a mechanical disadvantage. So as therapists, it's our duty, even with mechanically driven lateral elbow pain and dysfunction, we have to clear out the rotator cuff.

Dr. JJ Thomas: 07:23

I'm gonna I'm gonna bring another concept in here that is still mechanically oriented, but it's, it's slightly outside the mechanical box in that I want you to start conceptualizing both a mechanical relevance and a neurological relevance to the rotator cuff as it relates to the elbow. So, if you're if you're a patient listening this, please forgive me for all the all the words. Right? But as you clinicians, you a 100% get this, and I'm gonna I'm gonna recap it at the end for those of you that are actually, potential patients. So if we think about the nervous system level of control of the rotator cuff, the infraspinatus and supraspinatus, some of the primary external rotators, are controlled by c 56 in the cervical spine.

Dr. JJ Thomas: 08:08

In addition, now I want you to think about what level of the cervical spine refers pain to the lateral elbow. It's c 6. Right? So if we look at a referred pain pattern here of this is infraspinatus. It makes sense to see that c 5 is at the deltoid region.

Dr. JJ Thomas: 08:26

A c 5 referral dermatomal pattern is at the is at the deltoid, and c 6 is at the lateral elbow and down into the thumb. Right? We know that c 6 distribution when we're clearing neck, dysfunction or underlying neck pathology, we're gonna look at c 6 at the lateral elbow and into the thumb. Infraspinatus has that same referral pattern because it's a c 56 controlled muscle. This is true through every muscle in the body.

Dr. JJ Thomas: 08:54

Muscle referral patterns are a reflection of that level of nervous system control. The only way our brain, our body can actually, give us an alarm system that there's something wrong in an area is through the nervous system. So even for a mechanically driven, issue at the lateral elbow, you have to consider other c 56 muscles as contributing factors because they can produce symptoms and dysfunction in terms of, vascular blood flow to that area in that same pathology. So for lateral elbow pain, remember to consider other mechanical factors, including rotator cuff pathology that will mechanically put them at a disadvantage. So from a mechanical perspective, remember an overuse injury isn't just that somebody swung a racket too many times.

Dr. JJ Thomas: 09:46

Yes. It is. But the consequences that come from swinging a racket too many times are breakdown in other related muscles that relate mechanically and, myotomally to that, to that area of the body. So that's the mechanically driven lateral elbow pain. Remember not to just get so honed in and focused on just the lateral elbow when you're treating lateral epicondylitis, even if it truly is mechanically driven.

Dr. JJ Thomas: 10:17

Now, hopefully, that all made sense. We brought in some nervous system issues related to that, but remember that even with the rotator cuff pathology that I'm talking about there, I'm still not talking about true nerve driven elbow pain. That's what we're gonna talk about now. So the other reasons for lateral elbow pain, for unrelenting tennis elbow that's not responding to treatment is a true, refer to radicular pain from a nerve root from c 6 or a nerve pain related to an entrapped nerve, which would be the radial nerve. So now we're gonna talk about how to differentiate between a nerve driven, pain due to an entrapment at the neck at c 56 or really c 6, and a entrapment peripherally of the radial nerve.

Dr. JJ Thomas: 11:12

Okay? So for the to rule out the c 6 component of the elbow pain, and I just wanna back up for a second and say, for younger clinicians that don't have the experience of ruling out an underlying c 6 pathology, I want you to recognize, that when a patient comes in and they're like, oh my god. I hurt here. I can feel it. I can touch it.

Dr. JJ Thomas: 11:36

It is painful right here. And you feel it, and you're like, wow. Yes. I feel it's inflamed there. I feel it's tight there.

Dr. JJ Thomas: 11:43

I feel it's painful there. I'm able to reproduce their pain. That doesn't mean that alone, just because you touched their pain at the elbow, still does not mean that it is not driven by a more proximal nerve, pathology. So we can't stop at the elbow here. Just because they have pain with resisted extension, yes, that does mean that they have a mechanically driven pain with with the common extensor mechanism being painful on resistance.

Dr. JJ Thomas: 12:10

However, we still don't know by doing this test if there's an underlying nerve root pathology that has made this elbow susceptible to breakdown because of lack of neurovascular supply to that elbow, essentially. So taking that knowledge and now really seeding through more information so that we can find true underlying pathology is what's gonna set you apart from other therapists. So to delineate between a c 6 pathology and a radial nerve entrapment, what we have to do is go back to our foundational neuroscreen, and we're not gonna go through the entire neuroscreen here. But what we're gonna do is look at what other ways can we identify if there's a c six pathology that's creating this pain in the lateral elbow. So if you remember from our from PT school, from our original education, c 6 is gonna be controlled is going to control wrist extension, and it's also gonna control subscapularis.

Dr. JJ Thomas: 13:07

So one of the ways we can try to identify if there's an underlying, pathology at the c 6 at the level of the of the neck, then what we're gonna do is test both of those. And we need to test them for fatigability. And if you're not familiar with the term fatigability, fatigability is a way that we test strength in a muscle. But in a in the way that we do it, we'll test actually the nerve's capacity versus outlying strength. So we're not just gonna test a muscle and and see how, quote, strong they are.

Dr. JJ Thomas: 13:40

What we're gonna do is we're gonna take them in midrange. I usually like to have them lying on the table so everything else is fixed. They're gonna be lying on their back, kinda fixate them. Have the wrist go into mid range, and then stabilize their elbows so that they don't have to work hard there and they don't cheat by elbow flexing. And then you're just gonna resist wrist extension.

Dr. JJ Thomas: 13:58

I'm gonna bend my elbow so I can show you better, but, essentially, it's gonna be straight. The the wrist is gonna be in midrange, and and then you're gonna wrist extend. You're gonna hold them. You're gonna tell them, hold, hold, hold. Don't let me move you.

Dr. JJ Thomas: 14:10

But you're gonna hold it for a good 15 seconds and see if they fatigue out. That's fatigability. Right? Somebody might have have a short ability to burst, strengthen it, and hold it, but that's not gonna show how, well their nerve is conducting to the muscle. If they fatigue, that shows there's an issue there.

Dr. JJ Thomas: 14:30

There's an issue in the wrist extensors. Wrist extensors are fed by c 6, but they're also fed by the radial nerve. So if they have a fatigue ability with wrist extension, we know there's a nerve issue, but we don't know if it's c 6 or if it's radial nerve. So the next test we're gonna do is subscapularis. So they're gonna be supine again.

Dr. JJ Thomas: 14:50

You're gonna put them at the plane of scapula, and then you're gonna resist internal rotation for subscap. Subscap is a c 6 muscle, but it's not a radial nerve. So we're gonna put them in mid range, and we're gonna resist them. Hold me. Hold me.

Dr. JJ Thomas: 15:04

Don't let me move you. Don't let me move you. Don't let me move you. If they fatigue, now we know that there's an issue there too. Since subscap has a different peripheral nerve responsible for it, but has the same nerve root level of control, If they're both weak or not weak, if they both fatigue, then we know that we have a c 6 pathology.

Dr. JJ Thomas: 15:22

If wrist extension is limited in terms of fatigability, but subscapularis is not, then it's more likely a radial nerve entrapment. So that's how you're gonna delineate. I will say, in my experience, when a patient comes to me and they've they've failed treatment other places for their lateral epicondylitis, for their tennis elbow, and I check these things, there's oftentimes an underlying pathology either in the rotator cuff, which is what we talked about earlier, and or in in the corresponding nerves. And it's either c 6 or radial nerve. So it's really helpful to tease these things out.

Dr. JJ Thomas: 15:58

The last piece of this evaluation that I wanna help you with is if you decide that it if you confirm that it's a radial nerve entrapment responsible for their issues at the lateral elbow, We now have a couple sites that that could happen. So there's 2 sites that the radial nerve can get entrapped. 1 is at the shoulder at the triangle interval. And the triangle interval is if you look right here, it's where the teres major it it pokes through where teres major, the long head of the tricep, and the the humerus itself. That's what makes up the triangular interval, and the radial nerve peaks right through there.

Dr. JJ Thomas: 16:34

So you can imagine anyone that has tightness and protracted scapulae will have tightness in that teres major. And, additionally, if they have tightness in the long head of the tricep, they're getting they're basically choking out their nerve, and and the nerve can't get blood flow, and they're gonna feel it down at the at the elbow where the radial nerve has to feed to. So that's a number that's a number one hot spot. If you have a radial nerve entrapment, you need to go to teres major long headed tricep and clean up the rest of the cuff mechanics. That may also mean going to the front and treating the pecs, remember, because if they're pulling forward and their pecs are pulling forward, you can release the back all you want.

Dr. JJ Thomas: 17:14

But if you don't open up the pecs, they're still gonna end up falling back into that pattern and entrapping that radial nerve. The other site that it can get entrapped is, at the brachiali under the brachialis muscle. So the radial nerve in the front comes around and feeds the, obviously, feeds the elbow under the brachialis muscle. So if I remove, biceps brachii right here, And then the brachialis, look at this big hunk of a muscle right here. Radial nerve peaks out right there, right on the distal third, lateral portion.

Dr. JJ Thomas: 17:48

And so when you're checking their range of motion through both rotator shoulder range of motion, elbow range of motion. This is another reason why you have to remember that checking wrist flexion and elbow extension range of motion is super important because not only mechanically if they're limited wrist flexion, if wrist extension, wrist flexors, if they're limited, that's gonna mechanically put you at a disadvantage at the elbow. But neurologically, you're gonna you're gonna squish that nerve if they don't have full elbow extension. So all of these factors are really important to consider when looking at your lateral epicondylitis patient, when you're looking at that patient that has, quote, tennis elbow. And, really, if you can look at these things right from the get go, right from that first evaluation, rather than just honing in and focusing on the elbow without really looking to all the underlying factors from the start.

Dr. JJ Thomas: 18:43

When you can look at them from the start, you're gonna find that you can get your patients better so much faster. So thank you for joining me today. I know this was a lot of material. We'll have, recaps on it, and lots of clinical corners following up on it. So if you have any questions, please DM me, or leave messages in the comments, section below.

Dr. JJ Thomas: 19:03

And looking forward to working with you more. Let me know how it goes.