Gloria came to see me because she had been struggling with pain on the inside and outside of her elbow for over a year. These problems are often referred to as “tennis” or “golfer’s elbow”, as tendon pain in these areas is commonly seen in these sports. However, in Gloria’s case, her elbow pain was preventing her from doing her gardening, and some of her fitness routine (pilates and weight-lifting). She went to see an orthopedic surgeon, who prescribed an oral steroid,  referred her for physical therapy, and scheduled a follow-up for 5 weeks. If she was not better by then, he planned to give her a steroid injection. After reading our online reviews, Gloria contacted me. We discussed her case over the phone and she scheduled an evaluation.

On examination, Gloria was found to have a full range of motion through her neck, shoulder, elbow, wrist, and hand. Nerve testing was negative, but all tests for lateral and medial elbow tendinopathy (tennis and golfer’s elbow) were positive. The insertions of these tendons at the elbow were also quite tender. I could not detect any notable weakness except when the arm was raised above the horizontal, which was consistent with her history as she struggled with heavier, fast loads in positions distant from the trunk.

Typically, if left untreated, the average recovery time for tennis elbow is about a year. But at the time I first saw her, Gloria had had the problem for more than a year and it persisted, so it seemed unlikely that the problem was going to resolve on its own. Research indicates that exercise is helpful for tendon pain, but our understanding of how to treat tendon pain is rapidly evolving, and often we don’t yet have a definitive answer for how to best treat a specific tendon injury. But thankfully, a recently published paper¹ gives some guidance on the best practice for tennis elbow. Long combinations of isometric, eccentric and concentric exercises were found to be effective compared to other exercise combinations 8-weeks after treatment had started (longer-term data is not yet available; rest assured I will be keeping an eye out for any updates as new research is published!)). So, I recommended we start with these exercises specifically targeting the elbow tendons. Gloria also had weakness in the shoulder above the horizontal, so it made sense to also strengthen the shoulder and trunk. I also recommended heavy load strengthening exercises for these.

During the evaluation, I tried a manual therapy technique called a “mobilization with movement” (MWM) and it gave some instantaneous relief. When a client has been experiencing debilitating pain for a long time, it can be hugely relieving to experience the instantaneous reduction or even elimination of pain that manual therapy treatments can sometimes provide. However, the relief they provide is only short-term – still helpful to provide comfort and reduce potential need for medication or injections while the body heals, but they do not actually heal the injury in and of themselves. Gloria and I discussed the need to avoid her becoming dependent on passive treatments like manual therapy and that true long-term recovery would come from an active, exercise-based approach. This empowered Gloria to be in control of her own recovery, rather than dependent on frequent appointments with me.We also discussed that having had pain for a year, recovery could be slow and would be influenced by changes in how her body processes pain (not just structural tendon tissue changes at the elbow).

Gloria also asked about the injection the doctor had proposed doing only five weeks after starting therapy. Current evidence does not support injecting steroids into or around the elbow tendons as an early treatment and could lead to worse outcomes. If she was significantly further down the road and had tried other less risky conservative options the potential risk of a steroid injection might be worth considering. But given that we were just starting a physical therapy plan of care that I expected to take at least a matter of months, I recommended that she delay any injections until we determined whether PT was helping her to recover.  You can read my summary of some recent research² on this topic below in the footnote* below, but here is a spoiler: “The physical therapy group had less use of pain and anti-inflammatory medicines, and had the lowest level of recurrence at 1 year (Recurrence of 5% for physical therapy, 20% for placebo injection, and 55% for corticosteroids)”.

Gloria returned 3 more times, for a total of 5 visits over a period of 5months. At discharge, she felt 98% better. Her only pain was occasional and was in a motion that she did not often experience and was not that notable, and will likely resolve as she continues to be active and improve strength.

If you have a problem that has persisted and is keeping you from living your life the way you want, send me a message or give me a call! If you are on the fence about physical therapy due to doubt, or past experience, we offer no-risk FREE screenings where we can meet and I will do some brief examination to determine if I can help you. If I can’t help I provide recommendations on which health professionals you might want to consider seeing.

Footnote:

*We have blogged about tendinopathy before, and the research is pretty clear that many of the “quick fixes” don’t address the true issue, or can even be negative. Current physical therapy research does not support the use of traditional treatment such as ultrasound, friction massage, and in some cases stretching (compressive tendinopathy). The research is also against more modern treatment such as assisted soft tissue mobilization (using a metal tool on the tendon to scrape already degenerative tissue!). In medicine, steroid injections have often been used because tendinopathy had been considered an inflammatory problem. However, these injections have not been found to be very effective as tendinopathy is a problem of cellular degeneration due to poor load management. The main degenerative change is to the collagen within tendon cells (We want healthy collagen as it makes tendons stiff so they can withstand load). The reason steroids are not particularly helpful is that when injected, they slow down the turnover (regeneration) of collagen cells. It seems that steroid injections are actually not good for tendons! A recent study² compared steroid injection with placebo injection or physiotherapy. They found that 1 year following steroid injection patients had worse outcomes than those who had a placebo injection. Those who had the steroid injection were also more likely to have a recurrence of symptoms. The physical therapy group had less use of pain and anti-inflammatory medicines and had the lowest level of recurrence at 1 year (Recurrence of 5% for physical therapy, 20% for placebo injection, and 55% for corticosteroids).

References:

1. Stasinopoulos D, Stasinopoulos I. Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. J Hand Ther. 2017;30(1):13-19.
2. Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461-9.