Shift focus to shoulder muscle for treatment of tennis elbow

Pune: Sudha, a 28-year-old techie, suffered from pain in her right elbow for 11 months, during which she consulted nine specialists and tried almost all medical options, but to no avail.
She had almost given up hope for a cure when she was finally diagnosed with tennis elbow or lateral epicondylitis. With the right diagnosis, the pertinent treatment began and in no time, her condition improved.

Sudha’s case is not in isolation. Many patients of tennis elbow continue to suffer for months together, and even for years, as root cause of the malady is often missed, experts said.

Most importantly, tennis elbow has little to do with elbow, and results from weak rotator cuff muscle in the shoulder.

“The limitation of all the existing treatment options is that they largely focus on the elbow. The very fact that one menial condition has so many treatment options itself suggests that the root cause is often less understood,” orthopaedic surgeon Ashish Babhulkar told TOI.

After analyzing close to 400 patients over the last seven years, Babhulkar has established that this weak shoulder muscle is the causative factor in 99% of the patients suffering from the tennis elbow condition.

“I focus only on rotator cuff strengthening and scapular stabilisation exercise programme. Using this, we have so far recorded almost 99% success in people suffering from tennis elbow,” the surgeon said.

So, what is the best option for such patients?

Babhulkar said, “An exercise programme remains the most reliable, cost-effective and permanent solution to this vexing problem. The treating physiotherapist must focus on weak shoulder rotator cuff muscle to arrive at the complete resolution of the problem.”

He added that the diagnosis of tennis elbow can also be confirmed following clinical examination and there is no need to go in for any “fancy investigation”.

Rarely, it is possible that the tennis elbow is resistant to rehabilitation even after attempting to strengthen the rotator cuff.

“In such circumstances, the rotator cuff has a partial tear or there could be neurological weakness of the rotator cuff,” he said.

The common clinical problem has experts struggling not only in India, but elsewhere as well. “It is a common practice for doctors to address the site of symptoms with various treatments,” said Aaron Sciascia, president of the American Society of Shoulder and Elbow Therapists.

However, the body works as a unit meaning that some joints become impaired when dysfunction exists elsewhere in the musculoskeletal system. “This concept of the body working as a unit (known as the kinetic chain) is the primary reason we attempt shoulder rehabilitation when a person has an elbow injury or complains of elbow pain,” Sciascia said.

However, in his treatment approach, Sciascia does not initially address the rotator cuff muscles. “Because in our experience, the scapular muscles, the core muscles, and/or the pelvic muscles tend to be weaker than the rotator cuff muscles,” said Sciascia, who is also assistant professor at Eastern Kentucky University in the US.

This approach to treatment of the arm is known as the kinetic chain-based approach.

Anatomically, the rotator cuff muscles are positioned on the scapula (shoulder blade) and are designed to stabilize and slightly move the humerus (long bone in the upper arm). The scapula itself is held to the body by a number of other muscles (not the four rotator cuff muscles) and when they are not optimized, the scapula becomes dysfunctional.

Stabilised scapula allows the rotator cuff muscles to generate approximately 24% more force compared to a non-stabilized scapula.

“In our treatment programmes for the upper extremity, we reserve rotator cuff strengthening for later in the rehabilitation process. Only after the scapula has demonstrated increased stability do we attempt rotator cuff strengthening exercises,” Sciascia said in an email response.