A self help guide to beating tennis elbow
Imagine this scenario (it probably applies to most of us!)...
A while ago you may have hurt a muscle, or been in a stressful situation for a bit too long. Your muscles tensed up in an automatic protective response to limit range of movement (ROM) so as to prevent further injury. To free up your conscious mind, your sub-conscious mind took over the job of maintaining the tension. Some time has passed, the injury has healed, and the need for the ROM limiting tension is no longer there. You try to relax the muscle to stretch it, but because the sub-conscious mind is still fighting against you to restrict ROM, it hurts. The sub-conscious mind wins, and another "stiff muscle" develops as we get older. Its now time to re-program the sub-conscious mind to let go the tension, but this can be very difficult because most people don't know it needs to be done, let alone how to do it!
Re-programming the sub-conscious mind is a bit like self hypnosis. Before you can send a message to your sub-conscious mind to re-program it, you have to believe it first! You have to genuinely believe that its not going to hurt if you relax and let that muscle stretch - and that's hard to do if its got a recent history of hurting every time. The best way to stretch tight muscles is to take the time to totally relax first, using as many techniques at your disposal as necessary. Wear loose, warm clothing. Warm up the muscles before stretching with heat or exercise. Get as comfortable as possible, with soft padded support under all areas subject to local pressure forces - the sofa could be ideal. You need a relaxing environment with no interruptions. Think relaxing thoughts - relaxing music or relaxation tapes can be useful.
All this leads up to the most important point I have saved for last - consciously relax when stretching (breathing out helps) to release all tension and pain. If you are conscious of the possibility of overstretching, you will probably subconsciously tense up, so make sure your muscles are fully supported to prevent overstretching - preferably with soft firm padding. Also make sure that you have no unpleasant pain (sometimes a mild "stretch pain" can feel good and this is ok). The ROM of your stretch should not exceed your pain threshold if you want to successfully re-program your sub-conscious mind into "permanently" releasing the protective spasm.
Use the "contract-relax" method of stretching (described below) - it is probably the most efficient and effective method developed to date.
All muscles, particularly those that are damaged, should be protected from excessive overload at all times. In some cases, support systems such as braces may be appropriate.
Stretching and strengthening exercises can be a useful part of the rehabilitation process because controlled loading improves collagen alignment of the tendon and stimulates collagen cross-linkage formation, which improves tensile strength. It is important that the state of the muscle/tendon injury is given due consideration when prescribing the loading forces. The exercises should focus on improving the flexibility, strength, power and endurance of the entire muscle-tendon unit. The duration of this program would generally be at least 12 weeks.
Before starting any specific forearm exercises it recommended to loosen up the neck, shoulders, upper back and chest muscles with a hot shower or bath, followed by a few stretching exercises. After that, it is beneficial to heat the most problematic area (probably the wrist extensor muscles in the elbow region) before stretching, to improve its ability to stretch. Heat to 390 C to 430 C - the warmer the better. For best results follow up with tissue cooling prior to stretch release on the last passive stretch. Cooling the muscle to normal temperatures (370 C or less) before releasing the tension allows the passive stretch to be held longer and apparently allows the collagenous microstructure to restabilise in its new stretched length.
Check with your therapist to make sure you are ready for these stretching or strengthening exercises.
The exercises described below should be done carefully and are based on the well established principle of progressive overload to gradually improve both strength and flexibility. As a rule of thumb, don't exceed pain-free muscle loading or stretching by more than 5%. In other words, slowly stretch further (or push harder) until extremely slight pain is felt, then go a comfortable small margin past this point. These pain levels should not be unpleasant. If your injury is substantial, expect the flexibility and strength to be low, and the appropriate amount of "overload" will also be small. Progress will be slow and patience is required.
Stretching the wrist extensor group using the widely used "contract-relax" method provides the benefit of also strengthening the extensor muscles and the damaged extensor group tendon. A typical exercise is shown in the first photograph below for a right arm injury. First gently stretch the extensor group with the method as shown below - note that your range of movement will probably be less than that shown in the photograph if you are injured. Notice that the hand has also been rotated so the little finger approaches horizontal - this also stretches the elbow supinator muscle which is commonly involved in tennis elbow injuries. Hold the stretch position for about 30 seconds or 5 slow breaths. Next (while breathing out slowly through the nose) push carefully with a very light effort for about 5 seconds with the back of the right hand against the left hand, which is held steady. After that slowly breathe in through the nose, then breathe out slowly through the mouth and at the same time gently stretch a little further (try to relax and release any tension). Hold for one slow breath cycle, then repeat the procedure two more times. Unless you have overdone the stretch, you should be able to hold the last stretch position for 30 seconds or 5 slow breaths. I like to finish off with a slow "yawn stretch" to further accentuate the stretch, using the antagonist muscles to create the additional movement (reciprocal inhibition). Repeat the exercises twice a week. Allow about 3 days rest between exercise sessions.
A strengthening exercise for the wrist flexor group is shown in the next two photographs. Push from position 1 to position 2, with the left hand providing a resistance force which allows a pain free movement. The right hand would be typically pressing with approximately 20 to 30 percent of full strength, but this could be significantly less for more severe injuries. The number of repetitions would also vary with the severity of the injury, but would typically be one to three sets of 6 repetitions, building to 12 repetitions, done twice a week. Allow about 3 days rest between exercises. Using position 1, the contract-relax method can be used as described earlier for the wrist extensor group to provide a stretching exercise for the wrist flexor group. This exercise can be useful for carpal tunnel injuries. A more comprehensive set of exercises for the arm and hand, and a method of doing them can be seen in an excellent book by Kit Laughlin, see reference 2 below.
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| Stretch for extensor tendon | Strengthening - position 1 | Strengthening - position 2 |
References
- Hammer, W: On Stretching. Dynamic Chiropractic February 12, 1993, Volume 11, Issue 04
- Laughlin, K: Overcome Neck & Back Pain, Edition 4. Simon & Schuster, 2006
