Tennis Elbow/Yoga Therapy


There are two common chronic conditions that effect the ulnar side of arm, tennis elbow and cubital tunnel syndrome. Tennis elbow generally effects the common extensor tendon on the outer side of the arm and can cause tenderness or severe pain. Cubital tunnel syndrome is a peripheral neuropathy that effects the ulnar nerve and is similar to carpal tunnel syndrome but effects a different nerve. Despite tennis elbow and cubital tunnel syndrome being different chronic conditions, they are not mutually exclusive and patients can often suffer from both simultaneously. Tennis elbow and cubital tunnel syndrome have specific causes, symptoms, and specific treatment via Western medicine. However yoga therapy is also effective in treating tennis elbow and cubital tunnel syndrome.

Tennis Elbow

Tennis elbow has several known and theoretical causes. The injury occurs specifically at the common extensor tendon and the lateral epicondyle on the ulnar side of the elbow.  Another theory states that tennis elbow may occur by tears between the common extensor tendon and the periosteum (membrane surrounding all the bones in the body). The injury is often classified as an overuse or overexertion injury and is dubbed tennis elbow because avid tennis players often end up with this chronic condition. The repetitive nature of tennis or other racquet sports can cause tiny tears of the tendon attachment in the forearm. However repetitive racquet sports are not necessarily the only cause of tennis elbow. Injuries and traumas to the elbow like blows to the elbow and forceful extension can also lead to tearing of the common extensor tendon. No matter whether tennis elbow was caused by a repetitive use injury or a specific traumatic event, it is injury at the lateral epicondyle that causes the common symptoms of tennis elbow.

The symptoms of tennis elbow can be debilitating and can cause severe pain. The most common symptom of tennis elbow is pain on the lateral epicondyle (outer part of the elbow). This can be limited to point tenderness at the outer part of the elbow, especially at the prominent bone on the outer elbow. However in many cases the pain can radiate out from the elbow into the forearm and wrist. One activity that is especially painful in the wrist for patients that suffer from tennis elbow is wrist and elbow extension, especially when working with heavier items, such as lifting with the palm up and pouring a gallon of milk. Other activities that can cause pain are strong handshakes, turning a doorknob, or opening a jar. Tennis elbow can also cause weakness in the forearm and wrist as well as morning stiffness. The severe pain and symptoms caused by tennis elbow can become significantly worse and decrease the quality of life if not treated.

Western methods of the treatment of tennis elbow range from rest and future prevention up to possible surgery depending on the severity of the injury. The severity of the injury can vary from reversible inflammation, nonreversible pathologic changes to the extensor carpi radialis brevis muscle (in the forearm), rupture of the extensor carpi radialis brevis muscle region, and secondary changes in the elbow and forearm such as fibrosis and calcification. The first line of treatment is usually natural healing techniques such as exercises and stretches, usually while working with a physical therapist or done at home or work. A physical therapist may prescribe the use of a brace to prevent further injury and aggravation. When this treatment is not enough, the use of painkillers such as ibuprofen, tylenol, and sometimes prescription strength naproxen can help the pain associated with the injury. In more severe cases, corticosteriods have been prescribed to help reduce pain and inflammation. When none of these treatment methods work, surgery can be prescribed as a last resort. Normally surgery consists of releasing the strain on the muscles in the forearm and removing degenerating or scar tissue to promote healing and relieve pain. Although the strengthening and stretching exercises are similar to many of the techniques used in yoga therapy (more on this later) to heal tennis elbow, some of the other methods only treat the symptoms and not the underlying cause. Painkillers only mask the pain caused by tennis elbow while surgery is very invasive and has many of its own risks such post-surgical pain, scarring, and even death.

Ulnar Nerve Entrapment

Ulnar nerve entrapment is caused when the ulnar nerve (nerve on outer edge of the arm) is somehow pinched or trapped which can cause pain, a tingling sensation in the wrist or fingers, and numbness. The ulnar nerve extends from the cervical spine, down the outer edge of the arm, into the pinkie and ring fingers. Because the ulnar nerve is so long, pinching or trapping of the nerve at any location along its path can cause symptoms. Nerve pinching can occur at the cervical spine, in the brachial plexus (at the shoulder), at the elbow (cubital tunnel) from fractures or even scar tissue build up from tennis elbow, and at the wrist from problems such as fractures. Two common ways the ulnar nerve can be pinched either in an isolated event or repeatedly are when sleeping with the elbow sharply bent or when sitting in a desk chair with arm rests. There can be several other causes of ulnar nerve symptoms including rheumatism, diabetes, cancer, and infections.

The symptoms of ulnar nerve entrapment are similar in all patients no matter where the nerve is pinched and can range in severity. Mild symptoms include tingling and mild numbness in the pinkie, ring finger, and wrist. Ulnar nerve entrapment symptoms feel like hitting one’s “funny bone” but last longer, even most of the day. If not treated and the activity which caused nerve symptoms is not modified, symptoms can progress to numbness all the time, constant nerve pain, weakness in the hand, and lead to a condition in which the pinkie and ring finger are constantly flexed (sometimes dubbed the ulnar claw). Symptoms are generally worse in the morning or the middle of the night if ulnar nerve entrapment is caused by sleeping with a sharply bent elbow. If the pinching of the ulnar is caused by typing at a work station with arm rests, the tingling, numbness, and pain will get worse throughout the work day.

Treatment of cubital tunnel syndrome and ulnar nerve entrapment is only effective when the underlying cause is treated although some treatment of the symptoms is occasionally used. There are a few medications that help the numbness, tingling, and pain but they are not painkillers. Some anti-epileptic medications such as gabapentin have been shown to have some effect on symptoms of ulnar nerve entrapment. Usually the first and most effective treatment used to treat ulnar nerve entrapment treat the underlying cause. Modification of the behaviors that caused the nerve symptoms is usually the best way to prevent and treat ulnar nerve pain including starting to sleep with a straight arm instead of bent at the elbow, changing chairs at work stations so they do not have arm rests, and modifying the work station to be more ergonomic by putting the keyboard and mouse at the correct level for your body and changing the height of the monitor to be at eye level. Physical therapy and occupational therapy have also been shown to provide some relief by stretching the nerve and giving it more mobility along its path. In severe cases, surgery can relieve some of the symptoms associated with ulnar nerve entrapment. For cubital tunnel syndrome, intramuscular nerve transposition where the ulnar nerve is moved from the back of the elbow to the intramuscular space in front of the elbow has shown promise, but this procedure modifies the natural placement of the nerve and can cause problems of its own. Trauma at the elbow can cause scar tissue buildup and bone problems which prevent the nerve from sliding and put pressure on the nerve. Some surgical procedures are aimed at removing scar tissue and fixing bone protrusions while leaving the nerve in place. It is recommended that patients first try more natural methods of healing before surgery because surgery does not have 100% success rate at reducing nerve symptoms.

Yoga Therapy to Treat Tennis Elbow and Ulnar Nerve Entrapment

Although tennis elbow and ulnar nerve entrapment are separate conditions, they can often be linked and the more natural healing techniques used to treat these conditions are similar. This is especially true when cubital tunnel syndrome (a type of ulnar nerve entrapment) is caused or aggravated by tennis elbow. Scar tissue from chronic tennis elbow or an elbow trauma that caused tennis elbow can entrap the ulnar nerve in the cubital tunnel located at the elbow and cause symptoms of ulnar nerve entrapment, even after the tennis elbow is treated. Although the pain of tennis elbow is generally localized at the elbow, the pain can radiate from the elbow down into the wrists and fingers, and upwards in the neck, shoulders, and upper back. When providing yoga therapy for tennis elbow and cubital tunnel syndrome, it is important to treat all these areas of pain and nerve sensation.

Arm and wrist stretches are particularly good for treating symptoms at the elbow and down towards the wrists and fingers. Mountain pose with arms stretched up and hands interlocked overhead are good elbow extensions that stretch the tendons and muscles often effected by tennis elbow. There are additional stretches with the arms behind the back in prayer or in cow-face pose that not only help stretch the elbows and wrists, but they also increase circulation of healing oxygenated to the elbow, open the chest, and help stretch muscles in the neck and shoulders, all helping heal the joints most effected in chronic tennis elbow. Other seated postures that help stretch and strengthen the elbow, wrist, and shoulders are seated forehead to knee to pose and paschimottanasana (intense back stretch with hands locked under soles of feet). Not only do these poses help stretch the tendons and muscles effected by tennis elbow, but they also help slide the ulnar nerve through the cubital tunnel helping relieve symptoms of both conditions.

Treatment of tennis elbow also requires strengthening of the muscles in the upper arm and forearm. Arm strengtheners should be practiced carefully so as not to cause strain or pain and aggravate the injury, therefore it is recommended that arm balances be worked up to and not used as a form of treatment. However some poses in which both the arms and legs remain on the ground but strength of the arms is used for balance or in another way are particularly helpful. Some poses that help strengthen the arms in a healthy and gentle way are extended triangle pose, extended side angle, half-moon pose, and down dog. Down dog can be painful for some sufferers of tennis elbow therefore raising the hands on yoga blocks, a bench, or chair can take some of the weight off while still strengthening the arms.

The final kind of yoga postures that can aid in the treatment of tennis elbow and cubital tunnel syndrome are chest and shoulder openers. Chest and shoulder openers help stretch the upper arms and shoulders as well as correct alignment in the upper back which can be secondary areas of pain and discomfort. Yoga postures which help open up the chest shoulders include reclining fixed angle pose, camel pose, bridge pose, or inverted pose. It is also recommended that sufferers of tennis elbow use a supported corpse pose to keep the chest and shoulders open through the end of a yoga session.

Overall these three types of movement help treat the physical symptoms of tennis elbow and cubital tunnel syndrome, arm and wrist stretches, arm and shoulder strengtheners, and chest and shoulder openers. They help treat the physical damage, increase circulation of fresh blood into these areas, and correct alignment. However the advantages to yoga therapy are not limited to treating the physical condition. Regular yoga and meditation practice also helps heal some of the energetic issues associated with any injury. Yoga therapy helps restore the flow of prana or life force throughout the body, especially in areas of injury where the flow prana is often blocked. Yoga and meditation also helps sufferers of an injury to accept the pain and limitations associated with their condition and work with it to help heal slowly and naturally, sometimes to better level than Western medicine can do alone.

References

Iyengar, BKS. Yoga: the Path to Holistic Health. New York, NY: DK, 2008. Print.

“Tennis Elbow.” Wikipedia, the Free Encyclopedia. Web. 19 June 2011. <http://en.wikipedia.org/wiki/Tennis_elbow>.

“Ulnar Nerve Entrapment.” Wikipedia, the Free Encyclopedia. Web. 19 June 2011. <http://en.wikipedia.org/wiki/Ulnar_nerve_entrapment>.

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