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The cause of your tennis elbow might be your neck


The Scenario: pain on the outside of my right elbow. It’s been 4 months… I think… maybe 5? Physio appointment tomorrow for an assessment. Should probably ask him about my neck too. Probably unrelated… right?


Tennis elbow is known as a relatively self-limiting condition. Which means, do nothing, and with time the majority of cases will recover on their own. However, this wait-and-see approach can sometimes take up to a year.1 Even worse, several studies show that conventional elbow physiotherapy – ie. elbow joint mobilizations and theraband strengthening exercises – don’t seem to be able to shorten this recovery period – ie. it would give you a recovery period that is no shorter vs waiting and seeing what happens.2,3


So in 1976, Dr. Chan Gunn decided to look elsewhere: the neck.4 In this study Chan took 50 people with tennis elbow and split them into 2 different treatment groups: a conventional elbow physiotherapy group and a neck treatment group. In this study, conventional elbow physiotherapy included any or all of: steroid injection, local anaesthetic injection, elbow joint manipulation/adjustments, ultrasound, friction massage, and/or immobilization – ie. the typical tennis elbow treatment approach.


The Experiment: take the 50 people and split them into a neck treatment group (Group A) or an elbow treatment group (Group B). Group A people received physiotherapy treatment directed to the neck only (joint mobilization, neck traction, isometric strengthening exercises, and heat and/or ultrasound) while Group B received the conventional elbow physiotherapy treatment. If people in Group B showed no benefit to treatment after 4 weeks, elbow treatment was stopped, and treatment was then directed to the neck.


The Findings: the average duration of treatment in the responders within Group A was 4.7 weeks while the average duration of treatment in the responders within Group B was 11.1 weeks.


This study seemed to show a clear benefit of treating the neck in those with tennis elbow – but why would this help?


Let’s look at the anatomy. First the nerves of the arm. Then the bones of the neck. Lastly, the muscles of the forearm. And then we’ll put it together.


The Nerves: as the spinal cord exits the brain to travel down the spine, at the level of each vertebrae it gives off a nerve – these are called spinal nerves. Each spinal nerve is named after the level of the spine from which they emerge – ex. the C5 spinal nerve sits above the C5 vertebrae while the C6 spinal nerve sits above the C6 vertebrae, and etc. The 5 spinal nerves that control the movements of the arm come out from between the C4, C5, C6, C7 and T1 vertebrae. When the spinal nerves travel down the arm, they go to very specific parts of the body. Let’s leave it at that for now.


A schematic of the cervical spinal nerves

Cervical nerve sensation distribution pattern

The Bones: the bones of the neck – ie. the vertebrae. When it comes to the vertebrae – every single vertebrae has some degree of individual movement. Think of the vertebrae like a stack of soup bowls and the movement between the vertebrae like how one soup bowl can rock and slide over another. Unfortunately some vertebrae are a bit more mobile than others. What makes this unfortunate is that more movement potentially means more wear and tear over time…


The Muscles: there are a number of muscles that attach to the outside of the elbow (ie. the lateral epicondyle), and with tennis elbow, any one muscle or combo of multiple muscles can become tender and painful to the touch. The common attachment point on the lateral epicondyle where all of these muscles converge into a more or less singular tendon is termed the common extensor origin. The most common muscles to be affected are often the brachioradialis, extensor carpi radialis longus and brevis (ECRL and ECRB respectively), and the extensor digitorum (ED). The health of the muscles are partly regulated by the nerves – that is, irritation of the nerve that supplies a muscle can lead to eventual irritation of the muscle that that nerve goes to.


Schematic of your forearm musculature

Now let’s put it all together: remember, the spinal nerves go to very specific parts of the arm. There are 2 nerves that travel and supply the outside of the elbow: C5 and C6. The 2 vertebrae that are the most mobile in the neck and the most likely to suffer some wear and tear? C5 and C6. Which nerves go to the muscles at the common extensor origin? Both C5 (into the brachioradialis) and C6 (into the ECRL, ECRB and ED).


Interesting.


Could it be that C5 – C6 vertebral irritation in the neck leads to C5 – C6 spinal nerve irritation which then contributes to irritation within the tennis elbow muscles?


Absolutely that could be happening, and in fact it’s a leading theory in the field as to what could be largely contributing to this condition. It could also be a reason why treating the neck often results in quicker recovery.


The analogy I like to use is “the light bulb and the breaker switch”. Say the light bulb (ie. your elbow) supplying your bedroom keeps blowing out. Time and time and time again. What if it had nothing to do with the actual light bulb and instead it actually was a faulty breaker (ie. the neck)? We could be changing light bulbs until the cows come home without making a lick of a difference. Another analogy I like to use is the concept of a polluted river. What if pollution was being dumped into the mouth of the river (ie. the neck), but the clean-up crew only spent time cleaning up downstream (ie. the elbow)? Seems like a losing battle.


So is there any more research looking at the effect of treating the neck in those with tennis elbow? Let’s take a closer look at 3 other studies.

Study #1: Josh Cleland and company from Franklin Pierce College in Concord New Hampshire decided to analyze the charts of 112 people who were diagnosed with tennis elbow to investigate what type of treatment people were getting.5


After reviewing the charts, similar to Gunn’s study in 1976, the patients were split into 2 groups: a group who received treatment directed solely to the elbow; and another group that received treatment to both the elbow and the neck. All of these people were contacted by phone for an interview inquiring if they had experienced a successful outcome – defined as having the ability to return to all of their previous activities without symptoms coming back.


The Findings: although they found no difference between groups regarding how many experienced a successful outcome (~80% of the study population), they did find a difference in how many sessions it took to get there: 9.7 visits in the elbow only group vs only 5.6 visits in the neck group.


So similar results to Gunn. This study was significantly limited though in that none of the treatment was standardized, meaning a lot of things could have led to a successful outcome. So to control this, the same lead author performed a study in 2005 in which the neck and elbow treatment was standardized to help eliminate some of the confounding factors.6


Study #2: 10 people diagnosed with both tennis elbow as well as stiffness in the neck or upper back (although interestingly, not a single individual was complaining of symptoms within the neck or upper back at the time of the study) were randomly split them into 2 treatment groups: again, an elbow treatment only group vs a combination elbow + neck/upper back treatment group. Both groups received the same number of treatment sessions – 10 over a span of 6 weeks, and their pain-free grip was assessed before treatment, and during a follow-up 6 months later.


The Findings: at the 6 month follow-up, the elbow group had increased their pain-free grip by an average of 17.8 kg while the combination elbow + neck group increased their pain-free grip by 37.4 kg.


Study #3: a final study out of the Universidad Rey Juan Carlos in Madrid, Spain published in 2008 again looked at 10 people diagnosed with tennis elbow.7 This time they were randomly allocated to receive a single intervention: either a neck adjustment directed at the C5 – C6 vertebral level or a manual contact intervention (ie. a placebo treatment technique where the neck was set up for the adjustment but no adjustment was performed). Pain-free grip was assessed prior to the treatment session and 5 minutes post treatment session.


The Findings: within the 1 treatment session – pain-free grip strength had improved by an average of 37.8% in the neck adjustment group, but had decreased by an average of 8.5% in the placebo group.


All of these research studies have their own limitations, but all showed a trend that treating the neck in those with tennis elbow could lead to better and faster outcomes.


Don’t get me wrong – even though I’ve painted a picture stating otherwise, treatment of the elbow can be a helpful approach in some cases. But is there neck pain or stiffness on the same side? Or does the neck feel fine yet treatment of the elbow has been stagnating lately without any meaningful improvement? Maybe it’s time to change the approach and check out further upstream to see if anything else is going on.

References:

  1. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. “Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial.” British Medical Journal 2006;333(7575):939

  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 epicondylagia. A randomized controlled trial.” Journal of the American Medical Association 2013;309(5):461-469.

  3. Coombes BK, Bisset L, Connelly LB, Brooks P, Vicenzino B. “Study protocol. Optimizing corticosteroid injection for lateral epicondylagia with the addition of physiotherapy: a protocol for a randomised control trial with placebo comparison.” BMC Musculoskeletal Disorders 2009;10:76.

  4. Gunn CC and Milbrandt WE. “Tennis elbow and the cervical spine” CMA Journal 1976;114:803-809.

  5. Cleland JA, Whitman JM, Fritz JM. “Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylagia: a retrospective analysis.” Journal of Orthopaedic and Sports Physical Therapy 2004;34:713-724.

  6. Cleland JA, Flynn TW, Palmer JA. “Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylagia: a pilot clinical trial.” The Journal of Manual and Manipulative Therapy 2005;13(3):143-151.

  7. Fernández-Camero J, Fernández-de-las-Peñas C, Cleland JA. “Immediate hypoalgesic and motor effects after a single cervical spine manipulation in subjects with lateral epicondylagia.” Journal of Manipulative and Physiological Therapeutics 2008;31:675-681.

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