New York Dynamic Neuromuscular Rehabilitation & Physical Therapy Сlinic

1. Shockwave Therapy for Elbow Pain Treatment
Shockwave treatment for tennis elbow is a relatively new form of therapy
in which gentle pressure waves are released into the skin around the
lateral epicondyle, a bony protrusion of the outer elbow. When used in
combination with conventional treatments such as elbow supports and
pain relief exercises, shockwave treatment for tennis elbow has proven
an effective treatment in the fight against lateral epicondylitis.
Elbow Pain Diagnosis
Bilateral elbow pain is a term used to describe any condition in which
pain afflicts both elbows at the same time rather than just one. There are
nearly 50 different conditions that can cause simultaneous burning elbow
pain, among them bursitis, osteoarthritis, and lateral and medial
epicondylitis (tennis elbow and golfer’s elbow, respectively). Because
some of these conditions have similar symptoms, patients should consult
their physician for a proper elbow pain diagnosis.
Bursae are sacs made of slippery tissue, lubricated with a small amount
of fluid, that help reduce friction when skin, muscles, and tendons are
sliding over bones. The olecranon bursa, which is located between the
tip of the elbow (the olecranon) and the overlying skin, allows the elbow
to bend and straighten.
When the olecranon bursa becomes irritated and inflamed, a patient
develops elbow bursitis. This may occur because of a direct blow to the
elbow that tears the blood vessel tissues that make up the bursa,
causing the vessels to bleed into the bursa sac. When this happens, the
bursa swells up like a balloon. The influx of blood into the bursa causes
an inflammatory reaction, and the walls may remain thick and swollen
even after the blood has been reabsorbed. This condition of thickness
and swelling is the chief characteristic of olecranon bursitis.
However, olecranon bursitis may also develop more gradually.
Individuals who are constantly resting their elbows on a hard surface
may unknowingly be causing trauma to the elbow. Over time this may
lead to irritation and swelling of the bursa. The olecranon bursa can also

2. become infected, in which cause the bursa will fill up not with blood but
with pus, causing the surrounding tissue to become warm and tender.
Elbow osteoarthritis is a condition involving degeneration of the articular
cartilage in the elbow joints. Although this typically occurs over a period
of many years, in some cases it can happen as a result of a bad sprain
or fracture. Too much pressure placed on the cartilage surface may also
bruise the cartilage.
Symptoms of elbow osteoarthritis may include pain and stiffness. Initially
the pain only occurs during periods of intense activity. It may lessen in
the rush of activity and increase during rest. Over time as the condition
grows more severe, a patient may experience pain when at rest or
asleep. There may be swelling and tightness around the elbow and an
audible squeaking of the articular cartilage. Eventually the stiffness
caused by osteoarthritis will limit the elbow’s range of motion, making it
difficult for patients to straighten and bend their arms. Loss of motion will
ultimately lead to loss of function.
Lateral epicondylitis (tennis elbow) is characterized by pain over the
bone on the outside of the elbow, while medial epicondylitis (golfer’s
elbow) is characterized by pain over the bone on the inner side. When
the tendons attached to the lateral epicondyle become strained from
overuse, they can deteriorate, resulting in damage to the extensor
muscles in the forearm that are indispensable to gripping. In spite of its
name, tennis elbow can result from a number of different factors,
including repetitive arm motions in activities as varied as raking, rowing,
painting, playing golf, and using a screwdriver. Symptoms include
outside elbow pain, pain when swinging, tightness in the forearm
muscles, and stiffness in the elbows.
When the tendons attached to the medial epicondyle become strained
from overuse, golfer’s elbow may ensue. This happens as a result of
excessive use of the flexor muscles in the forearm. Activities that
contribute to golfer’s elbow may include improper golfing technique,
advanced age, and repetitive arm motions in activities like hammering
and golfing. Among the symptoms associated with golfer’s elbow are
pain and tenderness on the inner side of the elbow, sometimes

3. extending to the forearm; stiffness of the elbow; numbness or tingling in
one or more fingers, and weakness of the hands and wrists.
Elbow Pain Exercises
Elbow pain exercises done under the supervision of a trained therapist
can relieve elbow pains while increasing strength and flexibility.
Wrist extensor exercises are a form of elbow pain support for patients
suffering from tennis elbow. These exercises can alleviate medial elbow
pain by stretching the wrist muscles. In the wrist extensor stretch, a
patient kneels on all fours and places her hands knuckle-side down with
her fingers directed at her knees. Then, keeping her elbows straight and
the backs of her hands on the floor, she leans forward until the heels of
her feet touch her buttocks.
In the wrist flexor stretch, the patient begins in the same position, though
with her palms to the floor and hands facing to the sides. Then, while
carefully maintaining straight elbows, she leans backwards until her
buttocks touch the heels of her feet. This is a great exercise for those
suffering the effects of golf elbow on the lateral epicondylitis.
The hammer rotation is an exercise designed to improve circulation and
lubricate the connective tissues in the elbow. Sitting in a chair and
clenching an object like a hammer in her hands, the patient props up her
forearm with her leg while hanging her wrist over her knee. Then,
holding the hammer upright, she slowly turns it toward the left, then
upright, then towards the right. This strengthening exercise is ideal for
patients who are slowly re-acclimating themselves to their regular
activities.
In the “bend and straighten” exercise, a patient bends his elbow back as
far as it can go without feeling pain or excessive resistance. This can be
repeated between 10 or 20 times in a sitting and should be done at least
three times daily.
In the forearm rotation, the patient begins with his elbow at his side, bent
to 90 degrees. He then turns his palm up and down as far as it can go

4. without feeling pain. For best results this exercise, too, should be
performed between 10 and 20 times.
The elbow extension and elbow flexion are advanced exercises
designed to strengthen muscles. In the elbow extension, the patient uses
one hand to straighten the elbow on the opposite arm. In the elbow
flexion, he uses the other hand to bend the elbow on the opposite arm
as far back as it can go.
When stretching the biceps and triceps, the patient should begin with
back and neck straight. In the biceps stretch, his arm should be
supported behind him on an accompanying table. Lowering his body, he
allows his arm to move behind him until he feels a stretch. In the triceps
stretch, he places one hand behind his lower neck and the other on his
elbow. He then pushes his elbow backwards so that his hand moves
down the back until he experiences a mild stretch. In both exercises, he
should hold for 15 seconds and then repeat at least four times.
For best results, physical therapy should be undertaken in conjunction
with physical treatments like icing and anti-inflammatory painkillers.
Special elbow pain supports such as armbands or bandages may help
support and protect the elbow until symptoms subside. Wrist splints may
also lessen pain by resting the muscles that pull on the elbow. Wearing
elbow supports in conjunction with physical therapy may ultimately
provide better and more lasting pain relief.
Shockwave Therapy for Elbow Pain
Shockwave treatment for tennis elbow involves the use of pressure
waves on the injured tissue. These waves pass through the skin,
initiating a healing response that accelerates blood flow and the delivery
of nutrients.
Depending on the severity of the injury, shockwave therapy for tennis
elbow may employ either low-intensity or high-intensity shockwaves.
Low-intensity waves may provide a slight sensation of discomfort, but
are generally effective except in cases where the damage is severe.
High-intensity shockwaves are considerably more painful and should

5. only be taken in conjunction with some form of anesthesia. The
advantage of high-intensity shockwaves, however, is that they are
tremendously effective.
In a study reported in the American Journal of Sports Medicine in 2002,
the long-term effects of shockwave therapy for tennis elbow were tested
on 57 patients with lateral epicondylitis. In addition, a designated control
group of six patients was unknowingly given a sham treatment. The
study found that after one to two years of follow-up, 61 percent of
patients receiving therapy were free of all complaints; 29.5 percent were
significantly better; and one person was unchanged. The six members of
the control group, on the other hand, reported significantly more pain
and less range-of-motion. The study’s conclusion? “Shock wave therapy
is a safe and effective therapy for the treatment of patients with lateral
epicondylitis of the elbow.”
Elbow Pain Relief at the New York DNR
Patients seeking relief from burning elbow pain or bilateral elbow pain
will find it at the New York DNR. Shockwave treatment for elbow pain is
an innovative biological treatment that promotes self-tissue healing on a
cellular level by activating the body’s own healing processes. The
mechanical pulses we employ during shockwave treatment for elbow
pain exert pressure and tension force on damaged cells, creating
capillary micro-tears that promote new localized circulation and
metabolism through the release of special enzymes known as “growth
factors.” This results in the formation of new blood vessels that improve
blood supply and oxygenation, accelerating the healing process in the
elbow and relieving both unilateral and bilateral elbow pain.
Moreover, by modulating tissue plasticity, shockwave treatment for
elbow pain remodels damaged tissues and breaks down deposits of
calcium in the soft tissues, allowing a reabsorption of the calcium.
Because excess calcium deposits in the soft tissue the root of many
types of musculoskeletal pain, by breaking up these calcium deposits the
pressurized waves relieve elbow pains and increase range of motion.

6. On top of all this, shockwave therapy for elbow pain stimulates bone
cells that are responsible for healing and new bone growth, while
simultaneously diminishing pain by stimulating the so-called “gait control
mechanism.” The release of acoustic waves through the surface of the
skin stimulates the healing process, effectively bringing elbow pain relief.
Elbow Pain Treatment in New York
The elbow is a complex hinge joint that assists in arm flexion and wrist
rotation. However, it is also especially susceptible to tendinitis, sprains,
strains, and medial and lateral epicondylitis. Fortunately,
physician-approved programs of exercise for elbow pain and elbow pain
support can help the injured patient recover strength and range of
motion in the injured area and resume a normal life.
Elbow Pain Diagnosis
The first step in treating elbow pain relief is determining its origins. There
are several closely related conditions with painful symptoms that result
from injury or degeneration of the elbow.
Tennis elbow, or lateral epicondylitis, is an inflammation of the lateral
epicondyle, a small protrusion in the humerus just above the elbow joint
to which are attached four muscles that help extend the wrists and
fingers—the supinator, the supraspinatus, the triceps brachii, and the
brachiordialis—and a muscle that extends the elbow, the anconeus.
When the lateral epicondyle is damaged as a result of tennis elbow pain
and swelling, it can seriously impair the ability of the muscles to flex and
extend the lower extremities.
Tennis elbow pains result from damage to the extensor carpi radialis
brevis (ECRB), a muscle in the forearm that stabilizes the wrist. The
ECRB can be damaged from overuse through constant
backhanded-stroking during tennis (hence the name of the injury), which
places strain on the tendinous muscles, causing micro-trauma at the
tendon’s source of origin in the lateral epicondyle. As micro-trauma
accumulates, the patient experiences severe elbow pains and

7. inflammation. This is not limited to athletes who play tennis, but may
afflict anyone who repeatedly overloads the muscles in their arms or
shoulders.
In order to obtain a proper elbow pain diagnosis, a patient should be
able to pinpoint the exact area where the pain is emanating. Individuals
suffering from tennis elbow will report pain above their elbow when
gripping or flexing, and in other areas of the elbow and forearm. Tennis
elbow typically only affects one arm, the arm that is used most
prominently in high-intensity sporting events.
Closely related to tennis elbow is a condition called “computer elbow” or
“mouse elbow” that affects many of the same muscles of the wrist and
forearm. Computer elbow typically results from repetitive or forceful
movements of the fingers, wrist, and arm, and can develop because of
too much force applied over a prolonged period of time. Specific
movements that may place an individual at risk of developing computer
elbow are sudden throwing motions, stressful gripping in combination
with inward or outward movement of the forearm, and attempting to bend
the wrist and rotate the forearm simultaneously. Symptoms may include
extreme tenderness on the outer side of the elbow, tenderness when
bending the wrist while strengthening the elbow, and burning elbow pain
that can become chronic if not soon treated. Because the symptoms of
tennis elbow and computer elbow are so similar, a physician may be
needed to make a proper elbow pain diagnosis.
Radial head subluxation, or “nursemaid’s elbow,” refers to a condition in
which two of the three bones that comprise the elbow joint are torn out of
alignment. This typically affects children between the ages of one and
four whose bones have not fully developed, though it may occasionally
be found in older children as well. Frequently the immediate cause of
injury is excessive pull on the arms; this may occur when a child is being
swung by the arms or dragged along by one arm at a hurried pace.
Olecranon bursitis is one of the more common causes of bilateral elbow
pain, or pain in both elbows. A bursa is a fluid-filled sac situated between

8. bones and soft tissues providing a lubricant that prevents excessive
friction between tissues during movement. The olecranon bursa is
located at the tip of the elbow, and while in most cases it remains flat, it
may become swollen or inflamed when a patient is suffering from
bursitis. Causes of bursitis include sudden, traumatic injury and
repetitive, prolonged pressure on the tip of the elbow. Symptoms include
elbow pain and swelling, bilateral elbow pain, and limited range of
motion in the elbow joint.
Exercises for Elbow Pain
Elbow pain exercises for tennis elbow include what are called the “super
7,” seven basic exercises for elbow pain that are designed to strengthen
the muscles in the forearm and increase flexibility. For patients suffering
with straightforward symptoms, these exercises are designed to bring
complete elbow pain relief within four to six weeks.
In the first exercise, the patient stretches the muscles that extend the
wrist. He or she should straighten the arm and push the palm of the
hand down until a stretch is felt across the top of the forearm.
Like the first of the seven exercises for elbow pain, the second is
designed to stretch the flexor muscles. However, its method of operation
is an exact inversion of the first. The patient straightens her arms but
keeps her palms facing the ceiling. She then pushes the palm downward
until it faces the opposite direction from her. When performing this
exercise the patient may sit in a chair. Once she has become
accustomed to it, she may use a light weight such as a book or a
hammer. This should be done five times per session, three times a day.
In the third exercise for elbow pain, the patient holds a weight in his hand
with the palm facing the floor. Then, slowly extending the wrists upwards
till the palm faces the opposite direction, he holds this position for
between two to five seconds and releases. As with the previous
exercise, this one should be done up to fifteen times a day.

9. In the fourth exercise, as in the third one, the patient holds a weight in
his hand. However, this time he turns the palm up towards the ceiling.
Then, pulling the wrist towards his body, he holds the position for five
seconds and lowers slowly.
The fifth exercise is an exercise for strengthening the deviator muscles,
the muscles that move the wrists from side to side. Holding a weight or
small pipe in her hands, the patient points the thumb upwards. She then
moves the wrist up and down as though preparing to hammer a nail in
place. In order for this exercise to be effective, the patient should be
careful only to move the muscles of the wrist.
In the sixth exercise, the patient strengthens the pronator and supinator
muscles that twist the wrist by holding the pipe in her hand with the
thumb pointing up and then turning the wrist inward as far as possible
(eversion) and then outward as far as possible.
Lastly, in the seventh tennis elbow pain exercise, the patient performs a
massage over the area of soreness by applying firm pressure on the
injured area.
Elbow braces, or tennis elbow supports, are especially designed for the
treatment of tennis elbow and golfer’s elbow. Typically elbow supports
are plastic and U-shaped, designed to fit the upper forearm for the
purpose of applying pressure to the extensor tendons or flexor tendons,
protecting the tendon while reducing the pressures placed on them when
the wrist is in use. When pressure is applied to the muscles, the tendons
are less susceptible to sudden shocks and injuries.
The brace can be adapted to different uses depending on whether the
patient suffers from tennis or golf elbow. Wearing it under the forearm
with the larger end applying pressure to the lateral elbow treats tennis
elbow, while turning it around the other way so that it’s worn over the
front of the elbow will treat golfer’s elbow. Occasionally a physician may
instead recommend the use of an epicondylitis brace, a neoprene

10. support with a strap around the upper forearm that can treat both
conditions.
How Do We Treat Burning Elbow Pain?
For patients suffering from tennis elbow, computer elbow, and bilateral
elbow pain, the New York DNR can provide assistance. We offer elbow
pain support by guiding patients in moderating their activity according to
the demands of recovery, drawing up a program of exercise for elbow
pain designed to repair tendon and muscle dysfunction.
A patient suffering the early stages of elbow pain and swelling should
seek help as soon as possible, because conventional and home
treatments lose their efficacy as time passes without treatment and
injuries may become chronic. Dynamic neuromuscular stabilization helps
rehabilitate the elbow and surrounding tissues on inflamed nerves and
restoring motion in the joints. We use DNS and manual myofascial
manipulation to improve motor control in areas causing nerve
impingement, lengthening the myofascial tissue to provide more freedom
for the nerves.
In more severe cases, such as pain in both elbows, our physicians may
recommend biological treatments such as extracorporeal shockwave
therapy (ESWT), an advanced regenerative treatment that does not
require a sub-cutaneous incision and is therefore less invasive than
surgery. A set of pressure waves is used to stimulate metabolism and
enhance blood circulation, regenerating and restoring damaged tissue to
accelerate the healing process.
TENNIS ELBOW OR LATERAL EPICONDYLITIS
Lateral epicondylitis is a painful condition at the outer forearm, just
where forearm meets the arm. This condition is also known as tennis
elbow. Lately due to new evidence this condition has been brought
under the umbrella of OOS (Occupational Overuse Syndromes also
known as repetitive strain injury (RSI) syndromes.

11. SYMPTOMS
Tennis elbow pain is most often connected to the activity of the
arm or a wrist such as opening a jar or a door. Pain could also be
quite intense with burning quality.
ETIOLOGY
(Cause)
Latest studies have revealed a widespread mechanical
hypersensitivity in patients suffering with lateral epicondylitis. Studies
show that the brains perception of mechanical input such as occurs
with normal activities of daily living is heightened. Patients with tennis
elbow have significantly higher pain levels to pressure or cold applied
over the muscles of the forearm. This evidence supports a role of
peripheral sensitization mechanisms in the initiation of this syndrome.
● In patients younger then 45 years old the cause is repetitive
strain (overuse)
● Sensitization phenomenon (also occurring in younger
population)
● In patients older then 50 years old with presence of
degenerative joint disease in the cervical spine (neck

12. arthritis) the cause is secondary to the degenerative disease
disrupting neck arm nerve connection.
TYPES OF LATERAL EPICONDYLITIS
There are three types of lateral epicondylitis:
● Osteogenic – the pain is in the bony prominence of the
lateral epicondyle
● Myofascial – the muscles attaching to the lateral epicondyle
are either hypotonic (weak and flaccid) or hypertonic (too
tense)
● Tendinosis – there is a degenerative process occurring in
common extensor tendon (the tendons originating in the
lateral epicondyle which primary function is to extend the
wrist)
● Arthrogenic – facilitated hyperactivity of elbow musculature
secondary to secondary to the degenerative disease of the
cervical spine
●
DIFFERENTIAL DIAGNOSIS
Following conditions could mimic tennis elbow:
● Radial nerve impingement
● Posterior interosseous nerve impingement
● Elbow arthritis
● Fracture of lateral epicondyle (trauma must be present)
● Cervical radiculopathy
https://nydnrehab.com/what-we-treat/tennis-elbow-lateral-epicondylitis/