Tennis Elbow (Lateral Epicondylitis)

About Tennis Elbow

Pain, tenderness and weakness near your outer elbow may be symptoms of lateral epicondylitis, commonly known as tennis elbow. The condition is an overuse injury affecting the tendons that attach your forearm muscles to your elbow. It can occur from suboptimal form when playing tennis, using hand tools, and other activities that repeatedly load the forearm. Lateral epicondyle pain can also be caused by compression of the posterior interosseous nerve inside the radial tunnel, or by instability of the lateral collateral elbow ligaments.

Because other conditions share similar symptoms, misdiagnosis of tennis elbow is not uncommon, often resulting in mistreatment of undertreatment that prolongs the patient’s suffering. Accurate diagnosis using high-resolution ultrasound is key to differentiating tennis elbow from other conditions.

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Dr. Lev Kalika

Clinical director & DC RMSK

About Tendinopathy Specialist Dr. Lev Kalika

With over 25 years of experience treating tendinopathies, Dr. Kalika has formulated his own unique approach to diagnosis and treatment of overuse injuries. As an expert in diagnostic ultrasonography, he has published multiple scientific publications that have helped to take diagnostic medicine to the next level.

Based on the latest scientific evidence and years of experience treating elbow pain, Dr. Kalika considers not only the wrist and elbow, but also the complexities of the upper arm kinetic chain when diagnosing epicondylitis. His expertise in high resolution ultrasonography allows him to visualize the elbow and its associated structures in real time, to differentiate tennis elbow from other conditions with similar symptoms.

Dr. Kalika’s expertise in diagnostic ultrasonography makes him one of the most sought-after specialists in NYC for diagnosing and treating tennis elbow.

High Resolution Diagnostic Imaging Means Accurate Diagnosis and Successful Treatment

Because multiple structures converge at the elbow, it is impossible to know, based on symptoms alone, if your lateral elbow pain is caused by damage to the tendons that connect your forearm muscles to your elbow, or if other structural damage has taken place.

In many cases, lateral elbow pain does not originate in the tendon, but arises from compression of the posterior interosseous nerve (PIN). Even when PIN compression is not the primary cause of pain, it can be a significant contributor. Pain can also be caused by instability of the lateral collateral elbow ligaments. In severe cases, multiple structures involving the elbow and forearm may be affected, requiring a multifaceted treatment approach.

At NYDNRehab, we use the highest resolution diagnostic ultrasonography available, to closely examine the elbow and its surrounding structures. Ultrasound enables us to view the tissues in real time, with the elbow in motion, to rule out all possible causes of lateral epicondylar pain. With a precise and accurate diagnosis, we are able to provide the best condition-specific elbow pain treatment. Our use of regenerative technologies gives us nearly 100% success in resolving lateral elbow pain.

Ultrasound imaging takes the guesswork out of diagnosis and ensures that the multiple factors that may contribute to elbow pain are accurately identified and treated. Ultrasound imaging takes place in the comfort of our clinic on your very first visit. Quick and accurate diagnosis means you can begin therapy right away, with no wait time for lab results.

With diagnostic ultrasound, we can:

  • Compare the injured and uninjured elbows
  • View nerves, muscles, fascia and bones along their entire path
  • Identify fascial densifications and adhesions, and myofascial trigger points
  • Detect the exact site of nerve compression or entrapment
  • View multiple tissues and structures in a single session
  • Elicit patient feedback during the imaging session

For years, MRI has been considered the gold standard for musculoskeletal imaging, but advancements in technology have catapulted high-resolution diagnostic ultrasonography to the top of the heap.

Ways in which high resolution ultrasound is superior to MRI:

  • Much higher resolution means ultrasound can visualize small lesions and anomalies that are often missed by MRI
  • Ultrasound allows for dynamic evaluation that can reveal factors like ligament laxity, radial nerve entrapment, and other conditions that mimic tennis elbow – factors that cannot be detected by static MRI
  • Ultrasonography is fast, effective and relatively inexpensive
  • Ultrasound imaging can be performed on-site in the doctor’s clinic, with no wait time for lab results

Beware of Misdiagnosis that Leads to Unsuccessful Treatment

Because tennis elbow and golfer’s elbow are fairly common conditions, many doctors are quick to diagnose elbow epicondylitis based on symptoms alone, without ruling out other potential issues. Consequently, patients often go mistreated or undertreated, prolonging their pain without resolving their condition.

Recent research on elbow epicondylitis was presented at the International Society for Medical Shockwave Treatment (ISMST) Congress:

  • In one study of 56 patients who had been diagnosed with elbow tendinopathy, 16 percent (9 patients) had nerve compressions, and 32% (18 patients) had pain generated from trigger points.
  • In another study of 51 patients diagnosed with insertional epicondylar tendinopathy, one had humeral osteochondritis, and another had radio-ulnar synovitis.

Without ultrasound imaging, diagnosis of elbow epicondylitis is a hit-or-miss proposition. Misdiagnosis can cause critical conditions to go untreated, costing the patient time and money while prolonging their pain and dysfunction.

Tensegrity is the Secret to Pain-Free Mobility

Most people take everyday mobility for granted until an injury occurs or pain sets in. Sometimes pain and reduced mobility seem to arise out of nowhere, with no apparent cause of onset. Regardless of whether your pain is caused by trauma or by something less obvious, tensegrity plays a key role.

Tensegrity refers to tensile integrity – a state where a system of individual components is held together under continuous elastic tension. In the human body, tensegrity is created by the myofascial system, the network of muscles and fascia that work together to produce, control, and guide forces, and to hold the body’s various organs and structures in place during movement.

Tensegrity can be disrupted when myofascial tissues are injured or damaged in some way. When that happens, nerves and blood vessels can become entrapped, preventing them from gliding among other structures and producing pain. At the same time, the elastic tension that governs joint alignment and controls movement becomes compromised, creating motor deficits that undermine mobility and stability.

Factors that disrupt myofascial tensegrity include:

  • Traumatic injury that affects multiple tissue types
  • Overuse injuries from sports, exercise or occupation
  • Old injuries that were never properly rehabilitated
  • Sedentary lifestyle with excessive sitting
  • Obesity that overloads the body’s structures
  • Inadequate hydration that deprives soft tissues of water needed to function
  • Diet high in sugar and carbs that causes myofascial tissue glycation, making it dense and sticky

Many doctors do not understand the crucial role of the myofascial system in preventing pain syndromes, movement disorders, and disease. In fact, most medical doctors have no idea how to correct myofascial dysfunction or even recognize it as a factor. They simply treat pain symptoms with medications and eventually recommend surgery.

At NYDNRehab, we understand that the body’s systems work together as an integrated whole, and that treating pain is not enough to eliminate its source. We use dynamic high-resolution ultrasound to explore the myofascial system in real time. Ultrasound imaging lets us visualize muscles, fascia, nerves and other structures in motion, to identify places where tensegrity has been disrupted.

Once we identify the problem, we use the most advanced therapeutic approaches to restore myofascial integrity and promote tissue healing.

Why Physical Therapy Alone is Not
Enough to Resolve Tennis Elbow

Identifying and treating underlying issues prior to beginning physical therapy is key to getting fast and effective results. Failure to pre-treat your condition can completely undermine your treatment protocol, and in some cases, your condition may even worsen.

Obstacles to physical therapy success include:

  • Scar tissue and fascia adhesions
  • Neurogenic inflammation
  • Joint edema
  • Inflamed soft tissues
  • Myofascial trigger points
  • Compressed or entrapped nerves
  • Tendons that have degenerated and lost their elastic properties
  • Compensation patterns developed post-injury

At NYDNRehab, we use a broad range of regenerative technologies and integrative therapeutic approaches to resolve issues that can stand in the way of successful physical therapy. Our staff is certified in a diverse array of holistic treatment methodologies, and our one-on-one treatment sessions are personalized, based on your unique diagnostic profile.

Once we pre-treat your damaged tissues and eliminate compensation patterns, your body will be ready to begin physical therapy.

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Our Regenerative Therapies are Game-Changers

The human body has its own innate healing mechanisms, but tendons sometimes need a nudge to accelerate the healing process. Regenerative technologies help to jump-start healing by stimulating tissue repair at the cellular level. Our outpatient regenerative therapies expedite recovery with minimal discomfort for the patient.

Most injuries involve more than one tissue type. When used together, our advanced shockwave technologies enable us to specifically target multiple tissue types with the most effective shockwave treatment. Your tennis elbow treatment plan may include a combination of regenerative therapies, along with physical therapy to restore pain-free functional movement.

SoftWave Electro-Hydraulic Shockwave Therapy

SoftWave Electro-Hydraulic Shockwave Therapy

SoftWave is a groundbreaking regenerative mechanotransduction technology that accelerates tissue healing. Its patented electro-hydraulic applicator delivers high-speed soundwaves that can penetrate up to six inches in depth. SoftWave’s defocused and linear focused shockwaves recruit maximum stem cells to the treatment site to promote healing. SoftWave’s wider and deeper penetration using defocused energy is a preferred treatment option for a broad spectrum of conditions, ranging from orthopedic injuries to pelvic health. SoftWave is the only unfocused shockwave technology currently available. According to recent research, SoftWave defocused waves combined with focused and radial shockwaves have maximum regenerative potential.


Myofascial Acoustic Compression Therapy (MyACT)

MyACT is a new type of focused shockwave technology that allows for deeper compression of the focused waves. Its higher frequency allows for precise neuro modulation under ultrasound guidance, with a special linear head for treating myofascial pain. MyACT transforms the mechanical energy of shockwaves into biochemical signals that precisely target damaged tissues. Most injuries involve more than one tissue type. When used together, our advanced shockwave technologies enable us to specifically target multiple tissue types with the most effective shockwave treatment.

Myofascial Acoustic Compression Therapy (MyACT)
Focused Extracorporeal Shock Wave Therapy (ESWT)

Extracorporeal Shockwave Therapy (ESWT)

Focused ESWT is used as a regenerative treatment for damaged tendon, muscle and bone tissue. This technology produces high frequency sound waves to stimulate the body’s own reparative mechanisms. It is especially effective for chronic degenerative tendon disorders and myofascial pain syndrome.


Extracorporeal Magnetic Transduction Therapy (EMTT)

EMTT is a fairly new technology that transmits high energy magnetic pulses to targeted tissues. The magnetic waves synchronize with the body’s own magnetic fields, causing a disturbance that triggers a regenerative response. EMTT waves can penetrate deep tissues up to 18 cm beneath the skin’s surface, to target difficult-to-reach tendons, muscles, bones and nerves.

Extracorporeal Magnetic Transduction Therapy (EMTT)

Extracorporeal Pulse Activation Technology (EPAT)

Extracorporeal Pulse Activation Technology (EPAT)

EPAT, sometimes called defocused shock wave therapy, is not a true shockwave. It uses mechanical pressure waves to enhance blood circulation, improving oxygen and nutrient delivery to muscle and fascia tissues, but has minimal regenerative properties.The mechanical properties of EPAT make it especially effective for fascial manipulation in combination with focused shockwaves. We combine EPAT with different types of shockwaves for holistic treatment, without additional cost to the patient.


High Energy Inductive Therapy (HEIT)

HEIT delivers high-intensity magnetic pulses to peripheral nerve tissues, to stimulate neuroplasticity. We leverage this FDA-approved methodology to treat pain and regenerate nerve fibers, for enhanced motor control.

High Energy Inductive Therapy (HEIT)

INDIBA Radiofrequency Therapy

INDIBA Radiofrequency Therapy

INDIBA is a form of TECAR therapy that helps to restore the ionic charge of damaged cells, for faster injury healing and rehabilitation.


NESA Neuromodulation Therapy

NESA generates a low-frequency electrical current of intermittent and cyclical stimuli that soothes hypersensitized nerves and restores optimal signaling between the autonomic nervous system and the brain. We leverage this FDA-approved methodology to treat pain and regenerate nerve fibers, to enhance motor control.

NESA Neuromodulation Therapy

We Guide Our Needling and Orthobiologic
Procedures with High-Resolution Ultrasound

Injection therapies use orthobiologic solutions that stimulate cellular repair by either nourishing or irritating the targeted cells. Guidance by ultrasound ensures that the injected substances hit their mark, for maximum effectiveness.

Platelet Rich Plasma (PRP)

PRP therapy uses a sample of the patient’s own whole blood, which is spun in a centrifuge to extract a high concentration of platelets. When injected into damaged tissues, PRP initiates tissue repair by releasing biologically active factors such as growth factors, cytokines, lysosomes and adhesion proteins. The injected solution stimulates the synthesis of new connective tissues and blood vessels. PRP can help to jump-start tendon healing in chronic injuries and accelerate repair in acute injuries.


Alpha-2-Macroglobulin (A2M)

Alpha 2 macroglobulin (A2M) is a naturally occurring blood plasma protein that acts as a carrier for numerous proteins and growth factors. As a protease inhibitor, A2M reduces inflammation in arthritic joints and helps to deactivate a variety of proteinases that typically degrade cartilage.


Prolotherapy

Prolotherapy uses a biologically neutral solution to irritate stubborn tissues, triggering the body’s innate healing mechanisms to grow new normal tendon, ligament and muscle fibers.


Interfascial Plane and Nerve Hydrodissection

Tendon injuries often involve fascial tissue that has become densified and/or formed adhesions, entrapping nerves and blood vessels, causing pain and restricting movement. Hydrodissection is a procedure where a saline solution is injected into densified fascia under ultrasound guidance. The solution works by separating fascial layers and freeing up entrapped nerves and blood vessels. We often use hydrodissection in conjunction with manual fascial manipulation.

Ultrasound Guided Dry Needling

Myofascial trigger points often contribute to knee pain. The dry needling procedure inserts non-medicated needles into trigger points to evoke a twitch response, releasing the trigger point and immediately relieving pain. Ultrasound guidance eliminates the need for multiple insertions, reducing pain and discomfort for the patient.

Our Therapies Icon

Stecco Myofascial Release

The Stecco Method of fascia manipulation is one of the most effective methods for reversing fascia densifications and restoring the ability of fascial layers to glide among muscles, nerves and other structures. Stecco therapy involves deep friction that heats up tissues and stimulates mechanical action. When performed by a trained professional, Stecco fascial manipulation is a fantastic and evidence-based methodology for breaking up scar tissue and releasing adhesions, to restore the integrity of fascia tissue. Patients often report immediate pain relief after a single Stecco session.

Our Therapies Icon

SM Neuromuscular Electrical Stimulation (SMNMES)

SM neuromuscular electrical stimulation (NMES) dynamically interacts with the patient during therapeutic exercises, providing real-time sensory, auditory and visual biofeedback to the patient. This breakthrough technology helps patients to recalibrate muscle actions, to optimize joint function. SMNMES has helped numerous patients to avoid unnecessary shoulder, knee and ankle surgeries, even in complex scenarios.

Our Therapies Icon

Ultrasound Guided Percutaneous Neuromodulation (PENS)

During PENS treatment, filament-thin needles are inserted through the skin into muscle tissue adjacent to the targeted nerve. A low frequency electrical current is then delivered via the inserted needles to stimulate the dysfunctional nerve. PENS normalizes nerve activity, improves brain plasticity and optimizes muscle recruitment patterns. This therapy is so effective that patients typically need only 4-6 treatment sessions.

Symptoms, Causes and Risk
Factors of Lateral Epicondylitis

Symptoms

  • Tenderness, burning and outer elbow pain
  • Pain that spreads to your forearm and wrist
  • Pain while gripping small objects
  • Pain while carrying loads with the elbow extended
  • Weakened grip

Causes

  • Improper grip during tennis or racquet sports
  • Poor trunk rotation when striking
  • Poor backhand form
  • Frequent use of tools like jackhammers or chainsaws
  • Occupational overuse among dentists, musicians, butchers and carpenters

Risk Factors

  • Being out of shape for your activity
  • Using improper technique during racquet sports
  • Not being properly fitted for a racquet
  • Engaging in an occupation that overloads the arm
  • Being middle aged

Get Personalized Tennis Elbow Physical Therapy Designed Just for You

At NYDNRehab, we treat the whole patient, not just your symptoms. We never use one-size-fits-all rehab protocols or antiquated recovery timelines. We believe that every injury is unique, and treatment should be based on a holistic approach that factors in the patient’s unique profile.

Once we have successfully pre-treated damaged tissues, we can begin one-on-one physical therapy to restore strength and stability, optimize mobility, and re-establish optimal neuromuscular pathways and muscle coordination patterns.

Your physical therapy protocol may include a combination of the following approaches:

  • Stecco fascial manipulation, to eliminate densifications and adhesions and restore fascia’s gliding properties
  • Postural restoration therapy to optimize total-body joint alignment
  • Dynamic neuromuscular stabilization (DNS) to restore developmental motor strategies
  • Integrated systems model (ISM) to optimize function and performance
  • Anatomy in motion (AIM) to enhance movement quality
  • Neurodynamics, to restore communication pathways between the brain and body
  • Conventional eccentric loading and strengthening exercises
Your back-to-sports physical therapy protocol may include sport-specific training to optimize motor skills and restore peak athletic performance. We carefully monitor patient progress with ultrasound imaging to confirm complete recovery.

Our Advanced Therapies and Technologies Produce Superior Results

Advancements in technology are changing the game in rehabilitative medicine, enabling us to accelerate healing and restore performance at an unprecedented pace. The clinic at NYDNRehab features some of the most advanced therapeutic equipment currently available, and rarely found in private clinics.

Your tendinopathy therapy may include the use of high-tech equipment:

C.A.R.E.N Computer Assisted Rehabilitation Environment

Originally developed to rehabilitate injured soldiers, this multifaceted system gives us a broad range of tools for assessment, feedback and performance enhancement. Dr. Kalka has integrated his own unique selection of technologies to optimize the ways in which C.A.R.E.N helps patients to achieve their goals.

Blood Flow Restriction Training (BFRT)

Rebuilding muscle strength while joints and connective tissues are still healing is a challenge for athletes who need to return to sport in the shortest time possible. BFRT enables you to increase muscle size and strength at much lower training volumes, to reduce stress on still-healing structures while rapidly restoring muscle performance.

Kineo Intelligent Load System

We use the Kineo intelligent loading system to create customized training and rehabilitation programs for our patients. With Kineo, we can customize variable load protocols for functional training, core training, agility drills and more. The Kineo variable resistance system lets us design a personalized variable load curve based on the needs of the individual patient.

Cryotherapy

Cold therapy has long been used for injury treatment and recovery from sports and exercise. Modern cryotherapy has replaced ice baths and ice packs with a dramatically faster and more convenient technology using nitrogen gas, directed via a specialized device to target injured tissues.

Preventing Tennis Elbow

Follow these guidelines to avoid lateral epicondylitis:

  • Seek professional guidance when choosing your racquet, to ensure you have the proper size racquet with the appropriate grip.
  • Hire a coach or trainer to teach you proper form.
  • Allow for adequate recovery time between sports or work sessions.
  • When using hand tools, take frequent breaks throughout the day to rest your arm muscles.
  • Apply ice to your achy elbow at the first sign of pain, or submerge it in an ice bath.
  • Seek early treatment if your pain persists.

Get a biomechanical analysis from the sports medicine lab at NYDNRehab, to identify mechanical errors and enhance your performance.

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Get the Best Elbow Pain Therapy in NYC

Modern medicine’s reductionist approach to treatment zeroes in on the locus of pain while overlooking the tissues and structures of the arm that interact with elbow movement. Pain is only a symptom, not a condition unto itself. While pain management may provide temporary relief, it does not resolve the mechanical factors that contribute to tendon pathology.

At NYDNRehab, our personalized one-on-one treatment approach is based on the results of your clinical exam and dynamic ultrasound imaging. With high resolution ultrasound, we are able to identify factors like myofascial trigger points, fascia densifications, nerve entrapments, and mechanical issues that overload the elbow tendons. Our advanced regenerative technologies and cutting-edge therapies accelerate healing, so you can get back to your favorite activities with fully restored pain-free function.

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    Clinical Case Studies
    NYDNRehab


    Case Study: Patient with Elbow Pain Self-Misdiagnoses

    Our Patient Our patient is a 57 year-old barber and recreational bodybuilder complaining of “tennis elbow” that would not go away. The pain worsened while lifting weights at the gym, and he reported pain and stiffness after waking up in the morning. He had previously had physical therapy, and an orthopedist had blindly injected a […]

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    Case Study: Lateral Epicondylitis

    Our Patient Our patient is a 56 year-old male jeweler who came to us with lateral elbow pain. The patient is a very athletic tennis player who works out at the gym on a regular basis. He stated that his pain initially started at the front of his elbow and eventually moved toward his lateral […]

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    Tennis Elbow FAQs

    I've never played tennis in my life – how can I have tennis elbow?
    Tennis elbow can arise from a number of sports, occupations and activities that repeatedly overload the tendons, bones, and muscles used for gripping and wrist action. Tennis elbow often affects painters, dentists, construction workers, and people who lift weights, to name a few.
    What is the difference between tennis elbow and golfer's elbow?
    Simply put, tennis elbow (lateral epicondylitis) symptoms appear at the outer elbow, affecting the muscles and tendons you use to bend your wrist backward and straighten your fingers. By contrast, golfer’s elbow (medial epicondylitis) symptoms arise at the inner elbow, affecting the muscles and tendons you use to flex your wrist forward and close your fingers into a fist. Both can be painful and debilitating.
    Will my tennis elbow symptoms go away on their own?
    If proper care is taken to treat your symptoms and avoid activities that cause lateral epicondylitis, it will most likely self-resolve over time. Rest, ice, and compression can help speed recovery. However, symptoms can persist for months, especially if you continue to play tennis or engage in other activities that overload your forearm. Treatment with regenerative therapies can accelerate tissue healing and dramatically shorten your recovery time.
    I've had tennis elbow multiple times – what am I doing wrong?
    Recurrent bouts of tennis elbow are often related to your racquet technique. Your grip, wrist motion and trunk rotation can all affect your elbow. A 3D motion analysis can help you identify and correct faulty motor mechanics that are overloading your elbow – it can even improve your tennis game!
    Once I begin treatment, how long will it take for my tennis elbow to stop hurting?
    It all depends on your unique condition and the type of therapy you receive. At NYDNRehab, our diagnostic technologies, regenerative therapies and personalized holistic approach work together to expedite recovery, so you can get back to your favorite activities as quickly as possible.
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    In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

    Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

    The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

    Dynamic ultrasonography examination demonstrating
    the full thickness tear and already occurring muscle atrophy
    due to misdiagnosis and not referring the patient
    to proper diagnostic workup

    Demonstration of how very small muscle defect is made and revealed
    to be a complete tear with muscle contraction
    under diagnostic sonography (not possible with MRI)

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    Complete tear of rectus femoris
    with large hematoma (blood)

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    Separation of muscle ends due to tear elicited
    on dynamic sonography examination

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