Tennis Elbow / Lateral Epicondylitis

Tennis elbow or lateral epicondylitis is a common injury causing pain on the outside of the elbow.

Despite it's name, this condition is not commonly seen in tennis players but more in work related elbow injuries particularly where repetitive stress is involved. Symptoms can be similar to those of other elbow injuries so it is important to get a correct diagnosis early on.

Symptoms

Tennis elbow assessmentSymptoms typically consist of pain about 1 to 2 cm down from the bony part on the outside of the elbow called the lateral epicondyle. The patient will have weakness in the wrist and difficulty doing simple tasks such as opening a door handle or shaking hands with someone. Pain is reproduced when pressing just below the lateral epicondyle on the outside of the elbow as well as when trying to straighten or extend the hand and fingers against resistance. See assesment & diagnosis for more information.

Entrapment of the radial nerve as well as neck injury can have similar symptoms.

Tennis elbow explained

Tennis elbowLateral epicondylitis as it is sometimes technically known is inflammation of the lateral epicondyle or bony bit on the outside of the elbow where the muscles attach. However, actual inflammation of the tendon is rare and the cause of the lateral elbow pain could be degeneration of the tendon.

It occurs most commonly in the tendon of the Extensor carpi radialis brevis muscle where there is an increase in pain receptors making the region extremely tender.

The most common cause is overuse or repetitive strain caused by repeated extension or bending back of the wrist against resistance. Gripping heavy objects like a manual screw driver, weight training or handling bricks will also cause tennis elbow. This is seen much more often than in tennis players.

Tennis backhandHowever, if tennis is thought to be the cause then the following should be considered. A poor backhand technique in tennis. If the wrist is bent when striking a back hand the huge forces are transferred through the tendons to the elbow rather than through the entire arm. A racket grip that is too small. This will make the muscles work harder increasing the forces through the tendon. Strings that are too tight. More shock and energy will be transmitted through the forearm from the ball. Playing with wet, heavy balls.

Two types of onset are commonly seen. Sudden onset in a single instance of exertion such as a late back hand where the extensors of the wrist become strained. This is thought to correspond to micro-tearing of the tendon. Late Onset: This normally takes place within 24-72 hours after an intensive term of unaccustomed wrist extension. Examples may be a tennis player using a new racket or even a person who's spent a weekend doing DIY.

Treatment

No single treatment for lateral epicondylitis has been shown to be totally effective, however a combination of the treatments below are known to resolve tennis elbow over time. Each individual will react differently to different treatments.

What can the athlete do?

Tennis elbow braceApplying ice or cold therapy to the elbow (15 mins up to six times a day) to reduce pain and inflammation if present is a good start. Rest is an extremely important component of treatment and the patient that fails to rest the elbow sufficiently will struggle. Wearing a specialist elbow brace to protect the tendon whilst healing can take some of the strain off the elbow by changing the direction of forces through the tendon. As with all soft tissue injuries a comprehensive rehabilitation program of exercises should be completed.

What can a sports injury specialist or doctor do?

A professional will make an accurate diagnosis ruling out other conditions and nerve involvement. Applying ultrasound or laser treatment can help reduce pain and inflammation as well as stimulate healing. A doctor can also prescribe pain reducing and anti inflammatory drugs such as Ibuprofen. A steroid injection to reduce inflammation if present is also an option.

Wrist extensor exerciseManual therapy treatments such as massage therapy, myofacial release and transverse friction techniques across the tendon may also be beneficial, especially if initial rest and ice is unsuccessful. Acupuncture has also been shown to be effective for tennis elbow as well as extracorporeal shock wave therapy.

In addition to the correct diagnosis it is important to identify and correct any tennis elbow causes either work related or tennis technique related and a good tennis coach should also be able to provide advice.

A full rehab program should be prescribed with advice on exercises neural stretching exercises if nerve tissue involvement is suspected. If all conservative treatment fails then surgery may be indicated, although it is likely to be a year before this is considered by a surgeon.