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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 include pain about 1 to 2 cm down from the bony part on the outside of the elbow called the lateral epicondyle. There is likely to be weakness in the wrist with 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. Tennis elbow can be sudden onset or gradual onset.
- Sudden onset occurs from a sudden impact such as hitting a tennis ball backhand with poor technique. The extensor msucles of the wrist become strained and and there is thought to be small micro-tearing of the tendon.
- Late onset normally takes place within 24-72 hours after an intensive term of unaccustomed wrist extension for example using a new racket or even a person who's spent a weekend doing DIY.
Resisted wrist extention - In cases of tennis elbow, wrist extension (bending the wrist back) can be painful, and so to assess this symptom, the therapist will often provide resistance with their own hand for the patient to push against.
Resisted middle finger extension - Extending the middle finger alone is another test which is used to suggest tennis elbow is the cause of pain. The therapist applies resistance as the patient tries to extend their middle finger.
There are other tests which may be conducted, depending on the symptoms and the results of the tests above. These include the Mills maneuver and neural tension tests to determine if there is any neural involvement.
Self help treatment
Rest is important to allow the tissues to heal. Activities which place a large strain on the elbow such as gripping things, opening heavy doors, using a screw driver should all be avoided if possible. Applying ice or a cold therapy wrap to the elbow (15 mins up to six times a day) to reduce pain and inflammation is a good start, particularly in the early days when the elbow is acutely painful. Ice can also be applied after performing rehabilitation exercises.
A specialist tennis elbow brace is worn around the forearm to support the tendon whilst healing and when returning to activity. It works by applying compression around the upper arm and so changes the direction of forces through the tendon hopefully reducing the strain on the painful part of the tendon. To be effective it must be applied correctly.
No single treatment 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. In addition it is important to identify and correct any tennis elbow causes either work related or sport related and a good tennis coach should also be able to provide advice.
A full rehabilitation program should be followed which includes stretching and strengthening exercises.
A professional therapist can apply electrotherapy to help with symptoms. This involves applying energy of various types to the soft tissues and is thought to help reduce pain and inflammation. The evidence for the effectiveness of electrotherapy is mixed. Various methods are commonly used:
- Ultrasound involves passing high frequency sound waves into the tissues. This vibrates the molecules and depending on if it is applied continuously or in pulses can generate heat.
- Laser passes high intensity light into the tendon to reduce pain, inflammation and encourage cell reproduction. No heat is generated with laser treatment.
- Extracorporeal shock wave therapy works by passing shock waves (short but intense energy waves) which travel faster than the speed of sound, into the tissues.
Medication - A doctor can prescribe pain reducing and anti inflammatory drugs such as Ibuprofen.
Manual 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. Trigger points or tiny localized knots in the forearm muscles are often found and can be treated with massage techniques or acupuncture.
Acupuncture has also been shown to be effective for tennis elbow and involves inserting needles of various lengths and diameters into specific points over the body. The needle is usually inserted, rotated and then left in place for several minutes. It is thought to alter the way pain signals are transmitted by nerve pathways.
A corticosteroid injection is thought to be effective in the short term but less so later on after a month or so. There is thought to be an increased rate of the injury recurring with treatment by injection. If it is performed then it should be done around the tendons and over the most painful point, but not into the tendon tissue itself.
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. See our interview with Mr Elliot Sorene, Consultant Surgeon on surgery for Tennis and Golfers elbow.
Nitric oxide donor therapy patches applied to the elbow may be beneficial over a period of months although approximately 5% of patients will have side effects including headaches and skin rash.
Botox injections are thought to improve short term pain relief although there is a very high likelihood that the forearm muscles will not work as they used to.
Autologogous blood injection involves centrifuging blood to make it rich in platelets then injecting it back around the site of injury. It is thought to re-initiate or enhance the inflammation repair response.
Both stretching and strengthening exercises for tennis elbow are important and provide the main element of a rehabilitation program. Exercises should be done as soon as pain allows and continued after full fitness has been achieved. Wrist extension exercises are most important where the aim is to gradually increase the load through the tendon so it can cope with what is being demanded of it but within the limits of pain.
Stretching exercises should start as soon as possible and be continued throughout rehabilitation and beyond. The muscles specifically involved in the rehabilitation of Tennis elbow can be stretched by placing the arm out straight in front, palm down and gently pull the hand towards you. Rotating the forearm inwards can increase the stretch. Held for 20 seconds and repeated up to 5 times.
Strengthening exercises usually begin with isometric or static exercises. This means contracting the muscles without actually moving the wrist or hand. These should be started as soon as pain allows but if they are painful to perform then wait. The arm is positioned with the palm and forearm facing down. Aim to extend the wrist (lift it upwards) against resitance which can either be your hand or the therapists. Maintain the contraction for 5 seconds. Rest and repeat 10-15 times. There should not be any movement at the wrist joint.
The next step is to bring in dynamic strengthening exercises which involve movement. These include wrist extension exercises using a weight or resistance band to resist the movement. The load is gradually increased over time and within the limits of pain. An elastic band over the fingers can also be done as the arm becomes stronger.
Read more on exercises for tennis elbow.
Tennis elbow explained in detail
Tennis elbow occurs most commonly in the tendon of the extensor carpi radialis brevis muscle as it inserts into the bony bit on the outside of the humerus. There is an increase in pain receptors making the region extremely tender. The term tennis elbow is more of a general term to describe pain on the outside of the elbow rather than an accurate diagnosis of what is actually going on.
A number of other terms have been used to descriibe pain on the outside of the elbow:
- Lateral epicondylitis - the 'itis' on the end of the word implies inflammation of the tendon. This is not accurate in most cases, particularly long term chronic injuries as inflammation cells are not present.
- Lateral epiconylosis - the 'osis' on the end of the word implies a degeneration of the tendon. This is also not strictly accurate as not all cases have degenerative changes in the tendon.
- Extensor tendinopathy - is probably a better term as the 'opathy' assumes some kind of cause but does not imply any specific diagnosis.
Actual inflammation of the tendon is rare and the cause of the lateral elbow pain is more often degeneration of the tendon. 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.
If you pay tennis then it is possible a poor backhand technique is responsible. 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. Also, if your racket grip that is too small then this will make the muscles work harder increasing the forces through the tendon. Strings that are too tight will transmit more shock and energy the forearm from the ball and playing with wet, heavy balls also increases the load on the elbow.
See rehabilitation program for more details on how and when treatments are applied.
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