Tennis Elbow

Tennis elbow

Tennis elbow is also known as lateral epicondylitis, lateral elbow tendinopathy or extensor tendinopathy. It is a common term used to describe long term, chronic pain on the outside of the elbow.

Tennis elbow symptoms

  • Pain approximately 1 to 2 cm down from the bony protrusion (lateral epicondyle) on the outside of the elbow.
  • Symptoms may occur suddenly, but it usually develops gradually over time.
  • You may have weakness in the muscles around the forearm and wrist. As a result, performing simple tasks such as gripping objects, opening a door handle or shaking hands is painful.

Tennis elbow assessment tests

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A professional therapist may perform a number of specific assessment tests to help diagnose lateral elbow pain.

  • Resisted wrist extension. This involves attempting to extend the wrist (move upwards, palm down) against resistance. The test is positive if symptoms are reproduced.
  • Resisted extension of just the middle finger. This is usually the most sensitive tennis elbow test1 and is positive if symptoms are reproduced.
  • Other tests, such as the ‘Mills maneuver’ and the ‘neural tension’ test may be performed to check for nerve involvement. These may indicate other injuries, such as the entrapment of the radial nerve, and certain neck injuries.

Finally, they may feel (palpate) around the outside of the elbow to identify tender areas.


What is Tennis elbow?

It is a general term people use to describe pain on the outside of the elbow. However, the specific diagnosis may be lateral epicondylitis, which is tendon inflammation. Or more likely, tendinopathy, which describes wear and tear or degeneration of the tendon.

Tennis elbow - extensor muscles of the wrist

The wrist extensor muscles attach to the lateral epicondyle (bony bit) on the outside of the elbow. Tennis elbow pain usually occurs where the tendon of the ‘extensor carpi radialis brevis’ muscle inserts into the bone2. At this point, there are a large number of pain receptors. As a result, the region is particularly tender to touch. Symptoms are either acute, or chronic.

Acute Tennis elbow

  • Acute injuries occur immediately after an activity such as hitting a backhand shot in tennis with poor technique.
  • The extensor muscles on the back of the forearm (wrist extensors) become suddenly overloaded. This causes small micro-tears in the tendon where it attaches to the elbow.

Chronic Tennis elbow

  • Chronic injuries normally develop over a period of days/weeks. It often follows a bout of intense exercise or unccustomed activity. For example, lifting heavy boxes and other DIY jobs.

Is it lateral epicondylitis or extensor tendinopathy?

  • The medical term often used is lateral epicondylitis. However, this can be misleading as the ‘itis’ on the end of the word implies that there is inflammation.
  • In long term cases, the acute inflammatory stage has passed and tendinopathy is an appropriate term. This is because it describes degeneration of the tendon rather than acute inflammation.

What causes tennis elbow?

The most common cause of Tennis elbow is overuse or repetitive strain. In particular, repeated extension (bending back) of the wrist. For example:

  • Gripping or turning objects like a manual screwdriver.
  • Lifting heavy weights during strength training.
  • Repeatedly performing occupational activities, such as lifting bricks.

Tennis technique

The injury got its name because it playing a backhand in Tennis with poor techinique surefire way to cause injury. The huge force of the ball striking the racket is transferred through the forearm and is focussed at a point on the outside of the elbow.

This is made worse if your wrist is bent when striking the ball. This is because the forces are transmitted through the muscle and tendon, rather than the whole arm. Therefore, It is not an injury that affects regular players as they are likely to have good technique and strength.

Other factors related specifically to tennis include:

  • Gripping the racquet too tightly
  • Having racket strings too tight
  • If the grip is too small.

All these result in the forearm muscles overworking.


Tennis elbow treatment

Treatment involves reducing pain and inflammation, then gradually increasing the load through the elbow with exercises, to a point where normal training is resumed.

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No single treatment is likely to be effective but using a combination of approaches is recommended3.

What can the athlete do?

In the first 72 hours post-injury, apply the principles of P.R.I.C.E. (Protection, Rest, Ice, Compression, and Elevation).

  • Rest – Rest is probably the most important part of treatment and is often difficult to do. If you continue to use the painful elbow then it will not recover as quickly and may become chronic and very difficult to treat. Avoid gripping heavy things, opening heavy doors, using a screwdriver and of course playing a backhand in tennis.
  • Ice – Apply a cold compression wrap for no more than 15 minutes as the injured tissues are very close to the skin and do not need longer. 
  • Protection – Wearing a specialist elbow brace or support can help reduce the strain on the tendon enabling healing to take place. This works by applying compression around the upper arm which puts pressure on the injured tendon, changing the way forces are transmitted, allowing the injured tissues to rest.

Massage

Massage can be a useful treatment for tennis elbow, particularly more chronic conditions. In particular, cross friction massage of the tendon, but only once the initial inflammation has settled. This is usually after 5 days.

  • Place the 2nd finger of your opposite hand on the outside of the elbow and rub across the tendon (painful area) for 5 minutes.
  • Do not press too hard but there may be some mild pain whilst having the area ‘frictioned‘. Repeat once a day.
  • Stop if your pain worsens after the treatment.
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Every Tennis Elbow injury will react differently to the different treatments available so using a number of them concurrently is often the most effective way of treating the condition. In addition to treating the current injury, it is also important to identify and correct any possible causes that may be either work-related or sport-related and your therapist will be able to advise how to achieve this.


What can a sports injury professional do?

Medication – A professional therapist or doctor may prescribe medication such as Ibuprofen to help reduce symptoms in the early stages, however, the effectiveness of this long-term is disputed. Do not take Ibuprofen if you have Asthma.

Electrotherapy – Your therapist may choose to use different types of electrotherapy equipment to treat the symptoms. Some of the methods commonly used include the following:

  • Ultrasound – this 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 – works by passing 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 short but intense energy waves into the tissues.

Acupuncture – Dry needling or Acupuncture has been shown to be an effective treatment for tennis elbow (in some cases). It involves inserting needles of various lengths and diameters into specific points around the forearm and surrounding areas. Needles are inserted, rotated and then left in place for several minutes and the theory of how it works is to hopefully alter the way pain signals are transmitted via the nerve pathways.

Corticosteroid injections – Another treatment for Tennis elbow is injecting corticosteroid drugs into the area. Current evidence has shown them to be effective in the short term but the long term effects are debatable. In order to improve the chances of a good end result, the patient often requires a series of injections over a period of weeks or months as opposed to a one-off injection. The steroid should be injected around the area of the tendon attachment and not into the body of the tendon as there have been cases of tendon ruptures following steroid injections.


Other treatments

  • Nitric oxide donor therapy patches are applied to the elbow. These may be beneficial over a period of months, although approximately 5% of patients will have side effects including headaches and skin rashes.
  • Botox injections – thought to improve short term pain relief although there is a very high likelihood that the forearm muscles will not function properly afterward.
  • Autologous blood injection – involves centrifuging the patient’s own blood to separate the plasma from the red blood cells. The resulting plasma is rich in platelets that are effective for healing. This is then injected back in and around the site of injury. It is thought to re-initiate or enhance the inflammation repair response.

Exercises for Tennis Elbow

Both stretching and strengthening exercises4 are important for treating Tennis Elbow and provide the foundation for a rehabilitation program. Stretching exercises should be performed as soon as pain allows and then continued until and after your are fully fit. The most important stretching exercise is to stretch the wrist extensor muscles.

Read more on Tennis elbow exercises.


Tennis elbow surgery

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Both golfers elbow and tennis elbow are approached in a similar manner which it comes to surgery. Surgical treatment of tennis elbow consists of recessing and releasing the portion of the frayed or diseased tendon. In other words removing it from the bone.

Modern techniques usually involve endoscopic (keyhole surgery). A very small incision is made rather than opening up the area. The principle of tennis elbow surgery is the same whatever the surgical technique. That is to release the damaged tendon from the bone.

How long until I have recovered?

The vast majority of cases respond to conservative treatment (non surgical). However, if surgery is required then it maybe 8 weeks before the patient has recovered.


References

  1. Fairbank SM, Corlett RJ. The role of the extensor digitorum communis muscle in lateral epicondylitis. J Hand Surg Br 2002;27B(5):405–9.
  2. Milz S, Tischer T, Buettner A et al. Molecular composition and pathology of entheses on the medial and lateral epicondyles of the humerus: a structural basis for epicondylitis. Ann Rheum Dis 2004;63(9):1015–21.
  3. Coombes BK, Bisset L, Vicenzino B. A new integrative model of lateral epicondylalgia. Br J Sports Med 2009;43(4):252–8.
  4. Pienimäki T, Karinen P, Kemilä T et al. Long-term follow-up of conservatively treated chronic tennis elbow patients. A prospective and retrospective analysis. Scand J Rehabil Med 1998;30(3):159–66.
This article has been written with reference to the bibliography.