Tennis Elbow

Tennis Elbow

Tennis Elbow is a general term used to describe outer elbow pain. The most common causes are inflammation or degeneration of the tendon where the wrist extensor muscles insert into the elbow. This can occur from sports, like tennis, and other activities that put stress on the elbow muscles. It is also known as lateral epicondylitis or extensor tendinopathy.

Despite its name, this condition is not only seen in tennis players but is also seen in other sports or recreational activities that involve repetitive stress on the muscles around the elbow, such as heavy lifting or decorating.

The injury can be very troublesome to treat, especially if it becomes chronic, so it is very important to obtain an accurate diagnosis as early as possible. Tennis elbow can either develop very suddenly (acute) or over a period of days/weeks and more gradually (chronic).

Tennis elbow symptoms

Tennis elbow assessment and diagnosisThe main symptom is a pain about 1 to 2 cm down from the bony part on the outside of the elbow, known as the lateral epicondyle. In addition, there may be an associated weakness in the muscles around the forearm and wrist and this may cause difficulty in performing simple tasks with weakness gripping things, opening a door handle or shaking hands with someone.

How to diagnose Tennis Elbow

A doctor or professional therapist may perform a number of assessment tests to help diagnose lateral epicondylitis. After taking a full history from the patient of how the pain started, the strength levels and integrity of the various wrist extensor muscles will be tested. More specifically, the therapist may choose to do a lateral epicondylitis test involving middle finger extension as this is often the most sensitive tennis elbow test.

There are other tests that may be performed and these include the 'Mills maneuver' and 'neural tension' tests to assess the nerve tissue in the area. The reason for this is that similar injuries, such as the entrapment of the radial nerve as well as certain neck injuries can present with have similar symptoms.

Finally, the therapist may choose to feel (palpate) around the outside of the elbow to see if there are any tender spots particularly in the region of the tendon attachments of the wrist extensor muscles to the lateral epicondyle.

What is tennis elbow?

It is usually an overuse injury, most commonly occurring at the junction where the tendon of the extensor carpi radialis brevis' muscle inserts into the lateral epicondyle of the humerus (bony bit on the outside of the elbow near the 'funny bone'). In this area, there are a large number of pain receptors making this region particularly tender to touch.

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 causing micro tears of the tendon where it attaches to the elbow.

Chronic injuries on the other hand normally develop over a period of days/weeks and usually follows bouts of intense exercise/activity that the patient is unaccustomed to, such as lifting heavy boxes when moving house.

The medical term is lateral epicondylitis but this can be misleading as the 'itis' on the end of the word implies that there is inflammation in the area but in most cases, this is not true because most of the injuries are chronic or longstanding and therefore the inflammatory stage has finished.

The most common cause of Tennis Elbow is overuse of the muscles (also called “repetitive strain”) caused by repeated extension or bending back of the wrist against resistance. Gripping or turning objects like a manual screwdriver, lifting heavy weights during strength training or repeatedly performing occupational activities such as a builder laying a number of bricks are all common causes of tennis elbow.

As the name suggests, these injuries do sometimes occur whilst playing tennis and the cause is often a technical issue. The main contributing factor is poor back-hand technique because, during this particular shot, large forces are transmitted through the muscles and tendons of the forearm. This is made worse if the wrist is bent when striking the ball as the forces are transmitted through the muscle and tendon rather than the whole arm.

Other possible factors that are related specifically to tennis with this particular injury are gripping the racquet too tightly (if the handle is too small) and having the strings of the racquet too tight. In both of these situations, the consequence is that the forearm muscles are overworked which increases the load on the tendon and its attachment to the elbow. Professional tennis players don't usually get Tennis Elbow because their bodies have been conditioned to the demands of the sport and their technique is good.

Tennis elbow treatment

Treatment involves reducing symptoms of pain and inflammation through rest and applying ice or cold therapy, then gradually increasing the load through the elbow through exercises to a point where normal training and competition can be resumed.

Ice & compression - In the first 72 hours post injury, you should apply the principles of P.R.I.C.E. (Protection, Rest, Ice, Compression, and Elevation). 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 - Wear 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 through it allowing the injured tissues to rest.

Rest - this 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.

Sports massage can be a useful treatment for tennis elbow, particularly more chronic conditions. In particular cross friction massage of the tendon insertion but only once the initial inflammation has settled (after 5 days) is done. 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. Do not carry on with this exercise if the pain worsens after the treatment.

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. In addition electrotherapy such as ultrasound, laser, extracorporeal shock wave therapy, acupuncture, corticosteroid injections, nitric oxide donor therapy patches, botox injections, and autologous blood injection are all treatments available for treating medial epicondylitis.

Exercises

Both stretching and strengthening exercises are important for treating Tennis Elbow and provide the foundation for a rehabilitation program. The exercises should be performed as soon as pain allows and then continued until and after full fitness has been achieved.

Wrist extension stretches and exercises are the most important with the aim of gradually increasing the load transmitted through the tendon and its attachment whilst also being within the limits of pain. Isometric (also known as static exercises) are done first and involve contracting the muscles without actually moving the wrist. They should only be started once the initial pain and inflammation has settled down.

Read more on tennis elbow exercises.

Surgery

Both golfers elbow and tennis elbow are approached in a similar manner which it comes to surgery. The vast majority of cases of tennis elbow do respond to conservative treatment of rest, ice, ultrasound and occasionally a steroid injection, however, if however if surgery is required then it may be 8 weeks before the patient has recovered.

Mr. Elliot Sorene, Consultant Surgeon who explains when surgery may be indicated and which patients are most suitable.

Surgical treatment of tennis elbow consists of recessing and releasing the portion of frayed or diseased tendon, removing it from the bone whether it be on the inside for golfer's elbow or the outside for tennis elbow. More modern techniques undertake the same operation using endoscopic or keyhole surgery where 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 and that is to release the damaged tendon from the bone.

Also, these days patients can be treated with platelet-rich plasma injections where blood is taken from the patient themselves and with a centrifuge the clotting and healing factors of the patients blood are injected into the area on the elbow where the tendon has frayed.