Tennis elbow

Summary

Lateral epicondylitis (also known as tennis elbow) results from any movement which places strain on the tendon which attaches the muscles of the upper arm to the outer portion of the elbow

• You don’t have to be a professional tennis player to suffer from tennis elbow
• This can result from gardening, poor placement of mouse and keyboard and many other activities.
• In 90% of cases, it will get better on its own within a few weeks, particularly if the affected arm is rested.
• Surgery is reserved for very severe cases (10% of cases) which do not respond to conservative treatment.  

Description

Tennis elbow is an injury to the muscles and tendons on the outside of the elbow that results from overuse or repetitive stress. Muscles which work the wrist and fingers, attach to a tendon which links them to the humerus – the upper arm bone. Bending the wrist back (extension), turning the hand palm side down, and lifting an object with the elbow straight are the more common activities that affect these tendons.

Patients with tennis elbow experience pain at the lateral (outside) aspect of the elbow that can travel into the forearm. The pain occurs when grasping an object. This may be accompanied by a sense of weakness. An achy type of discomfort may also be experienced while resting.

Cause

Tennis elbow is caused by repetitive arm movements, whether it is pruning roses, hammering a nail or actually playing tennis. Overusing the muscles in your arm can lead to tiny tears in the tendons that attach the muscle to the bone on the outside of the elbow. If one continues to do the activity without allowing the tears to heal, the tendons can become inflamed.

Wear and tear occurs in the tendon over time and leads to a situation where the tendon is weaker than normal. Degeneration in a tendon usually shows up as a loss of the normal arrangement of the fibre of the tendon. The healing process in the tendon causes the tendon to become thickened as scar tissue tries to repair the tendon. This condition is called tendonitis – or inflammation of the tendon.

A theory on the cause of tendonitis is that small tears in the tendons occur through overuse. They begin to heal, but when re-injured by continued use, the tendons seem to stop healing and a condition called angiofibroblastic degneration begins to take over. Another theory is that the tendon changes are a result of decreased blood flow in the area.

Who gets it and what are the risk factors?

The term “tennis elbow” is somewhat of a misnomer, considering that tennis players account for only five percent of all cases. This means that anyone who has a hobby or occupation that involves rotational movement of the forearm is susceptible. In the computer age, more and more people suffer from Lateral Epicondylitis. This can emerge from faulty body mechanics while sitting at the computer with a keyboard that is positioned too high for the elbow and wrist.

These conditions usually affect people between 20 and 65 years of age, with the most frequent occurrences in the 40’s.

Risk factors

One can increase the risk of contracting or aggravating tennis elbow by:

• Using improper techniques while playing sport (e.g. using the wrong gripping technique in tennis or squash or holding a hockey stick incorrectly) or twisting objects in the working environment which puts strain on your muscles.
• Making use of incorrect equipment, such as bats or tools that are too heavy or have handles which are too big.
• Repeating movements of the forearm, wrist and fingers on a continual basis. People in professions, such as plumbing and car mechanics are at risk, because of the constant twisting motions needed. Sports, such as swimming, tennis, cricket and baseball have the potential to put strain on one’s forearm. Avid gardeners and homemakers can also be at risk.
• If you do not warm up well before you play or use your forearm at work. It is also important to keep the muscles warm during the activity.
• Age has an influence on people at risk. Middle aged men and women are at greater risk.

Symptoms

• Recurring tenderness and pain on the outside of the elbow just above the bend of the elbow; occasionally, pain radiates down the arm towards the wrist.
• Pain caused by lifting or bending the arm or grasping even light objects.
• Difficulty extending the forearm fully because of inflamed muscles, tendons and ligaments.
• Pain that typically lasts for six to twelve weeks. Discomfort can, however, continue for as little as three weeks or as long as several years.
• Pain occurs in the dominant arm.
• Some patients lose some motion in the elbow, usually a few degrees of extension.

Diagnosis

The diagnosis of tennis elbow can usually be made from physical examination alone. Your doctor will review a history of your daily activities, your elbow problem and past injuries to your elbow. Because tennis elbow can be confused with other causes of elbow pain such as radial tunnel syndrome, (a condition that is caused by compression of the radial nerve as it crosses the elbow), X-rays are often taken.

Other diagnostic techniques are used if non-surgical treatment has not helped:

• Magnetic Resonance Imaging (MRI) assists the doctor to detect soft tissue problems.
• In rare cases, bone scans are used to show tumours or stress fractures in and around the elbow.
• Intra-articular injections can be used to differentiate intra- from extra-articular causes.

Outcome

The symptoms of tennis elbow usually begin gradually. It may start with a dull soreness or aching that one feels during activity. This feeling goes away within 24 hours. With time, pain can be felt 48 hours after the actual activity.

Pain may increase in the evening and the elbow will be stiff in the morning. The elbow may be tender when touched. Eventually, pain will be experienced with any movement, even everyday activities. Finally, there will be pain even when the elbow is not being used and it may be hard to sleep.

Prevention

Tips for preventing injury or aggravating an existing condition:

• Warm up well before you play or use your forearm at work. It is important to keep the muscles warm during the activity.
• Maintain good overall physical fitness.
• Alternate hands to prevent overuse of one arm.
• Relieve stress off your elbow by strengthening the muscles of your arm and shoulder. Make sure that the technique you use is correct.
• Use the correct equipment, which is suitable for your body and your ability.
• Make use of a counterforce brace during activities that require twisting and gripping.

Treatment

Home
Surgery is only needed in the treatment of severe cases of tennis elbow. Your doctor will examine your elbow and advise conservative treatment at first. This can be done in steps:

• Rest:
  Rest is the first step in treating tennis elbow. Activities that aggravate the pain should be avoided or minimised. Rest allows the small tears in the tendons to heal.
• Ice:
  Cold therapy is used to decrease inflammation and pain. Treat the arm with an ice bag or make use of ice massage after activity. The area should be treated two to three times a day for a period of ± 25 minutes.
• Compression:
  Tennis elbow straps are used by some patients. Strapping the forearm below the elbow sometimes helps speed recovery by increasing blood circulation and by taking strain off the injured tendon.
• Elevation:
  When you elevate your forearm you will experience pain relief and reduced swelling.
• Rehabilitation:
  Special exercises for flexibility and arm muscle strength are a very important part of treating tennis elbow. Gentle stretching exercises for the forearm and wrist is combined with a general fitness and strength enhancing programme. Aerobic exercise helps maintain healthy conditioning of the heart, increases circulation to your entire body and stimulates nerves in the injured tissue. This will enhance the healing process.
• Altering of activity:
  Techniques and equipment should be modified to enable you to continue using your arm within the limits of pain.
• Medication:
  Oral anti-inflammatory medication which include ibuprofen and other prescription medications are helpful in controlling the pain. Medication does not cure tennis elbow as such, but can reduce inflammation, which in turn allows you to start rehabilitation. Corticosteroid injections are given in more severe cases of tennis elbow and are usually only given after weeks of nonsurgical treatment. The cortisone is injected into the area of the inflamed tendons in order to decrease the inflammation. Cortisone should be used with caution due to possible side effects.
• Wrist braces:
  Wrist braces are only used when pain is severe and other measures have failed. These braces are usually worn while sleeping to bend the wrist backwards and thus taking the stress off the muscle attachments.

Supervised treatment
If home treatment does not solve the problem, physiotherapy treatment is advised. Several choices, such as heat and ice treatment, iontophoresis, ultrasound, TENS or phonophoresis are available to limit inflammation and pain associated with tennis elbow.

The cycle of inflammation and scarring is treated by keeping the scar pliable. Physiotherapists make use of friction massage, forearm stretching, soft tissue mobilisation and manipulation. In the initial stages, isometrics help maintain muscle mass without over stressing the tissue. Later on, endurance and strength are increased by progressive resistive exercises.

As the arm strengthens and the pain is resolved, emphasis is placed on the wrist extensors. These muscles should be able to control forces in an eccentric contraction.

The fingers, wrist, forearm, elbow and even the shoulder should be treated and strengthened.

Surgery
Surgery is available when all of the above measures have failed over a period of months and severe pain continues to exist to such an extent that normal activities are inhibited.

There are different approaches to surgery for tennis elbow. The approach is determined by the type, location and severity of the injury and by the doctor’s preference.

There is a 85-95% success rate after surgery and a return to normal daily activities is usually possible within three to six weeks. However, a return to strenuous sport and the intense use of the arm can take several months.

When to see your doctor

A doctor should be seen if your elbow has been injured and:

• Pain persists for more than a few days
• Normal movement of your elbow is affected
• Deformation of your elbow appears
• The elbow joint begins to swell within 30 minutes of the injury (although it is more likely to be caused by arthritis, gout or an infection)
• You experience pain when twisting, grasping or lifting objects
• Treatment is causing more pain
  • You show signs of nerve or blood vessel damage, such as:
  • Numbness or a tingling feeling below the injury
  • Pale skin
  • The limb feels colder than normal
• Pain not relieved by ordinary painkillers.

Reviewed by Dr Sirk Loots, orthopaedica surgeon.

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