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Tennis Elbow
Otherwise know as “Lateral Epicondylitis”, Tennis Elbow is a common injury affecting the outside of the elbow. It got its name because tennis players tended to get it but it is not a condition confined to tennis or racquet players as it can affect anyone who is involved in gripping or extending the wrist against resistence eg squash players, carpenters and DIY enthusiasts. The underlying cause is degeneration of the tendon as it inserts into the lateral epicondyle, the bony prominence on the outer aspect of the elbow. This tendon connects the ECRB muscle from the back of the hand to the elbow and is involved in extending the wrist. It has a particular poor blood supply 1-2 cm below its attachment at the elbow which, when combined with excessive use can lead to degenerative changes in the tendon.
Tennis Elbow can affect any age group but particularly affects the 40-50 year olds. The condition can affect people in one of two ways. The most common is an insidious onset of pain, usually 24 – 72 hours after an unaccustomed activity involving wrist extension. This is often seen after a weekend of bricklaying, using a screwdriver, or prolonged knitting. In tennis it may occur after using a new racquet which may be heavier or have a different grip, playing with heavy wet tennis balls, or over-hitting especially into the wind. All these actions increase the strain on the ECRB tendon causing pain. Tennis style also plays a role, especially in the backhand where a ‘wristy’ action will also strain the tendon. This is avoided by keeping the wrist firm and not bent so that forces are transmitted up the arm to the shoulder and body rather than being focused on the tendon insertion at the elbow.
The other presentation is a sudden onset of pain after a single episode of exertion such as lifting a heavy object. In this form of tennis elbow it is thought to be due to small tears in the tendon which cause pain.
Symptoms of tennis elbow include pain over the lateral epicondyle or 1-2 cm below it, weakness of the wrist, and pain in the elbow when the wrist is extended against resistence. There is tenderness over the outside of the elbow and typically pain when the middle finger is raised against resistence when the palm of the hand is faced down on a table surface.
Other conditions that should not be confused with tennis elbow are lateral ligament strains, disorders of the head of the radial bone, radial nerve entrapments, elbow arthritis and conditions from the nerves in the neck. It is important that you get the diagnosis confirmed by a Medical Professional before embarking on treatment.
Treatment of tennis elbow is varied and no single treatment as been proven to be totally effective. A combination of different treatments will result in resolution of the symptoms in most cases.
Control of pain and any inflammation will require a period of rest, application of ice (moving an ice cube over the painful site for 15 minutes up to six times a day), and the use of non-steroidal anti-inflammatory drugs eg ibuprofen.
If this does not improve the symptoms then referral to a Sports Physician or Physiotherapist for the following treatment would be worthwhile.
Electrotherapeutic modalities such as ultrasound or laser may encourage the healing process. Massage therapy is performed to the tendon and adjacent tight or thickened structures. Stretching of the ECRB muscle and releasing of trigger points are also useful. Muscle strengthening with eccentric muscle exercises as advised by the therapist are essential to recovery and prevention of further exacerbations. Counterforce bracing reduces the forces on the tendon and can give symptom relief if applied correctly. The use of steroid injections is controversial however their use is helpful if recovery has hit a plateau after 2-3 months of treatment where periostitis or bone inflammation can occur. Injections should be used as an adjunct to other forms of treatment and is not the panacea for all conditions. Very occasionally in resistant cases where conservative treatment fails surgery to excise the degenerative tissue and release the tendon is performed.
Whatever the treatment modality, once improvement is seen, there should be a graduated return to activity concentrating on gradual loading of the tendon in phased activity. It is important to alter any predisposing factors such as grip size, string tension, racquet weight, size of the ‘sweet-spot’ on the racquet, and backhand technique.
Tennis elbow is a common condition that is often disabling to a spectrum of people whatever their sport of hobby. Treatment often requires a multifaceted approach and with the correct therapy from a Sports Specialist recovery occurs in most cases.
Dr Mike Bundy
MBBS, MRCGP, Dip Sports Med, FFSEM
Sports Physician