What is Tennis Elbow?
Tennis elbow involves inflammation of tendons which connect the muscles of the forearm to the outside of the elbow. Medically known as lateral epicondylitis, this painful condition is usually caused by overuse.
Affecting between one and three percent of the adult population, it is not only caused by tennis, as the name suggests. Plumbers, painters and carpenters, as well as butchers, cooks and auto workers suffer from this condition. (1, 2)
In fact, anyone using repetitive lower arm movements, playing sports or doing any other activity could get tennis elbow. It affects both men and women, generally between 30 and 50 years old and is more prevalent in the dominant arm. (3)
This condition involves the tendons which attach the muscles in the forearm to the knobbly part of the elbow (lateral epicondyle). The main muscle involved is called the extensor carpi radialis brevis, which extends down the forearm from the elbow.
This muscle helps to stabilize and straighten the wrist and is attached to the elbow by tendons. The function of the tendons is to transmit signals between the muscle and bone, and allow movement.
As we have already mentioned, tennis elbow is sometimes caused by playing tennis, but only in up to 10 percent of cases. (6)
Many other activities also result in repeated stress being placed on the elbow joint, both work related and recreational. Actions that can contribute include using screwdrivers, hammers and pliers, turning door knobs, arm wrestling, and other twisting movements.
Fine movements that are repetitive using the wrist and hands, such as typing or using scissors, also contribute. Lifting objects with an extended wrist can also result in this condition. (7)
A less common cause of this condition is a direct blow to the elbow. This could allow the tendon to swell and leave it susceptible to a repetitive use injury. (8)
The symptoms of tennis elbow include pain or tenderness on the outer part of the elbow. This can also extend to the forearm, and from the back of the hand to the wrist.
This joint pain can be mild and only felt when the elbow is used, or severe and felt even when the elbow is still. Often the pain will worsen when you use your arm, especially in a twisting motion. Repetitive wrist movement when gripping or extending the wrist will also exacerbate the pain.
Other places you might feel pain include the outer part of the forearm below the elbow.
Some activities may make the pain worse or cause stiffness when extending the arm fully. These include: bending or lifting the arm, gripping small objects or writing.
Twisting forearm motions like opening a bottle or jar might also cause pain. (9)
The majority of people, about 90 percent, will usually fully recover from an injury of this nature within twelve months. However, it can last up to two years or longer. (10)
This repetitive injury to the tendon is generally not as a result of inflammation. It falls under a class of damage to the tendons termed tendinopathy. These result in weakness, degeneration, pain and tearing of the tendon following overuse. (11)
The tendon is made up of fibers called collagen, blood vessels and cells (tenocytes). A normal tendon, when examined under imaging, will display these components in orderly lines, side by side and end to end.
They essentially run parallel to one another with a very slight wave pattern. The tenocytes will be seen as elongated, uniformly spread and even in number.
When they are damaged this pattern varies and tendinopathy is graded according to the amount of damage to the tendon. There are four grades applied to the different levels of tendinopathy. These are: (12, 13)
This reveals that the uniform lines formed by the collagen fibers have become slightly wavy in appearance.
In stage 2, the collagen fibers become more disorganized and break away from each other. The appearance of the cells (tenocytes) are more rounded and move away from their uniform position. New blood vessels sprout from existing ones.
In this stage the cells near the damaged area breakdown. Collagen also breaks down and increased cell migration will be seen. MMP-9, an enzyme which plays a role in tissue repair and growth, is produced.
This level of injury involves tears which would be visible to the naked eye and possible separation of the tendon from the bone.
In up to 95 percent of people with tennis elbow, non surgical treatment will be successful. These treatments include: (14)
Properly resting the arm is the first step to recovery for this condition. Stopping any movements which exacerbate the condition are key. This means not playing sports that might have caused tennis elbow. A person might also need to modify work tasks or recreational activities that contribute to the pain.
Non steroidal anti inflammatory (NSAIDs) drugs like aspirin or ibuprofen can help manage the pain and reduce swelling. If the pain is severe you might need prescription pain medication.
There are certain exercises specifically designed to strengthen the muscles in the wrist and forearm. A physical therapist will advise the best ones and the frequency at which they should be done.
A medical professional might also use ice massage, ultrasound or other techniques to stimulate the muscle and reduce pain and swelling. The ultimate aim of these techniques is to promote healing and give full movement and function back.
A brace used to stabilise the elbow and forearm might help relieve the pain and swelling associated with this condition. Using this type of device will allow the tendons and muscles to rest and recover.
There are anti inflammatory medicines like cortisone which can be injected into damaged muscle to relieve pain. This is an option that a doctor can consider when treating tennis elbow.
Injecting other substances like your own blood (platelet rich plasma) or botox might also stimulate tissue repair and provide symptom relief. (15)
Extracorporeal Shock Wave Therapy
This therapy uses very short bursts of sound waves delivered to specific parts of the injured elbow. The reason this works is unclear, but it is believed that the shock waves stimulate healing of the damaged tissue.
Using equipment which is not a proper fit for you can exacerbate symptoms and lead to further instances of tennis elbow. If you use tools at work then changing to a different weight or handle thickness might help.
Likewise, if you play racquet sports, changing the racket might reduce the amount of effort it takes to use it. Trying a lighter one, or one that that is strung properly for you might help.
Surgical treatment might be considered in certain circumstances. These include when symptoms of tennis elbow are persistent, not responding to non-surgical treatments, or if damage is severe.
These surgeries generally involve removal of damaged tissue and reattachment of healthy muscle to the bone.
The type of surgery can vary depending on individual circumstances and will be decided between you and your doctor. Any associated risks will be fully explained. These could include infection, loss of strength or flexibility, damage to nerves or blood vessels, or a lengthy rehabilitation.
There are two types of surgery that can be considered: open surgery and arthroscopic or keyhole surgery.
This invasive surgery involves an incision being made which allows access to the elbow joint to repair damage.
This procedure can usually be done as an outpatient and does not normally require a stay in hospital.
This procedure is less invasive and allows miniature instruments to be inserted in to the elbow to repair damage via small incisions.
This again is an outpatient procedure usually not requiring an overnight stay in the hospital.
It is likely that following either type of surgery the arm will be immobilized with a splint for about a week. After this any sutures and the splint are removed and further rehabilitation is started.
Following your doctors and/or physiotherapists advice might allow you to return to full activities in about four to six months. Surgery for this condition is successful in up to 90 percent of cases. It is however common to experience a loss of strength in the affected arm. (18)
What is tennis elbow? Tennis elbow involves inflammation or damage of tendons which join the muscles of the forearm to the outside of the elbow. Medically known as lateral epicondylitis, this painful condition is usually caused by overuse.
What are the signs of tennis elbow? Pain in the elbow, forearm or wrist are signs of tennis elbow. Loss of strength or grip are also associated with this condition.
How do you develop tennis elbow? This injury is caused by repetitive movements of the lower arm, including gripping and twisting movements.
How are you diagnosed for tennis elbow? Apart from the associated symptoms, imaging scans can reveal damage to the tendons in the elbow.
What is the best treatment for tennis elbow? In most cases non-surgical treatments including rest and pain relief will rectify this condition. However, if it persists beyond nine to twelve months surgery might be considered.
What are the long term complications of tennis elbow? While the prognosis for recovery is generally good, there may be a loss of strength or grip in the affected arm.
Is tennis elbow considered a disability? This condition is not considered a disability, however there may be occasions when you might qualify for social security benefits. (19)
Is there a cure for tennis elbow? Majority of cases of tennis elbow are successfully treated either non-surgically or surgically.
Is tennis elbow life threatening? This condition is not considered life threatening.
Tennis elbow is a painful repetitive strain injury affecting the tendons in the elbow and muscles the forearm.
Fortunately, there are treatments available which in up to 90 percent of cases relieve the symptoms, leading to full recovery.