Specializing in Pain Management and Sports Medicine

Tennis Elbow

Couple playing tennis waiting for a serve

So what is the best treatment for tennis elbow? Well, let’s learn a little bit about it first.

Tennis elbow, or lateral epicondylitis, is a painful condition of the elbow caused by overuse. Not surprisingly, playing tennis or other racquet sports can cause this condition. However, several other sports and activities can also put you at risk.

Tennis elbow is caused by pain from the tendons that join the forearm muscles on the outside of the elbow. The forearm muscles and tendons become damaged from overuse — repeating the same motions again and again. This leads to pain and tenderness on the outside of the elbow and interference with daily activities and even sleep.

There are many treatment options for tennis elbow. In most cases, treatment involves a team approach with a Physiatrist, physical therapists, and, in some cases, surgeons work together to provide the most effective care.

Your elbow joint is a joint made up of three bones: your upper arm bone (humerus) and the two bones in your forearm (radius and ulna). There are bony bumps at the bottom of the humerus called epicondyles. The bony bump on the outside (lateral side) of the elbow is called the lateral epicondyle.

Muscles, ligaments, and tendons hold the elbow joint together.

Lateral epicondylitis, or tennis elbow, involves the muscles and tendons of your forearm. Your forearm muscles extend your wrist and fingers. Your forearm tendons — often called extensors — attach the muscles to bone. They attach on the lateral epicondyle. The tendon usually involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB).

Causes

Overuse

Recent studies show that tennis elbow is often due to damage to a specific forearm muscle tendon. The extensor carpi radialis brevis (ECRB) muscle helps stabilize the wrist when the elbow is straight. This damage can occur during a tennis groundstroke, for example. When the ECRB is weakened from overuse, microscopic tears form in the tendon where it attaches to the lateral epicondyle. When first starts if the person lays off the aggravating activity many times the tendon will heal and the pain will resolve. If the person continues to try and “work through the pain” the tendon may not heal properly and with this frequently comes pain. The thought was that the tendon was inflamed but microscopic studies of injured tendon biopsied at surgery revealed that inflammation is usually not present but a poor tendon healing response is. We therefore refer to the condition more as a “tendinosis” than “tendinitis.” To learn more about chronic tendinitis click here.

Activities

Athletes are not the only people who get tennis elbow. Many people with tennis elbow participate in work or recreational activities that require repetitive and vigorous use of the forearm muscle.

Painters, plumbers, and carpenters are particularly prone to developing tennis elbow. Studies have shown that auto workers, cooks, and even butchers get tennis elbow more often than the rest of the population. It is thought that the repetition and weight lifting required in these occupations leads to injury.

Age

Most people who get tennis elbow are between the ages of 30 and 50, although anyone can get tennis elbow if they have the risk factors. In racquet sports like tennis, improper stroke technique and improper equipment may be risk factors.

Unknown

Lateral epicondylitis can occur without any recognized repetitive injury. This occurence is called “insidious” or of an unknown cause.

The symptoms of tennis elbow develop gradually. In most cases, the pain begins as mild and slowly worsens over weeks and months. There is usually no specific injury associated with the start of symptoms.

Common signs and symptoms of tennis elbow include:

  • Pain or burning on the outer part of your elbow
  • Weak grip strength

The symptoms are often worsened with forearm activity, such as holding a racquet, turning a wrench, or shaking hands. Your dominant arm is most often affected; however both arms can be affected.

Physician Evaluation

Your doctor will consider many factors in making a diagnosis. These include how your symptoms developed, any occupational risk factors, and recreational sports participation.

Your doctor will talk to you about what activities cause symptoms and where on your arm the symptoms occur. Be sure to tell your doctor if you have ever injured your elbow. If you have a history of rheumatoid arthritis or nerve disease, tell your doctor.

During the examination, your doctor will use a variety of tests to pinpoint the diagnosis. For example, your doctor may ask you to try to straighten your wrist and fingers against resistance with your arm fully straight to see if this causes pain. If the tests are positive, it tells your doctor that those muscles may not be healthy.

Tests

Your doctor may recommend additional tests to rule out other causes of your problem.

  • X-rays. These tests provide clear images of dense structures like bone. They may be taken to rule out arthritis of the elbow.
  • Diagnostic Ultrasound– this can be performed in the office and often times is best way to evaluate the tendon for injury or degeneration. The evaluation only takes a few minutes and can greatly add to diagnosis.
  • Magnetic resonance imaging (MRI) scan. If your doctor thinks your symptoms are related to a neck problem, an MRI scan may be ordered. MRIs scans show details of soft tissues, and will help your doctor see if you have a possible herniated disk or arthritis in your neck. Both of these conditions often produce arm pain.
  • Electromyography (EMG). Your doctor may order an EMG to rule out nerve compression. Many nerves travel around the elbow, and the symptoms of nerve compression are similar to those of tennis elbow.

Treatment

Nonsurgical Treatment

Approximately 80% to 95% of patients have success with nonsurgical treatment.

Rest. The first step toward recovery is to give your arm proper rest. This means that you will have to stop participation in sports or heavy work activities for several weeks.

Non-steroidal anti-inflammatory medicines. Drugs like aspirin or ibuprofen reduce pain and swelling.

Wrist stretching exercise

Wrist stretching exercise with elbow extended.

Physical therapy. Specific exercises are helpful for strengthening the muscles of the forearm. Your therapist may also perform ultrasound, ice massage, or muscle-stimulating techniques to improve muscle healing.

Brace. Using a brace centered over the back of your forearm may also help relieve symptoms of tennis elbow. This can reduce symptoms by resting the muscles and tendons.

Steroid injections. Steroid injections are commonly used in the treatment of lateral epicondylitis but recent research suggests that cortisone injections may worsen the overall recovery process in the long term. I recommend against cortisone injections for my patients that present with tennis elbow but many people I evaluate have already had them.

Tenex procedure. The Tenex procedure is a newer treatment that was introduced about 5 years ago and it can be very effective for this individuals that do not respond to conservative treatment and their pain persists for longer than 4-6 months.

Surgery. As a last resort an open surgical procedure can be performed by an orthopedic surgeon. It has a good track record for those that are just not able to recover from their chronic elbow pain.

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