Tennis Elbow

What is it?

Lateral epicondylitis, commonly known as tennis elbow, is a painful condition involving the tendons that attach to the bone on the outside (lateral) part of the elbow (see Figure 1). Tendons anchor the muscle to bone.The muscle involved in this condition, the extensor carpi radialis brevis, helps to extend and stabilize the wrist.With lateral epicondylitis, there is degeneration of the tendon's attachment, weakening the anchor site and placing greater stress on the area.This can then lead to pain associated with activities in which this muscle is active, such as lifting, gripping, and/or grasping. Pain is usually worst with activities done with the wrist extended and the palm facing away (pronated). Sports such as tennis are commonly associated with this, but the problem can occur with many different types of activities, athletic and otherwise.The most common age group that this condition affects is between thirty to fifty years old, but it may occur in younger and older age groups, and in both men and women.

What Causes It?

Overuse - The cause can be both non-work and work related. Strain on the tendon attachments is caused by increased stress on the extensor muscle tendon unit.These stresses can be from holding too large a racquet grip or from “repetitive” gripping and grasping activities, i.e. meat-cutting, plumbing, painting, weaving, etc.

Trauma - A direct blow to the elbow may result in swelling of the tendon that can lead to degeneration. A sudden extreme action, force, or activity could also injure the tendon.

Signs and Symptoms

Pain is the primary reason for patients to seek medical evaluation.The pain is located over the outside aspect of the elbow, over the bone region known as the lateral epicondyle.This area becomes tender to touch. Pain is also produced by any activity which places stress on the tendon, such as gripping or lifting.With activity, the pain usually starts at the elbow and may travel down the forearm to the hand. Occasionally, any motion of the elbow can be painful.

Non-Surgical Treatment

Most patients will have complete relief of lateral epicondylitis symptoms with conservative (nonsurgical) treatment.Treatment should include activity modifications, anti-inflammatory medications and bracing. In more severe cases, physical therapy and steroid injections are generally necessary.

Activity Modifications - Initially, the activity that causes pain should be limited. Limiting the aggravating activities is important, but it is not necessary to totally stop using the arm. Modifying grips or techniques such as using a different size racket and/or a two-handed back hand in tennis may help relieve symptoms as well. Generally, any activity that is done with the wrist extended and the palm facing away from the body will aggravate this condition. This activity should be avoided.

Medications - Nonsteroidal anti-inflammatory medication is generally helpful. It is important not to take this on an empty stomach and to stop the medication if heartburn develops.

Brace - A tennis elbow strap or band can be very helpful.This compresses the muscles just below the elbow and helps to decrease tension on the muscles at their origin on the lateral elbow.

Physical Therapy - Physical therapy can be helpful both to stretch the affected muscles and decrease the tension in them, as well as to promote healing of the origin itself by the use of ultrasound, heat treatments and electrical stimulation.

Steroid Injections - Cortisone injections are very helpful for this condition. Ninety percent of patients will have full resolutions of their symptoms with one to three injections as well as the treatment described above.

Surgical Treatment

Surgical treatment is the best option for patients who do not respond to a full trial of the conservative measures described above. Generally, ninety percent or more of patients who failed conservative treatment will have excellent pain relief from surgery. Surgery involves removal of the damaged muscle/tendon and shaving of the bone at the left of the lateral epicondyle.The arm is generally casted for a week and the extensor muscles need to be protected for four to six weeks. Recovery from surgery involves physical therapy and a strengthening program after there has been time for initial muscle healing.