Lateral Epicondylitis

(Tennis Elbow)

You may think your elbow pain cannot possibly be tennis elbow because you have never played tennis or even swung a racket. However, this painful elbow condition is quite common in the general population, even in individuals who do not play racket sports.

The pain can be debilitating and bothersome even with simple daily activities such as picking up your coffee cup or shaking hands. The understanding of this condition has evolved over time and many treatments have been proposed, but there is still debate as to the precise cause and most effective treatments.

Tennis Elbow: What is it?

Tennis elbow, also known as lateral epicondylitis or enthesopathy of the Extensor Carpi Radialis Brevis (eECRB), is a condition characterized by irritation, degeneration or micro-tears in a tendon along the outside of the elbow. The extensor carpi radialis brevis tendon attaches to the outside of the elbow and runs down the forearm to attach to the back of the wrist. This muscle and tendon are involved in stabilizing the wrist or extending the wrist. If this tendon is not healthy and strong, it can cause significant pain and weakness in the arm and hand.

Symptoms: What does Tennis Elbow feel like?

Tennis elbow most commonly results in achy, occasionally sharp pain along the outside of the elbow.
The pain is often worse with lifting or gripping activities especially with the palm facing down, shaking hands, or turning doorknobs.
Because of the pain, there is often a sense of weakness in the hand and wrist.
Stiffness of the elbow or wrist may develop because it is more comfortable to hold the arm still.

Causes

Historically tennis elbow has been attributed to inflammation related to repetitive type of activities. However, there is usually not a single identifiable activity or injury or cause of tennis elbow. In most cases it is a combination of factors that contribute to the symptoms. Individuals from all occupations and activity levels can be affected.

Individual factors: age is the most common risk factor with tennis elbow affecting individuuals between 30-50 most commonly and almost never affecting those over 70. Smoking and obesity have also been associated with increased risk of developing tennis elbow.

Activity factors: prolonged, repetitive or forceful gripping activities increase the risk of developing tennis elbow. Individuals such as electricians, plumbers, painters, carpenters, mechanics, and assembly/manufacturing are more commonly affected. Playing racket sports can also cause or aggravate the symptoms.

Evaluation: How is Tennis Elbow diagnosed?

Your doctor will ask you questions about your symptoms and what makes your symptoms more bothersome. Several physical exam tests can be done such as pressing over the elbow to see where you are most tender or asking you to extend your wrist back against resistance.

X-ray: sometimes X-rays of your elbow are done to assess for conditions such as arthritis that may be contributing to your pain

Ultrasound: ultrasound can be used to visualize the tendons at the elbow and assess the health of the tendon. Ultrasound can also be used to guide injections into the appropriate tendon.

MRI: occasionally if the symptoms do not improve with initial treatments, an MRI may be obtained to assess the tendons at the elbow as well as the ligaments and joint itself.

Treatment

Non-operative treatment

80-90% of patients will get better without surgical treatment over the course of 6 to 12 months

Therapy: instruction in home exercises and pain relieving modalities is the foundation of treatment for tennis elbow.

Stretching the muscles across the wrist and elbow help to keep them loose and prevent further injury

Eccentric strengthening stimulates the body to repair the tendon with healthy, strong tendon tissue

Splinting

Tennis elbow strap: some people get relief wearing a strap around the forearm with more vigorous activities
Wrist splinting: wearing a rigid splint on the wrist at night can help to prevent the extreme wrist flexion position that can strain the muscle and tendon while you sleep
Kinesio tape: some individuals get relief with Kinesio tape across the elbow and forearm

Non-steroidal anti-inflammatory drugs (NSAIDs): anti-inflammatories such as ibuprofen or naproxen can help reduce the discomfort associated with tennis elbow. Some individuals get relief with topical anti-inflammatories or pain creams as well.

Activity changes: avoiding activities that aggravate the pain such as forceful, repetitive gripping as much as possible, taking breaks to stretch and change positions can help to lessen symptoms.

Injections

Corticosteroid injections: corticosteroid (also known as cortisone) injections help to decrease the pain associated with tennis elbow and are often used to treat the symptoms before considering surgery
Platelet-rich plasma (PRP) injections: a sample of blood is drawn from the patient and spun in a centrifuge separating the plasma from the red blood cells. The plasma, which contains many growth factors, is then injected into the area of diseased tendon to stimulate healing.

Surgery

Surgery to remove the diseased tendon and occasionally repair the tendon can be considered if symptoms persist beyond 6-12 months. The surgery can be done either arthroscopically or through a small open incision along the outside of the elbow. This can also be done through a minimally invasive approach using an ultrasound guided device called the Tenex procedure. Occasionally the damaged tendon is repaired back to the bone.

Risks of surgery are low and include, but are not limited to infection or wound healing problems, painful scar tissue, elbow stiffness, and incomplete pain relief.

Recovery: What Can Be Expected?

Surgery to remove damaged tendon tissue is an outpatient procedure meaning patients go home the same day as surgery. Light use of the hands is permitted immediately after surgery. Elbow range of motion exercises are started soon after surgery to prevent elbow stiffness. Washing the arm is often allowed within days after surgery. Splints may be used for the elbow or wrist for comfort.

Therapy focusing on stretching and eccentric strengthening exercises are started within the first 2 weeks after surgery. Diligence with these exercises is key to a successful outcome. Activities and use of the arm are gradually advanced as tolerated and return to unrestricted activities is usually possible between 6-12 weeks after surgery

It is possible, but uncommon for tennis elbow symptoms to come back after surgery. If some of the pain in the arm is due to other conditions such as fibromyalgia, it may not fully go away with surgery.

Frequently asked questions about Tennis Elbow

How do I know if my pain is from tennis elbow or arthritis?

Tennis elbow pain is localized just to the lateral or outside aspect of the elbow. Pain from elbow arthritis is a deeper type of pain and usually felt all the way around the elbow, not just on one side. Elbow arthritis pain is often associated with more stiffness or loss of motion of the elbow and occasionally a catching or grinding sensation.

When should I seek treatment for my tennis elbow?

If your symptoms are interfering with your daily activities and are not getting better with rest, ice, and anti-inflammatories it is worthwhile to be evaluated to confirm the diagnosis and be instructed in an appropriate home exercise program to help manage the pain and strengthen the tendon in a way that does not aggravate it. Your doctor can also discuss the timing of other treatment options such as injections with you as well.

Is ice or heat better for tennis elbow?

Either ice or heat can be used to manage the pain and discomfort associated with tennis elbow. Often, using heat before activities or before you do your exercises can help to loosen the tissues and ice after activity can help to calm inflamed or irritated tissue and provide pain relief.

Can tennis elbow heal on its own without surgery?

Yes, it usually does. The healing can take months, but most of the time tennis elbow eventually goes away. Some of the above described treatments can help accelerate that process or make the pain more manageable while it heals.

What happens if tennis elbow is not treated?

Even without treatment, tennis elbow usually eventually gets better. Other than managing the pain, there is not a rush or urgency to proceed with more aggressive treatments such as injections or surgery.

How long does it take for tennis elbow to get better?

While the good news is that tennis elbow almost always gets better without surgery, the bad news is that it can take 6-12 months to get better. The exercises, ice, anti-inflammatories or pain creams, and splints or straps can help to manage the pain while it heals.

Can my elbow pain be caused by something other than tennis elbow?

Yes. There are several conditions that can mimic tennis elbow pain. Radial tunnel syndrome is a condition where a nerve can get pinched or irritated causing similar pain just a little lower down the forearm. Fibromyalgia or myofascial pain is another condition that can cause pain in the elbow and forearm similar to tennis elbow. Golfers elbow is similar to tennis elbow but causes pain on the inside or medial aspect of the elbow.

How long will I be out of work after surgery?

This depends on the nature of your work and the willingness of your work to accommodate light duty. Low demand activities such as clerical work can often be resumed within days after surgery. Higher demand activities can be resumed as tolerated often between 6-12 weeks after surgery.

How soon can I drive after tennis elbow surgery?

You should not drive while taking narcotic pain medications. Once you are off the prescription pain medications and your pain is manageable to allow you to safely operate a vehicle you may resume driving. Often this is within a week or two after surgery.

Physicians

The following physicians specialize in the treatment of Tennis Elbow:

Keith M. Baumgarten, MD

R. Blake Curd, MD

Jason L. Hurd, MD

David B. Jones Jr., MD

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