Tennis Elbow – Causes & Management

Tennis elbow is known as lateral epicondylitis. Tennis elbow occurs most commonly between the ages of 30 and 50 years. Despite the name, the painful condition is more common among non-athletes rather than athletes. The pain is due to inflammation and tears of the tendons attached to the outer side of the elbow.

Anatomy

The elbow joint forms between the lower end of the arm bone and the upper end of the two forearm bones. The arm bone is known as the humerus and the two forearm bones as radius and ulna. Various muscles, tendons, and ligaments stabilize the joint. There are small bony bumps on the inner and outer side of the elbow known as epicondyles.

The bump on the outer side is known as the lateral epicondyle. The muscles of the forearm used to straighten the wrist and fingers are attached to the lateral epicondyle. The muscles attach to the bone through tendons.

Cause

Overuse injury due to repetitive contractive of muscles used to straighten/extend the wrist and fingers result in tennis elbow. Repetitive movements may cause small tears in the tendons attached to the lateral condyle. The small tears may lead to the formation of scar tissue or the complete rupture of the tendon.

Extensor carpi radialis brevis is the most commonly involved tendon in the disease process. The tendon plays an important role in stabilizing the wrist joint with an extended forearm. Activities involving rotational movements of the elbow with a straight arm are especially culpable.

• Backhand stroke while playing tennis with improper technique.
• Other sports such as racquetball, squash, fencing, etc.
• Painters, plumbers, carpenters, meat butchers, etc.
• Typing, driving a screw, using a computer mouse, knitting, etc.

Symptoms

The symptoms of tennis elbow are the pain located on the outer side of the elbow and mild swelling. The pain often may go down the forearm and wrist. The symptoms may also include a weakened grip. The patients often find it difficult to hold a cup, turn a doorknob, shake hands, and play racquet sports.

Diagnosis

A sports medicine physician will examine the patient after a thorough history of the pain. An examination may involve applying pressure over the outer side of the elbow. The physician may do various maneuvers such as apply resistance to straightened middle finger and wrist.

For further evaluation, an X-ray may be ordered to look for bone spurs or arthritis. Other studies such as an MRI may be requested.

Nonsurgical Management

Tennis elbow usually gets better with conservative methods and limiting activities that involve repetitive forearm muscle contraction.

• Rest to the elbow is important to give time for healing of the diseased parts. The patient has to stop any activities which may be further detrimental to the condition.
• Nonsteroidal anti-inflammatory drugs are usually helpful to reduce inflammation and swelling.
• A tennis elbow brace usually tied 1 fingerbreadth below the tender point helps to decrease tension developed by the tendon.
• Physical therapy aimed to stretch and strengthen the muscles around the elbow is helpful.
• Eccentric exercises are done under physical therapists which involve slowly bending the wrist.
• Steroid injections may be given at the outer side of the elbow for relieving inflammation.
• Plasma Rich Platelet (PRP) injections involve injecting the patient’s own blood rich in growth factors. It is a new treatment being explored for the treatment of tennis elbow.
• Ultrasound Therapy involves the delivery of high-frequency ultrasonic waves through a needle to dissolve the diseased tissue. The liquified diseased tissue is subsequently taken out of the elbow with the syringe.
• Needling involves making multiple holes in tendon with the ultimate goal to hasten the healing process.

Surgical Management

The surgical management for tennis elbow is reserved for patients not benefitting from conservative management. Usually, a trial of conservative management is given for at least 4-6 months. Surgical management is also used in patients with significant restrictions on daily activities due to pain and weakness.

The choice of surgery usually depends on the patient’s condition and requirements. The surgery can be an open procedure or arthroscopic procedure. Both procedures are usually daycare procedures and rarely require any hospital stay.

Open Surgical Procedure

The goal of the surgical procedure is to debride or remove the diseased tendon/muscle. The healthy tendon/muscle is then reattached to the bone. A small incision is made on the outer side of the elbow. The diseased extensor carpi radialis brevis is resected and directly attached to the bone.

Arthroscopic Procedure

The arthroscopic procedure utilizes a minute camera and minuscule tools. The camera relays the live feed to a digital screen. The surgeon utilizes the digital output to guide the minuscule tools. As with the open surgery, the diseased tissues are removed and the tendon repaired back to the bone.

The arthroscopic procedure provides an additional advantage of minute incisions. The surgery is a daycare and the patient can walk home the same day. After the surgery, the patient follows a rehabilitation process for strengthening the muscles around the elbow.