Tennis Elbow (lateral epicondylitis)

Overview

Tennis Elbow - Girl in pain

Tennis elbow also known as lateral epicondylitis is caused by overuse, most commonly by playing tennis or other racquet sports, but not exclusively. People whose work or recreational activities involve vigorous and repetitive extension of the wrist and hand are susceptible to tennis elbow. Painters, plumbers, and carpenters repeating the same motions over again can cause inflammation or micro tearing of their elbow tendons also. Those between the ages of 30 and 50 are commonly seen for tennis elbow, but it can be evident when risk factors are high. In unique cases, lateral epicondylitis can occur without repetitive injury and is referred to as idiopathic or of unknown cause.

Tendons, ligaments, and muscles hold your elbow joint together. Lateral epicondylitis or tennis elbow affects the tendons and muscles of your forearm, which are responsible for the extension of your wrist and fingers. Extensors are your forearm tendons that attach the muscles to bone. In most cases, the tendon affected with tennis elbow is called the extensor carpi radialis brevis (ECRB). The ECRB muscle helps stabilize your wrist when your elbow is straight or in tennis, during a player’s groundstroke motion. When the ECRB is weakened with this repetitive motion, microscopic tears begin to form in the tendon where it attaches to the lateral epicondyle causing pain and inflammation. The position of the ECRB makes it more susceptible to damage because as your elbow bends and straightens with overuse, there is more wear and tear on the muscle as it rubs against bone.

Elbow diagram and anatomy

Forearm and Elbow

In adult forearm fractures, both the radius and ulna of the forearm can be broken. The forearm’s primary function is rotating our palms up and down.

Symptoms

In most cases, tennis elbow symptoms develop gradually. There is mild pain or burning on the outer part of your elbow and then it worsens over weeks and months. Your grip may become weak and sometimes your elbow hurts more in the night. Certain forearm motions may aggravate your pain level like shaking hands or even turning a wrench. It can affect both arms, although it is more commonly seen in the dominant arm.

Treatment

Dr. Stowell will consider a variety of factors in making a diagnosis including the development of your symptoms, occupational risk factors, and participation in recreational sports. He will ask you what activities cause symptoms and the location of the pain in your arm. He will perform a variety of tests to pinpoint the diagnosis like straightening your wrist and fingers against resistance with your arm fully straight. Dr. Stowell may apply gentle pressure to the lateral epicondyle to check your level of pain and tenderness.

Dr. Stowell will ask about your medical history. It is important to inform him if you have a history of rheumatoid arthritis or nerve disease. He may recommend additional tests to further confirm his diagnosis with X-rays, an MRI scan, or an EMG or electromyography to rule out nerve compression. There are many nerves that travel around the elbow; nerve compression symptoms are like symptoms of tennis elbow.

A variety of treatment options exist for tennis elbow. The most effective care involves a collaborative effort from a team of primary doctors, physical therapists, and, in some cases, skilled orthopedic surgeons like Dr. Stowell. 

Nonsurgical Treatment

Nonsurgical treatment is effective in most patients, approximately 80-95%, and include the following:

  • Rest – your arm needs proper rest, which means stopping or significantly decreasing participation in activities that cause pain for several weeks.
  • Medications – to reduce pain and swelling, acetaminophen or nonsteroidal anti-inflammatory drugs like ibuprofen or naproxen may be taken.
  • Physical Therapy – muscle healing can progress more rapidly with the help of physical therapists. They can help with specific exercises to strengthen your forearm muscles. They may also perform ice massage or muscle-stimulating techniques to further healing.
  • Brace – Symptoms of tennis elbow may be relieved by wearing a brace that is centered over the back of your forearm.
  • Steroid injections – Steroids like cortisone are very effective anti-inflammatory medicines. Dr. Stowell may inject cortisone around your lateral epicondyle to relieve your pain.
  • Platelet-rich plasma (PRP) – is a treatment option to help improve the biologic environment of the tissue. It involves taking a small sample of blood from your arm and centrifuging it to obtain platelets that can then be injected around your lateral epicondyle.
  • Extracorporeal shock wave therapy – is a treatment option that sends sound waves to the elbow to promote the body’s natural healing processes.
  • Equipment check – If your injury was caused by playing a racquet sport, Dr. Stowell may encourage you to have your equipment checked for proper fit. Looser strung and stiffer racquets can reduce forearm stress.

Surgical treatment

Dr. Stowell may recommend surgery if you do not respond to nonsurgical treatments within 6 to 12 months. Tennis elbow surgery usually involved removing diseased muscle and reattaching healthy muscle back to bone. Dr. Stowell will consider a variety of personal factors to determine his surgical approach including: the scope of your injury, your healthy history, and personal expectations. He will explain any risks associated with your procedure.

Open surgery is the most common approach to tennis elbow repair and it involves making an incision over your elbow. Be prepared for an outpatient surgery as it rarely requires an overnight stay at the hospital.

Arthroscopic surgery is another approach Dr. Stowell may use with small instruments to make small incisions over your elbow. As with open surgery, arthroscopic surgery for tennis elbow is usually an outpatient procedure.

Surgical risks exist with tennis elbow surgery as with any surgery. The most common risks include:

  • Infection
  • Nerve and blood vessel damage
  • Loss of strength and/or flexibility
  • Prolonged rehabilitation
  • Further surgery

Following surgery, Dr. Stowell may immobilize your arm with a splint. About a week later, you will have a follow-up appointment with Dr. Stowell, and he will remove the suture. Once your splint is removed, you will be encouraged to begin exercises to stretch and restore flexibility in your elbow. About 2 months after surgery, you may be advised to begin light, gradual strengthening exercises. Dr. Stowell will evaluate your rehabilitation and when you can return to athletic activity–typically, 4 to 6 months after surgery. There is an average historical success rate of 80 to 90% of tennis elbow surgery patients that return to normal; however, it is not uncommon for loss of strength even after rehabilitation.

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