Tennis Elbow [Elbow]

What is tennis elbow?

Tennis elbow is a condition in which there is inflammation of the tendons (tendinitis) attached to the outside, or lateral side, of the elbow at the bony prominence of the arm bone (humerus). Muscles which work the wrist and fingers turn into a tendon which attaches to this area. This bony prominence is called the lateral epicondyle; hence this condition is also called “lateral epicondylitis.”

Patients with tennis elbow experience pain at the lateral aspect of the elbow, which can radiate or travel into the forearm and occasionally the hand. The pain occurs with grasping activities and may be accompanied by a sense of weakness. An achy type of discomfort may also be present at rest or at night time after activity. Once the tendons get inflamed, it can be difficult to eradicate because those tendons are used every time the hand grips or squeezes.

What causes tennis elbow?

Injury to these tendons can result from a sudden violent injury or more commonly, from repetitive activity in which the tendons are essentially overworked. This situation can result from a variety of activities, including sports and work, or from a change in one’s regular activity. The overworking of tendons is commonly seen in someone who plays more tennis than usual and then develops pain at the outer aspect of the elbow (thus the common name “tennis elbow”). However, a weekend of hedge clipping, excessive use of a screwdriver or hammer or performance of other activities requiring constant squeezing or gripping can lead to the same problem. A similar condition can develop on the inner or medial side of the elbow (medial epicondylitis). Since this condition is fairly common in golfers on their non-dominant arm, it is also called golfer’s elbow.

Is tennis elbow a serious condition?

Tennis elbow is painful but usually does not lead to serious problems. However, if the condition is untreated or becomes severely painful, then loss of function and loss of motion at the elbow can develop. Treatment in these cases may be a little more difficult but rarely does long-term disability result.

What is the treatment for tennis elbow?

The majority of cases of tennis elbow get better without surgery. Your doctor will examine your elbow and perhaps take X-rays to evaluate the bones and joints of the elbow. If the problem is determined to be lateral epicondylitis, then treatment consists of the following (all techniques may not be necessary at once):

1. Modification of activity.

General activities that make the pain worse should be avoided or at least cut back. For tennis players this may mean playing less tennis. Alternatively, modifying the stroke or the grip size on the racquet may help. Use of the arm and hand within the limits of pain is recommended. In general, the patient can do anything that doesn’t hurt. While continued activity in the presence of mild discomfort is not harmful, severe pain will only prolong the necessary recovery time and should be avoided.

2. Ice.

Cold therapy is very helpful for this condition to limit pain and to decrease inflammation. It is recommended that the area be iced two to three times a day, especially after any activity, such as sports or work. Ice can be applied with an ice bag or the area can be rubbed or massaged with an ice cube (ice massage). The ice should be applied for 20 to 30 minutes each time.

3. Medication.

Oral nonsteroidal anti-inflammatory drugs are very helpful in controlling the pain and inflammation of tennis elbow. These medications are aspirin-like medicines, which include ibuprofen (Motrin, Advil, Nuprin, Medipren, etc.) and other prescription medications (Naprosyn, Indocin, Feldene, Relafen, etc.). It is recommended that the medicine is taken daily for at least four to six weeks when treating severe cases. For less severe cases, these medicines may be taken only as needed. All of these medications can have side effects and should be used under the direction of a physician.

4. Stretching and strengthening exercises.

Stretching and strengthening of the involved muscle and tendon unit is one of the mainstays of treatment for this condition. A gentle stretching program is started through a range of motion at the elbow and wrist. This is combined with a program of muscle strengthening. A simple home program can be demonstrated by your physician in the office. In more severe cases, a referral to a physical therapist can be made for a supervised program.

5. Straps.

Tennis elbow straps are found to be helpful by some patients. There are several different models available, and they are designed to be worn 2 to 3 centimeters from the elbow.

This is intended to take the stress off the tendon where it attaches to the bone. The strap is to be worn during sports and during work. These straps should not be used as a sole means of treatment, but should supplement muscular stretching and strengthening exercises.

6. Wrist braces.

These are worn on the wrist to keep the wrist bent backwards, taking the stress off of the muscles as they attach at the elbow. Although not utilized routinely, some physicians utilize them when the pain is severe and when other measures have failed. They are primarily for use at night while sleeping but they can be used during the day as well.

7. Cortisone shots.

These are considered when the measures above have not worked and the pain is severe. The cortisone is injected into the area of the inflamed tendons in order to decrease the inflammation. After the shot, most physicians recommend that the patient return to using ice and anti-inflammatory medication. Sometimes the shot is curative and sometimes more than one shot is necessary.

When is surgery used to treat tennis elbow?

Surgery is indicated when all of the above measures have failed over a course of several months and the pain continues to prevent activity. Most physicians feel that several cortisone shots are indicated before surgery is considered. In general, surgery is considered an option when all other treatment options have failed and pain continues to be severe and limits a patient’s level of activity or function.

What type of surgery is used to treat tennis elbow?

The procedure that is performed depends upon many factors, but there are basically two types of operations. In the first type a small incision is made (3 to 4 centimeters) and the abnormal tendon is trimmed. The defect created is sewn back together and allowed to heal. In the second type of operation, a portion of tendon is released from the bone and then reattached.

What to do after surgery to treat tennis elbow?

In both operations, the patient usually goes home the same day of surgery. An arm sling and occasionally a plaster splint are used. The arm is to be elevated and kept dry. Stitches are removed five to seven days after surgery and motion is begun. Rehabilitation and recovery depend upon the extent of the surgery and the type of surgery performed. Most people cannot drive for a week. The success of these operations is generally 85 percent to 95 percent excellent relief from the pain. While return to daily activity without pain is often possible within three to six weeks, return to sports or heavy use of the arm can take several months.

This condition, commonly called tennis elbow, is an inflammation of the tendons that connect the muscles of the forearm to the elbow. The pain is primarily felt at the lateral epicondyle, the bony bump on the outer side of the elbow.


Who is affected?

Although called Tennis Elbow at the end of the 19th century,   this terms remains despite the fact that most of the people affected are not tennis players; instead other common causes are gardening, brick laying, excessive use of a screwdriver, hammering, computer typing and shaking hands.

What does tennis elbow feel like?

The main clinical symptom is pain centered on the lateral epicondyle (bony prominence on the outer aspect of the elbow) that radiates down into the forearm. The foremarm muscles may feel tight and sore. It is worsened by manouvres like lifting and gripping, especially so when the wrist is bent backwards. Tenderness just below the epicondyle and  weakness of dorsal flexion of the wrist. Simple day to day actions like turning a door handle or picking up a bottle of milk can cause severe pain.

How is the diagnosis confirmed?

The diagnosis is mainly confirmed by clinical examination.

Normally plain X-Rays are not needed at the onset of the disease, but may be requested later on by the orthopaedic specialist to exclude other problems. An ultrasound scan may be performed if acute tendon tears are suspected or to visualize local sign of degeneration like calcific deposit that are associated with worse prognosis.

How is the condition treated?

Non-operative management

90% of the patients heal spontaneously within one year.

Conservative treatment is the treatment of choice for the first phase.

Avoiding repetitive wrist dorsiflexion (bending the wrist backwards) and modification of  sport or offending activities are generally the most important prescriptions.

Pain killers and Non steroidal anti-inflammatory medications

Local corticosteroid injections (up to 3 injections) are effective for short term pain control.

A Counterforce dynamic brace can be used; but there is poor patient compliance.

A physical therapy program (aimed to  stretch and progressively strengthen the extensor muscles with  pain free active and isometric exercise) has been shown to be effective in the long term.

PRP (Platelet Rich Plasma) injection

Platelet rich plasma (PRP) is blood plasma with concentrated platelets (the body’s repairmen for damaged tissue). The concentrated platelets found in PRP contain growth factors that are vital to initiate and accelerate tissue repair and regeneration. These bioactive proteins initiate connective tissue healing and repair, promote development of new blood vessels, and stimulate the healing process.
How does PRP therapy work?
Blood will be taken from you and then placed in a machine that spins at high speed to separate the different types of blood cells. The surgeon will extract the platelet rich part of the blood, mix it with local anaesthetic and inject this into the area of your injury. The entire process to prepare your blood takes about 15 minutes and increases the concentration of platelets and growth factors at the site of injury by up to 500% (you will have five times the normal number of platelets/growth factors). By having a PRP injection, we aim to stimulate your body’s ability to heal chronic conditions like tennis elbow.
What are the potential benefits of treatment?
The main benefit is that patients can see a significant improvement in symptoms. This treatment may eliminate the need for more aggressive treatments such as long term medication or surgery, as well as a remarkable return of function and a much shorter recovery time.
A major advantage of this treatment is that no foreign substance is used – we use the patient’s own growth factors from his or her own blood   so there is no risk of any disease transmission.
What are the alternatives?
They include:
− Surgery
− Anti-inflammatory drug therapy
− Steroid injections
− Physiotherapy
What are the possible risks or complications of this procedure?
As with all surgery there is a risk of some complications. These are rare, but you should be aware of them before your operation. They include:
− Infection at the site of the injection.
− An increase in inflammation and pain at the site of the injection.
− Bleeding and/or bruising.
− No relief or worsening of symptoms.
− Skin discolouration.
− Allergic reaction to the local anaesthetic drug.
− Failure to achieve successful result.
− Injury to the nerves or blood vessels.
− Prolonged stiffness and or pain.
If you require further information about risks or complications, please discuss with the doctors in clinic or on admission.
How long will the procedure take?
The procedure usually takes around 30 minutes. Most of this time is separating the platelet-rich plasma from your blood sample.
This procedure is performed with the patient awake.
The PRP is injected together with local anaesthetic drug.

Operative management

About 10% of cases are not responsive to conservative treatment. These patients could have symptoms more than 1 year of duration, more than 3 steroid injections in the past, constant pain without activity, local calcification or exostosis on XRay. In these cases surgery is a good option.

Patients satisfaction after surgery has been reported very high with more than 90% of good or excellent results.

3 different surgical options are available: open surgery, keyhole surgery, or per-cutaneous techniques.

Minimally invasive techniques like percutaneous or key hole techniques have been described as less harmful with quicker recovery and return to work activities. The key- hole technique also has  the advantage to recognize and treat associated intra-joint abnormalities, if they are present.