Tennis Elbow: Causes, Symptoms and Treatment

Tennis elbow is described as an overuse injury secondary to an eccentric overload of the common extensor tendon at the origin of the extensor carpi radialis brevis (ECRB) tendon.
It is characterized by pain and inflammation near the lateral epicondyle of the humerus, also known as lateral epicondylitis. The lateral epicondyle of the humerus is a large, tuberculated eminence, curved a little forward, and giving attachment to the radial collateral ligament of the elbow joint, and to a tendon common to the origin of the supinator and some of the extensor muscles.

Tennis Elbow

Causes and Pathophysiology

The exact causes of tennis elbow are not fully understood, but it often occurs due to overuse or repetitive strain of the forearm muscles and tendons. The condition is often work-related.

The pathophysiology involves:

  • Repetitive contraction of the wrist extensor muscles originates from the lateral epicondyle region. Racquet sports like tennis require strong and repetitive wrist extension.
  • This leads to microtears and inflammation of the tendons attaching to the lateral epicondyle. The affected tendons are usually the extensor carpi radialis brevis tendon, and sometimes the extensor digitorum tendon.
  • The microtears impair the tendon’s ability to transmit muscular forces, which further perpetuates the problem.
  • If the repetitive strain continues, this can lead to tendon degeneration, calcium deposition, and the formation of inelastic scar tissue.

Other contributing factors include:

  • Poor technique and inappropriate equipment in racquet sports
  • Muscle imbalance or weakness around the elbow joint
  • Direct trauma to the lateral epicondyle region

Symptoms of Tennis Elbow

The main symptoms of tennis elbow include:

  • Pain focused on the lateral elbow region – Typically located around the bony lump on the outside of the elbow joint. Pain is often exacerbated with resisted wrist extension activities.
  • Tenderness – There is focal tenderness upon palpation of the lateral epicondyle region and attached tendons.
  • Weakened grip strength – The patient has pain and difficulty gripping activities involving wrist extension.
  • Stiffness – The elbow joint may feel stiff, especially after periods of inactivity.
  • Pain with daily tasks – Activities involving repetitive gripping and wrist movements often aggravate symptoms. Examples include opening jars, turning doorknobs, typing, racquet sports, etc.
  • Chronic course – Symptoms often occur gradually and worsen over weeks to months if the aggravating activity continues.

Diagnosis

Tennis elbow is usually diagnosed based on the typical clinical presentation, with focal lateral elbow pain and exacerbation upon resisted wrist extension:

  • Medical history – The doctor inquires about the patient’s activities, occupation, sports participation, trauma history, and location of pain. Details help determine causes and guide treatment.
  • Physical exam – Tenderness directly over the lateral epicondyle is indicative. Pain exacerbated with resisted wrist extension helps confirm the diagnosis.
  • Imaging studies like x-rays or MRI scans are not required for diagnosis, but may sometimes exclude other elbow joint pathologies.

Differential diagnoses like radial tunnel syndrome present similarly and should be considered. Cervical radiculopathy can also cause lateral elbow/forearm pain.

Treatments and Lateral Epicondylitis Exercises

Tennis elbow is initially managed conservatively with activity modification, bracing, physical therapy, anti-inflammatories, and time:

Activity Modification

  • Avoiding aggravating activities that induce repetitive gripping and wrist extension motions allows inflamed tendons to rest and heal.
  • Stretching and gentle range of motion exercises may help prevent stiffness.
  • Gradual return to activities as symptoms improve is recommended to avoid re-injury.

Bracing/Taping

  • Braces, straps, or taping can help immobilize and offload strained tendons around the elbow joint. This supports recovery.

Physical Therapy

  • Physical therapists employ various treatment modalities like ice, heat, iontophoresis, TENS, and ultrasound for pain relief and healing.
  • Stretching tight muscles and strengthening exercises improve flexibility, endurance, and joint stability.
  • Massage techniques like transverse friction massage may help break down scar tissue and speed recovery.
  • A supervised gradual return to activity program is implemented.

Strengthening Exercises: Physical therapists often prescribe slow eccentric muscle training focused on the wrist extensors. Evidence demonstrates such focused exercises effectively treat chronic tennis elbow when done properly and consistently.

Medications

  • Oral NSAID medications like ibuprofen or naproxen reduce inflammation and pain.
  • Some patients receive localized corticosteroid injections, but evidence of long-term benefit is inconclusive. Risks like tendon rupture are possible with steroid injections.

Time

The majority of patients improve with conservative measures over 6-24 months. Symptoms generally resolve eventually with activity modification and physical therapy exercises.

Alternative Treatment Options

Some patients find relief using alternative therapies like:

  • Acupuncture – Fine needles are inserted into specific body points to reduce pain and inflammation. Multiple sessions may be needed, but some studies show acupuncture can help alleviate chronic tennis elbow.
  • Massage – Various massage techniques aim to reduce muscle tightness, increase blood flow, and break down scar tissue around the elbow joint. Massage may provide temporary pain relief.

When Surgery May Be Needed

  • Tennis elbow release surgery may be considered for those with persistent and refractory symptoms lasting over 12 months despite focused conservative measures. Various open and arthroscopic surgical techniques exist.
  • The goals of surgery are to remove damaged tissue, release scar tissue adhesions around affected tendons, and repair and reattach damaged tendon tissue.
  • Post-surgical therapy focuses on gradually restoring range of motion and strength. Most patients experience significant improvement in symptoms after tennis elbow surgery, but recovery takes many months.

Long Term Outcomes

With appropriate conservative treatment, most patients see gradual resolution of their tennis elbow symptoms over time. However, recurrence is common if aggravating activities resume too early. Chronic injuries lasting over a year increase the likelihood of longer-term functional deficits. Other preventative measures include:

  • Maintaining muscle flexibility and strength around the elbow
  • Using proper technique and equipment for racquet sports
  • Avoiding overuse through workplace ergonomics and frequent rest breaks

While often a frustrating injury, tennis elbow generally carries an excellent overall prognosis. Most patients achieve full functionality and recovery in 1-2 years with a focused rehabilitation program.

When to See a Doctor

Consult a physician promptly if you have lateral elbow pain worsened by repeated gripping and wrist motions lasting over 2 weeks, especially if interfering with daily activities. While usually gradual in onset, sudden trauma to the elbow also warrants medical evaluation. Qualified health professionals guide proper treatment for this commonly encountered overuse injury.

Glossary

Lateral epicondyle: A small bony bump on the lateral side of the humerus. Site of tendon attachment for forearm muscles that extend the wrist and fingers.

Tendonitis: Inflammation of a tendon, often due to overuse injury and small tears in the tendon fibers.

Radial tunnel syndrome: Compression of the radial nerve as it crosses the elbow joint, causing similar lateral elbow pain.

NSAID medications: Non-steroidal anti-inflammatory drugs like ibuprofen that reduce pain and swelling.

Corticosteroid injections: Powerful anti-inflammatory steroid medications injected into injured tendons to try to reduce symptoms.

Eccentric exercises: Strengthening exercises focusing on elongated muscle contractions to retrain tendons.

Source

National Institutes of Health (NIH)

FAQs

Q: Does tennis elbow only affect tennis players?

A: No, tennis elbow can affect anyone who repetitively uses their forearm muscles, whether for sports, work, or everyday activities. The name is misleading.

Q: Will tennis elbow get better on its own?

A: Possibly, if the aggravating activity is stopped early on. But symptoms often linger for months without proper treatment involving active physical therapy.

Q: Do I need an MRI scan for tennis elbow?

A: No, the diagnosis is based on clinical symptoms and examination. Imaging like MRI scans are only needed to rule out other unusual conditions.

Q: Should I stop all exercise with tennis elbow?

A: Avoid stressful repetitive gripping activities, but keep the elbow moving with gentle stretching. Your physician or physical therapist guides appropriate activities.

Q: How many physical therapy visits are needed?

A: Most patients attend therapy 1-2 times per week for 4-8 weeks. More visits are needed for chronic cases. Eccentric exercises must continue daily at home.

Q: When can I get back to playing tennis or golf after the injury?

A: Gradual return to sports should only begin after completing initial treatment and recovery goals under the guidance of your provider.

Q: Will a brace or compression sleeve help my elbow?

A: It might be temporary if worn when active. However, evidence on long-term benefits is limited. Proper treatment exercises remain the most important.

Q: Is surgery absolutely necessary for chronic tennis elbow?

A: No, many improve with conservative measures over 12+ months. However recalcitrant cases can benefit from surgery to excise damaged tissue and promote healing.

Q: Does ice or heat help more for my elbow pain?

A: Generally ice for acute flare-ups, then heat before performing exercises. Alternate as needed for pain relief based on your stage of injury.

Q: Once I’m better, will my tennis elbow return?

A: Recurrence risk is high if overuse continues. Post-recovery conditioning programs help prevent reinjury long term.

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