Tennis Elbow (Lateral Epicondylitis)

Tennis elbow, or lateral epicondylitis, is a painful condition of the elbow caused by overuse. Not surprisingly, playing tennis or other racquet sports can cause this condition. But several other sports and activities can also put you at risk.

Tennis elbow is an inflammation of the tendons that join the forearm muscles on the outside of the elbow. The forearm muscles and tendons become damaged from overuse — repeating the same motions again and again. This leads to pain and tenderness on the outside of the elbow.

Anatomy
The elbow joint is made up of three bones: your upper arm bone (humerus) and the two bones in your forearm (radius and ulna). There are bony bumps at the bottom of the humerus called epicondyles. The bony bump on the outside (lateral side) of the elbow is called the lateral epicondyle and the inside (medial side) is called the medial epicondyle. Muscles, ligaments, and tendons hold the elbow joint together.

Lateral epicondylitis, or tennis elbow, involves the muscles and tendons of your forearm. The forearm muscles attach to tendons (extensor tendons) that extend your wrist and fingers. These tendons attach on the lateral epicondyle of the elbow. The tendon most commonly involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB).

Cause
When the extensor carpi radialis brevis (ECRB) tendon is weakened from overuse, such as a repetitive tennis groundstroke, microscopic tears develop in the tendon where it attaches to the lateral epicondyle. This ultimately may lead to inflammation and pain.

The ECRB may also be at increased risk for damage because of its position. As the elbow bends and straightens, the muscle rubs against bony bumps. This can cause gradual wear and tear of the muscle over time.

Athletes are not the only people who get tennis elbow. Many people with tennis elbow participate in work or recreational activities that require repetitive and vigorous use of the forearm muscle.

Painters, plumbers, and carpenters are particularly prone to developing tennis elbow. Studies have shown that auto workers, cooks, and even butchers get tennis elbow more often than the rest of the population. It is thought that the repetition and weight lifting required in these occupations leads to injury.

Most people who get tennis elbow are between the ages of 30 and 50, although anyone can get tennis elbow if they have the risk factors. In racquet sports like tennis, improper stroke technique and improper equipment may be risk factors.

Lateral epicondylitis can also occur without any recognized repetitive injury. This occurrence is called "insidious" or of an unknown cause.

Symptoms

Location of pain in lateral epicondylitis

The symptoms of tennis elbow develop gradually. In most cases, the pain begins as mild and slowly worsens over weeks and months. There is usually no specific injury associated with the start of symptoms.

Common signs and symptoms of tennis elbow include pain or burning on the outer part of your elbow and weakness of grip strength. The symptoms are often worsened with forearm activity, such as holding a racquet, turning a wrench, or shaking hands. Your dominant arm is most often affected; however both arms can be affected.

Treatment
Approximately 80% to 95% of patients have success with the following nonsurgical treatments:

Rest: The first step toward recovery is to give your arm proper rest. This means that you will have to stop participation in sports or heavy work activities for several weeks.

Non-steroidal anti-inflammatory medicines: Drugs like aspirin or ibuprofen reduce pain and swelling.

Equipment check: If you participate in a racquet sport, your doctor may encourage you to have your equipment checked for proper fit. Stiffer racquets and looser-strung racquets often can reduce the stress on the forearm, which means that the forearm muscles do not have to work as hard. If you use an oversized racquet, changing to a smaller head may help prevent symptoms from recurring.

Physical therapy: Specific exercises are helpful for strengthening the muscles of the forearm. Your therapist may also perform ultrasound, ice massage, or muscle-stimulating techniques to improve muscle healing.

Wrist stretching exercise with elbow extended.

Brace: Using a brace centered over the back of your forearm may also help relieve symptoms of tennis elbow. This can reduce symptoms by resting the muscles and tendons.

Counterforce brace.

Steroid injections: Steroids, such as cortisone, are very effective anti-inflammatory medicines. Your doctor may decide to inject your damaged muscle with a steroid to relieve your symptoms.

PRP: Platelet-Rich Plasma is a relatively new treatment option that has shown to be beneficial in chronic tendon conditions such as tennis elbow. PRP is administered by injecting a concentrated solution of your own blood that is rich in growth factors thought to help stimulate healing.

Surgical Treatment
If your symptoms do not respond after the above nonsurgical treatments, your doctor may recommend surgery. Most surgical procedures for tennis elbow involve removing torn and inflamed tendon and reattaching healthy tendon back to bone.

Open surgery: The most common approach to tennis elbow repair is open surgery. This involves making an incision over the elbow. Open surgery is usually performed as an outpatient surgery.

Arthroscopic surgery: Tennis elbow can also be repaired using tiny instruments and small incisions. Like open surgery, this is a same-day or outpatient procedure.

Surgical risks:
As with any surgery, there are risks with tennis elbow surgery. The most common things to consider include:

• Infection
• Nerve and blood vessel damage
• Possible prolonged rehabilitation
• Loss of strength
• Loss of flexibility
• The need for further surgery

Rehabilitation
Following surgery, your arm may be immobilized temporarily with a splint. About 1 week later, the sutures and splint are removed.

After the splint is removed, exercises are started to stretch the elbow and restore flexibility. Light, gradual strengthening exercises are started about 2 months after surgery.

Your doctor will tell you when you can return to athletic activity. This is usually 3 to 6 months after surgery. Tennis elbow (lateral epicondylitis) surgery is considered successful in 80% to 90% of patients.