Tennis Elbow (Lateral Epicondylitis)

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

This condition involves the degeneration (wearing down) or, in some cases, microtearing 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, which leads to pain and tenderness on the outside of the elbow.

Tennis elbow, also known as lateral epicondylitis, is primarily caused by repetitive movements of the forearm muscles, especially those involved in extending (lifting up) the wrist and fingers. These muscles are connected to the elbow via tendons, and repeated contraction can cause small tears and inflammation at the tendon’s attachment to the bone. The key muscle group involved is the extensor carpi radialis brevis (ECRB). This muscle helps in wrist extension and stabilizing the wrist during gripping activities. When overworked, the tendon of this muscle becomes irritated and inflamed.

The name of this condition (tennis elbow) comes from its association with tennis players, especially those who use poor technique when hitting a backhand stroke. The repeated motion puts excessive stress on the elbow tendons. However, tennis elbow can affect anyone who does repetitive forearm and wrist movements, not just athletes. Other repetitive activities and professions that may cause tennis elbow are the following:

• Plumbers
• Painters
• Carpenters
• Use of Screwdrivers and Small Tools
• Butchers
• Prolonged Use of the Computer Mouse, etc.

Tennis elbow (lateral epicondylitis) is not a condition that only affects athletes but also other professionals, such as plumbers, painters, carpenters and butchers. These jobs require repetitive gripping, lifting, or wrist movements that strain the tendons. The pain of tennis elbow originates at the lateral epicondyle, a bony bump on the outer part of the elbow. This is where the tendons of the forearm muscles attach to the bone.

The pain may radiate down the forearm and sometimes to the wrist and maybe worsen with gripping, lifting, or twisting motions. Simple actions such as turning a key, shaking hands, or lifting a light object can become painful.

The continued repetitive strain without rest or treatment may cause worsening of pain and dysfunction. If untreated, the injury can lead to chronic pain and reduced strength. Prompt evaluation by an orthopedic specialist is recommended when symptoms persist or worsen.

The pain of tennis elbow is located on the outer (lateral) side of the elbow, exactly where the tendons attach to the lateral epicondyle. This localized tenderness is often the first sign.

The pain may also spread or radiate down the forearm, sometimes reaching the wrist and fingers. This is because the muscles and tendons involved extend into these areas. At the early stage, the pain appears only when direct pressure is applied to the lateral epicondyle or the involved tendons whereas in the middle stage, the pain develops during movement of the hand and wrist, especially with gripping or lifting.

Finally, during the advanced stage, the pain becomes persistent and can even occur when the arm is at rest, indicating ongoing inflammation and possibly microtears in the tendons. The pain worsens with rotational movements of the hand (like turning a doorknob or screwdriver) or lifting objects. Even simple daily activities, such as lifting a bag or a bottle of water, can become painful during intense phases. Sometimes, tennis elbow can cause vague neurological symptoms, such as numbness or tingling sensations in the forearm or hand. This might be due to irritation of nearby nerves. If left untreated, the inflammation and pain can lead to weakening of the forearm muscles. This muscle weakness reduces the ability to grip or hold objects, even lightweight ones. The overall outcome of untreated tennis elbow is a significant restriction in the use of the affected hand, impacting daily activities and quality of life.

Tennis elbow, or lateral epicondylitis, is primarily diagnosed through a clinical examination where pain is reproduced upon palpating the outer elbow and during attempts to extend fingers against resistance. If the symptoms are unclear, further imaging tests such as X-rays, ultrasound, or MRI may be used to confirm the diagnosis and rule out other conditions.

The first and most crucial step for the treatment of tennis elbow (lateral epicondylitis) is to rest the affected arm. Avoid activities or movements that caused or worsen the symptoms, allowing the inflamed tendons to heal. For tennis players or others who use the arm heavily, it might mean changing the way they grip the racket or tools, as well as temporarily modifying their training or work routines to reduce strain. An important part for the treatment for tennis elbow commonly includes pain relievers and anti-inflammatory medications, combined with physiotherapy that focuses on specific stretching and strengthening exercises, and may also incorporate therapeutic ultrasound to promote healing.

The effectiveness of special braces for lateral epicondylitis (tennis elbow) is not definitively established. Some patients feel pain relief, while others may find their symptoms worsen with brace use. This inconsistency suggests that bracing should be personalized and possibly combined with other treatments. The treatment of tennis elbow is often gradual and prolonged, with many patients requiring up to six months or more before becoming symptom-free. Patience and adherence to treatment and activity modifications are the key factors for a successful treatment.

If conservative treatments fail and symptoms worsen or remain severe after several months, the condition must be treated surgically, either with endoscopic, minimally invasive techniques or with classic open techniques. The surgical treatment generally has excellent results, often providing a definitive solution and lasting pain relief.

Stopping or reducing the repetitive activity that caused the symptoms is crucial, especially in the initial stages. This prevents further damage and gives the tendons a chance to heal.

At the same time, the administration of over-the-counter painkillers and non-steroidal anti-inflammatory drugs (NSAIDs) for a limited period and the start of physiotherapy are recommended.

Timely and appropriate physiotherapy is crucial for managing the condition, helping to reduce pain, improve mobility, and restore function.  If pain persists despite rest and physiotherapy, a cortisone injection into the affected area can reduce inflammation and provide relief. However, steroid injections are usually limited because repeated use may weaken the tendon tissue. A potential, breakthrough treatment for tennis elbow is the injection of biological factors (PRP). PRP is a newer treatment involving the injection of a concentration of the patient’s own platelets to stimulate healing of damaged tendons. Usually, 2-3 injections are given and many patients report significant symptom improvement. PRP is considered a promising treatment for patients who do not respond well to standard therapies.

If conservative treatments fail and symptoms worsen or remain severe after several months, the condition must be treated surgically, either with endoscopic, minimally invasive techniques or with classic open techniques. The surgical treatment generally has excellent results, often providing a definitive solution and lasting pain relief. The surgery lasts about 30 minutes and the patient is discharged from the hospital the same day.

I don’t play tennis, so why do I have tennis elbow (lateral epicondylitis)?

While commonly called “tennis elbow,” lateral epicondylitis is not limited to tennis players and can affect anyone who engages in activities that involve repetitive wrist and finger extension and gripping. These repetitive motions can strain the forearm muscles and tendons, leading to inflammation and pain on the outer side of the elbow.

Will I need surgery to treat tennis elbow (lateral epicondylitis)?

Tennis elbow treatment is typically non-surgical, focusing on rest, physiotherapy, and potentially cortisone or biological agent injections. However, if conservative treatments don’t provide relief within 6-9 months, surgery via a small incision (about 2cm) on the elbow’s outer side may be considered.