Tennis Elbow Overview

Dr. Mahdi Saeedi

Tennis elbow is a condition caused by inflammation of the tendons on the outer bony prominence (lateral epicondyle) of the elbow. Certain repetitive movements of the wrist can cause this condition. Tennis elbow can occur in anyone who strains the tendons of the forearm and is not limited to tennis players.

Tennis Elbow Causes

  • Any repetitive motion of the wrist, including tennis, hedge clipping, excessive use of a hammer or screwdriver, painting, or any activity that requires excessive constant gripping or squeezing can cause tennis elbow.
  • In the game of tennis, the following maneuvers can lead to tennis elbow:
    • One-handed backhand with poor form
    • A late forehand swing resulting in bending the wrist significantly
    • Snapping and turning the wrist while serving with full power

Tennis Elbow Symptoms and Signs

Patient CommentsShare Your Story

  • Tenderness on the outer bony part of the elbow
  • Morning stiffness of the elbow with persistent aching
  • Soreness in the forearm
  • Pain worse when grasping or holding an object

Medically 

When to Seek Medical Care

Tennis elbow does not usually lead to serious problems. If the condition continues and is left untreated, however, loss of motion or loss of function of the elbow and forearm can develop.

Call your doctor if the following conditions develop:

  • Pain that limits your daily activity
  • Pain that lasts despite ice, resting, and over-the-counter anti-inflammatory pain relievers
  • Any weakness or numbness in the hand, which may mean you have another type of injury in the wrist or elbow

Diagnosis of Tennis Elbow

Your doctor may use any or all of the following to diagnose tennis elbow:

  • In taking your medical history, the doctor may ask you questions about your activity level, occupation, recent recreational activities, medications, and other medical problems.
  • During the physical exam, your doctor will feel your elbow and possibly other joints. Your nerves, muscles, bones, and skin are also examined.
  • X-ray images may be required if the symptoms suggest another problem in the elbow joint.
  • Nerve studies may be needed to look for entrapment of the radial nerve in the elbow joint (radial tunnel syndrome) if your symptoms continue despite aggressive treatment.
  • It is unlikely your doctor will need to perform blood tests, a CT scan, or an MRI to make the diagnosis, but these may be used to rule out other conditions in certain cases.

Self-Care at Home

  • Home remedies include icing the area for 20 minutes twice a day to help to decrease inflammation and relieve pain. Freezing water in a paper cup and tearing away the top rim as the ice melts is an easy way to use ice. Do not put ice directly on the skin. Wrap it in a towel.
  • Rest the sore area to prevent further injury and decrease pain.
  • Over-the-counter anti-inflammatory medications such as ibuprofen(Advil, Motrin), aspirin, or naproxen (Aleve) may help decrease the pain and help the healing.

What are the treatment options for tennis elbow?

Modifying activities that bring on your symptoms

You will be able to recognise which movements tend to bring on your pain and you should try to avoid these as much as possible. Typically, pain is made worse by lifting, gripping and twisting movements of the affected arm. Resting from activities that bring on pain can help to reduce inflammation so that the tendon injury can heal. In some people, just modifying their activities and cutting out repetitive movements of the arm or hand can be enough to improve tennis elbow.

You may need to discuss with your doctor and/or your employer if you feel that your job may be contributing to your tennis elbow. There may be different tasks that you can do at work while your tennis elbow is healing. It is also advisable for everyone to take regular breaks when they are working.

Pain relief

Ice can sometimes be a good pain relief if you have tennis elbow. Try using an ice-pack (such as a pack of frozen peas wrapped in a towel) on the tender area twice a day for ten minutes.

Also, anti-inflammatory painkillers such as ibuprofen are commonly used to ease pain in tennis elbow. Some anti-inflammatory painkillers also come as creams or gels which you can rub over your painful elbow. These tend to produce fewer side-effects than those taken by mouth. There are various brands which you can buy, or get on prescription. Ask your doctor or pharmacist for advice.

If you cannot take anti-inflammatory painkillers, other painkillers such as paracetamol, with or without codeine added, may be helpful.

Physiotherapy

Physiotherapy has been shown to be helpful in the treatment of tennis elbow. Your physiotherapist may be able to use techniques such as massage, laser therapy and ultrasound therapy as well as exercises to treat your tennis elbow. It is not certain if any one of these physiotherapy treatments is better than others.

Studies have shown that physiotherapy may not be as good as a steroid injection at relieving pain in the short term (that is, within the first six weeks). But, it may be superior to steroid injections in the long term. However, there may be a wait for your physiotherapy appointment.

Supports and splints

These can include wearing a special elbow armband or bandage. This may help to give support and protection to your elbow until symptoms ease. Another option may be to wear a wrist splint which may ease pain by helping to rest the muscles that pull on your elbow. Wearing supports such as these and having physiotherapy at the same time may give you better symptom relief in the long term.

Steroid injection

If the above measures do not work, or if you have severe pain and difficulty using your arm, an injection of a steroid into the painful area of your elbow may ease the pain.

A number of studies have shown that steroid injections may be helpful in easing pain in the short term but that pain tends to come back in many people. In one study, short-term (six weeks) success rates were greater for steroid injections than for physiotherapy or a wait-and-see policy. However, in the long term (one year), success rates were greater for both physiotherapy and a wait-and-see policy than for injections. The short-term benefit may be sufficient to warrant an injection, for example, for a student about to sit important examinations.

Remember that, even if a steroid injection has eased your pain, you still need to rest your arm and avoid any activities that may have brought on your pain previously. Build up your activities over some weeks to try to reduce the chance of your tennis elbow coming back.

A steroid injection may sometimes be repeated after some weeks if pain recurs. However, it is usual to have no more than three injections at the same site. There may also be some side-effects of steroid injections; for example:

  • Pain on injection.
  • Atrophy (shrinking) of the fatty tissue under the skin at the injection site.
  • Depigmentation (loss of colouration) of the skin around the injection site.
  • Damage to the tendon around your elbow (this is very rare).

Shock wave therapy

Shock wave therapy using high-energy sound waves is sometimes used to treat tennis elbow. A special device allows the shock waves to be passed through the skin around your elbow to the affected area. A local anaesthetic may also be given, as sometimes the shock waves can be painful. One or more treatment sessions may be needed.

Shock wave therapy appears to be safe but it is not clear yet exactly how well it works and more research is needed. This does not mean that the procedure should not be done but you should discuss the benefits and risks fully with your doctor.

There is a small chance of side-effects, including short-term reddening of your skin, swelling of the area that is treated and pain during the procedure. It is thought that there may also (rarely) be a risk of the tendon around your elbow rupturing.

Autologous blood injection

This procedure is generally only considered if other treatments have failed. It is not clear yet how effective this treatment is and more research is needed. You should discuss the possible benefits and risks with your doctor before you have the procedure.

Blood is taken from you and then injected into the area around the damaged tendons at your elbow. It is thought that the blood helps to heal the tendons. A local anaesthetic is often given as a pain relief during the procedure. Several treatment sessions may be needed. You may need to wear a splint after the procedure and will often be offered physiotherapy.

Possible problems with this procedure include pain, bruising, damage to other structures near the tendon (such as nerves or blood vessels) and infection.

Botulinum toxin A injection

Injection of botulinum toxin into muscles in the forearm has been shown to be an effective treatment for tennis elbow. Injection of botulinum toxin may be considered if symptoms are severe enough for surgery to be considered.

Surgery

If your tennis elbow symptoms persist for some time and are really troublesome, then a specialist may advise an operation. The common operation to ease symptoms is to remove the damaged part of the tendon. Only a small number of people require surgery to relieve symptoms.

What is the prognosis (outlook) for tennis elbow?

If you rest your arm and avoid any activities that bring on your symptoms, your tennis elbow will usually settle over time. Rest and painkillers is all that most people with tennis elbow need.

Pain from tennis elbow usually lasts for six to twelve weeks. In some people it can go after as little time as three weeks. However, in other people, pain can last for longer (for between six months to two years). Unfortunately, once you have had tennis elbow, it may return.