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Tennis Elbow

To understand what tennis elbow is it is important to understand the anatomy of the joint. The elbow is a synovial joint between three arm bones – the humerus, radius, and ulna. The bone ends are covered with cartilage (a rubbery consistency) which acts as a shock absorber allowing the bone joints to easily slide against one another.

Ligaments provide stability for the elbow by holding the bones tightly together, forming the joint capsule. The joint capsule surrounding the joint is a fluid-filled sac that lubricates the joint. On the inside of the elbow is the medial collateral ligament and on the outside is the lateral collateral ligament. These two ligaments tightly hold the humerus and ulna together. While the annular ligament is responsible for holding tight the radial head against the ulna.

Tendons in your elbow are what attach muscle to bone. The biceps tendon attaches the biceps muscle just in front of your arm, while the triceps muscle attaches the triceps muscle that is behind your arm.

Two other important tendons in your elbow are the lateral epicondyle and the medial epicondyle. The lateral epicondyle or the bony knob outside the arm just above your elbow, attaches forearm muscle to the humerus.

Most of the muscles responsible for straightening the wrist and fingers converge and attach to the bump just above your elbow inside your arm, called the medial epicondyle.

It is important to understand these two tendons because they are common locations of tendonitis.

Tendonitis is the inflammation or irritation of a tendon. It often occurs to a person who injures or overuses a tendon. It is usually related to acute injury with inflammation. Tendonitis affects the elbow, fingers, wrists, thigh, and various other parts of the body.

A man holding his tennis elbow

Tennis elbow: Overview and epidemiology

Tennis elbow, also known as lateral epicondylitis (a type of tendonitis), is the inflammation of the lateral epicondyle.

It is the most common overuse syndrome of the elbow characterized by pain felt on the outside of the elbow, possibly radiating down the wrist. Although this pain is referred to as “tennis elbow,” only 5% of the patients with tennis elbow actually relate the disease to tennis. So apart from tennis, you will commonly find this condition in sports such as badminton, squash, swimming, baseball, and field throwing events. Certain jobs also require repetitive movement or gripping with the hand involving the thumb and first two fingers. These repetitive movements strain the lateral epicondyle. Over time, the continuous strain on the tendon leads to inflammation and contributes to the tennis elbow.

The annual incidence of tennis elbow in the U.S. population is 1-3%. It is equally common in the male and female sexes. This injury is most prevalent in people between the ages of 30-50 years. Lateral epicondylitis has the greatest chance of occurring in the dominant arm, susceptible to overuse. It is rare to experience this disease on both elbows.

Three main risk factors responsible for tennis elbow, according to a review, includes:

  • Repetitive movements for over 2 hours a day
  • Handling loads that are heavier than 20 kg, not less than 10 times a day
  • Handling tools that a heavier than 1 kg

Other possible risk factors include – overuse, training errors, flexibility issues, misalignments, aging, muscle imbalance or strength deficits, poor circulation, and psychological factors.

Pathophysiology and etiology of tennis elbow

Lateral epicondylitis is categorized as an overuse injury possibly resulting in hyaline degeneration of the extensor muscles origin. Disorganized collagen arrangement replaces normal tissues causing structural tendon changes. The structural changes in the tendon affect the origin of the extensor muscles, causing pain.

Tennis elbow is a degenerative condition primarily affecting the extensor carpi radialis brevis (ECRB) muscle origin. It may sometimes spread towards the extensor digiti minimi, which involves some wrist extension and the extension of the little finger.

The elbow tendons are strained when the tendons and muscles of the forearm are overused, coupled with manual tasks or repetitive contractions. These contractions typically require hand manipulations that cause maladaptation in the structure of the tendon, thus leading to pain in the lateral epicondyle. The pain is mainly located in the outer bony knob of the elbow. It may start with little pains but gradually gets worse as the condition develops.

A diagram of tennis elbow

Clinical presentation and diagnosis of tennis elbow

The most evident symptom of tennis elbow is pain generated by palpation on the origin of the extensor muscles on the lateral epicondyle. The pain can spread up towards the upper arm and down the outside of the forearm, even to the third and fourth fingers in rare cases. Furthermore, the posterior shoulder and wrist exterior muscles often lose strength and flexibility.

Patients report pain in the bony knob outside of their elbow when they try to lift something, shake hands, grip an object or make a fist, straighten their wrist or even raise their hand. It gets worse with movement. The pain may spread into the arm or forearm. There may be swelling, sometimes with redness or heat. And a crackling or grating sensation when the tendon is moved.

Patient diagnosis typically starts with asking about activity level, recreational sports participation, occupational risk factors, medical issues, and medication. Then the clinician will thoroughly examine the elbow structure, other joints, the skin, muscles, nerves, and bone, to locate where it hurts. Conditions similar to tennis elbow are golfer’s elbow – which affects the medial epicondyle, and osteoarthritis.

Further investigations are rarely required, but you may need imaging tests to rule out other problems and determine the degree of damage to the tendon. Some of the imaging tests include X-ray, ultrasound, magnetic resonance imaging (MRI), and electromyography (EMG). Other tests used to ascertain the severity of tennis elbow include – dynamometer, Cozen’s test, Mill’s test, chair test, Maudsley’s test, and coffee cup test.

Tennis elbow treatment

Treatment of tennis elbow may involve one or some of these options – non-operative treatment, physiotherapy, and surgical treatment.

Non-operative treatment

Symptoms of tennis elbow, on average, last from about 2 weeks to 2 years. About 19% of the cases persist for more than one year. The remaining 80% recover within a year without receiving any treatment, just avoiding painful movements. All you have to do is rest your arm and avoid strenuous activities that will contribute to the problem.

Simple treatments that may help with the pain include –

  • holding an ice compress against the injured elbow for up to 20 minutes per day
  • taking painkillers such as topical NSAIDs etc. recommended by a doctor
  • Platelet-rich plasma (PRP) injection: this injection contains concentrated platelets that evidently speed up the healing process in some people. The preparation and procedure will take about 30 minutes.

Physiotherapy treatment

If the tennis elbow is persistent or causes increased severe pain, you may be referred to a physiotherapist by your GP. The physiotherapist will then apply some therapy techniques such as manipulation and massage. These techniques help to improve blood flow to your injured arm, alleviate pain and relieve stiffness. The physiotherapist may also introduce you to several exercises that will increase the strength of your muscles and keep your arms flexible.

You may need to wear strapping, brace, or orthosis on a short term for your injured arm. To alleviate pain symptoms on a short-term basis, corticosteroids injections may be prescribed to you.

Surgical treatment

In some cases, non-operative methods may fail to alleviate symptoms of tennis elbow even after 6 months. Surgery will then be recommended as the next treatment plan. The surgery options for tennis elbow are same-day ops and may not really require you to spend the night at the hospital. Your doctor will choose a surgical approach for you after considering related factors. He may go for open surgery or arthroscopic surgery.

 

 

References

https://www.ortho.wustl.edu/content/Patient-Care/3151/Services/Shoulder-Elbow/Overview/Elbow-Arthroscopy-Information/The-Anatomy-of-the-Elbow.aspx

https://www.medicalnewstoday.com/articles/175596#types

https://emedicine.medscape.com/article/96969-overview#a1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2465303/#:~:text=The%20condition%20was%20most%20prevalent,positively%20correlated%20with%20lateral%20epicondylitis.

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