What is “tennis elbow” all about?

Tennis elbow #1What is it?

Tennis elbow is also called lateral epicondylitis or lateral epicondylosis. In essence, a portion of the tendinous origin for the muscles that lift the wrist either degenerates or partially tears, and has a hard time healing right. The term tennis elbow is somewhat misleading, since most patients with this condition do not play tennis. The term epicondylitis is also somewhat misleading, because in medicine, words ending in –itis mean inflammation, and tennis elbow does not seem to have a major inflammatory component. The tendinous origin of a muscle, called extensor carpi radialis brevis (ECRB), is the typical location of the condition.

Why does it happen?

The intimate mechanism for lateral epicondylosis is not fully understood. As mentioned above, some individuals develop the condition as a result of tearing of tendon fibers. Tendon fibers on the outside of the elbow have limited healing potential and if continued used of the hand for activities of daily living results in constant overload of the torn fibers, they will never get a break to heal. Most likely, some individuals are predisposed by the nature of their collagen structure. The truth is that this condition is more common in people that use their hands and forearms all the time: long hours of computer keyboarding, manual labor, and of course tennis, are some of the activities known to be associated with tennis elbow.

How to diagnose it?

Lateral epicondylosis is pretty classic. Most people with the condition complain of dull to intense pain on the outside of the elbow, which clearly worsen with gripping activities. If you have tennis elbow and try to pull a laptop vertically out of a bag, your pain will increase. If you go to the doctor, you will be asked to lift your wrist or turn your palm up against resistance, and that will hurt. Plain radiographs will appear normal, but evaluation with ultrasound or magnetic resonance will show the changes in tendon structure. These tests are a seldom necessity.

How to deal with it?

Many studies seem to indicate that the symptoms of tennis elbow eventually disappear on their own without treatment. The problem is that it may take a long time for that to happen, and we all get frustrated. If symptoms bother you for more than six months, then the chances of spontaneous recovery are probably minimal.

Braces are commonly considered for treatment. There is a specific kind of brace, called a counter-pressure brace (or tennis elbow brace) that physicians actually do not like. It is based on the thought that wrapping a narrow band around the origin of these tendons will unload them, but this brace may actually compress a nerve in the forearm (called posterior interosseous nerve or PIN) and be counterproductive. Our preference is to use a wrist splint to unload the wrist extensors. Patients can use it all day long, at night, or when performing certain activities that irritate the tendon.

If you want to remember one exercise to improve your tennis elbow, this is the one: eccentric training of the extensor group. With the forearm resting in a flat surface such as a table or countertop, grab a small weight (you can use a can of soda) with your hand. Use the opposite hand to passively bring the wrist up (into extension). Then let the weight in your hand bring your wrist down in a controlled fashion. This exercise can initially hurt a little, but if you are patient and persistent, this may speed up your recovery.

eccentric training
Eccentric training

A more sophisticated way of achieving the same effect is use of a flex-band. You can purchase these flex-bands online.

If you do not improve, despite the use of a wrist splint and eccentric training, it may be time to see an elbow specialist. The physician may be offer a steroid injection. One injection is probably OK, but please avoid multiple injections because they will weaken the tendon structure and eventually cause more harm that do good. Other treatments that your doctor may consider include stimulating tendon healing with an ultrasound probe, or even surgery. However, very few people with tennis elbow end up requiring surgery. Currently, the most common procedure is called tennis elbow release, and it can be performed with a classic open surgery using a relatively small incision. However, we prefer to perform it arthroscopically.

Is there anything else?

Yes,… there is always something else! Some patients with lateral epicondylosis also have elbow instability. In these individuals, it is unclear whether the same degeneration that affects their tendon structure extends deep into the ligament, or if the inability to properly unload the ligament causes the ligament to become stretched.

Elbow instability is very difficult to detect by non-elbow experts. If your tennis elbow is taking a funny course and you do not see improvement, even after surgery, then perhaps your elbow is unstable as well. In this case, imaging of the elbow with radiographs under stress, ultrasound or magnetic resonance are more useful. Individuals with the combination of tennis elbow and instability often do not get better without surgery. In these circumstances, the procedure must involve both tendon surgery and ligament reconstruction.

If you play tennis…

and have tennis elbow (which can obviously happen) you need to pay attention to your racquet and your technique. It is best to be measured so that the best matching racquet can be selected for your grip. You may also need to re-evaluate the tension of the racquet and your technique overall. All the recommendations outlined above do help tennis players with tennis elbow as well.