Tennis elbow (lateral epicondylitis) is a painful condition that occurs when tendons in your elbow are overloaded, usually by repetitive motions of the wrist and arm.
Despite its name, athletes aren’t the only people who develop tennis elbow. People whose jobs feature the types of motions that can lead to tennis elbow include plumbers, painters, carpenters and butchers.
The pain of tennis elbow occurs primarily where the tendons of your forearm muscles attach to a bony bump on the outside of your elbow. Pain can also spread into your forearm and wrist.
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. However, several other sports and activities besides sports can also put you at risk.
Tennis elbow is inflammation 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. This leads to pain and tenderness on the outside of the elbow.
What Is Tennis Elbow?
Lateral epicondylitis, commonly known as tennis elbow, is swelling of the tendons that bend your wrist backward away from your palm.
A tendon is a tough cord of tissue that connects muscles to bones. The tendon most likely involved in tennis elbow is called the extensor carpi radialis brevis. Tennis elbow is usually diagnosed in both men and women between the ages of 30 and 50 years.
With lateral epicondylitis, there is degeneration of the tendon’s attachment, weakening the anchor site and placing greater stress on the area. This can lead to pain associated with activities in which this muscle is active, such as lifting, gripping and/or grasping. Sports such as tennis are commonly associated with this, but the problem can occur with many different activities.
Common Signs and Symptoms of Tennis Elbow
Pain is the primary reason for patients to seek medical evaluation for tennis elbow. The pain is located on the outside of the elbow, over the bone region known as the lateral epicondyle. This area can become tender to the touch. Pain is also produced by any activity which places stress on the tendon, such as gripping or lifting. With activity, the pain usually starts at the elbow and may travel down the forearm to the hand. Occasionally, any motion of the elbow can be painful.
Recent studies show that tennis elbow is often due to damage to a specific forearm muscle. The extensor carpi radialis brevis (ECRB) muscle helps stabilize the wrist when the elbow is straight. This occurs during a tennis groundstroke, for example. When the ECRB is weakened from overuse, microscopic tears form in the tendon where it attaches to the lateral epicondyle. This leads 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 or repetitive extension of the wrist and hand.
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 occur without any recognized repetitive injury. This occurence is called “idiopathic” or of an unknown cause.
The diagnosis of tennis elbow is made through a medical history and physical examination. Additional tests may be ordered to rule out other conditions that cause elbow pain.
Medical History and Physical Examination
In addition to inquiring about the characteristics of your elbow pain (e.g., location and severity), your doctor will ask you about any potential risk factors, like whether you have participated in a certain job or sports-related activities or experienced a recent elbow injury or trauma.
Your doctor will also ask you about your medical history, like whether you have a history of rheumatoid arthritis or elbow nerve entrapment.1
During the physical exam, your doctor will press on your elbow at various sites to evaluate for tenderness. With tennis elbow, there is usually tenderness about one centimeter from the lateral epicondyle itself.
Your doctor will also move (flex and extend) your wrist while your arm and elbow are held out to see if this increases or reproduces your pain.
Various tests may be used to diagnose some of the above conditions. For example, while an X-ray should be normal with a tennis elbow, it may reveal changes consistent with elbow arthritis.
Likewise, a magnetic resonance imaging (MRI) scan is also often normal, although in some individuals the affected tendon may show some abnormal changes. An MRI can also be useful for diagnosing radial tunnel syndrome
Other tests, such as nerve conduction study and electromyography (EMG), are sometimes conducted to rule out nerve compression.1 Blood tests may be utilized to help diagnose inflammatory conditions like rheumatoid arthritis.
Approximately 80% to 95% of patients have success with nonsurgical treatment.
Rest. The first step toward recovery is to give your arm proper rest. This means that you will have to stop or decrease participation in sports, heavy work activities, and other activities that cause painful symptoms for several weeks.
Medications. Acetaminophen or anti-inflammatory medications (such as ibuprofen) may be taken to help reduce pain and swelling
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.
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.
Steroid injections. Steroids, such as cortisone, are very effective anti-inflammatory medicines. Your doctor may decide to inject the painful area around your lateral epicondyle with a steroid to relieve your symptoms.
Platelet-rich plasma. Platelet-rich plasma (PRP) is a biological treatment designed to improve the biologic environment of the tissue. This involves obtaining a small sample of blood from the arm and centrifuging it (spinning it) to obtain platelets from the solution. Platelets are known for their high concentration of growth factors, which can be injected into the affected area. While some studies about the effectiveness of PRP have been inconclusive, others have shown promising results.
Extracorporeal shock wave therapy. Shock wave therapy sends sound waves to the elbow. These sound waves create “microtrauma” that promotes the body’s natural healing processes. Shock wave therapy is considered experimental by many doctors, but some sources show it can be effective.
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.
If your symptoms do not respond after 6 to 12 months of nonsurgical treatments, your doctor may recommend surgery.
Most surgical procedures for tennis elbow involve removing diseased muscle and reattaching healthy muscle back to bone.
The right surgical approach for you will depend on a range of factors. These include the scope of your injury, your general health, and your personal needs. Talk with your doctor about the options. Discuss the results your doctor has had, and any risks associated with each procedure.
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. It rarely requires an overnight stay at the hospital.
Arthroscopic surgery. Tennis elbow can also be repaired using miniature 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:
- 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 4 to 6 months after surgery. Tennis elbow surgery is considered successful in 80% to 90% of patients. However, it is not uncommon to see a loss of strength.
To reduce the risk of tennis elbow, it is important to pay attention to movement techniques during exercise or exertion.
It is better to spread the load to the larger muscles of the shoulder and upper arm, rather than focus activity on the smaller muscles in the wrist and the elbow.
Warming up: Warming up before playing a sport that involves repetitive arm movements, such as tennis or squash, is essential. Gently stretching the arm muscles will help to avoid injury.
Using lightweight tools: Lighter sports equipment or racquets with a larger grip size will help reduce strain on the tendons. Damp tennis balls and older balls load the arm with unnecessary force.
Increasing the strength of forearm muscles: This can help support arm movement and prevent tennis elbow.
A physical therapist can also recommend suitable exercises to help strengthen the appropriate muscles.