Everything You Need To Know About Tennis Elbow

What is Tennis Elbow?

Tennis elbow is an inflammation of the tendons of the elbow characterized by pain and tenderness over the outer aspect of forearm caused by overuse or repeated use of the extensor group of muscles of the forearm. It is also known as lateral epicondylitis.

What may cause you Tennis Elbow?

• Overuse of forearm and hand
• Repetitive motions
• Repetitive trauma
• Tear in the muscle belly and tendon
• Calcified deposition
• Excessive gripping or wringing activities
• Poor forearm muscle strength or tight muscles
• Poor technique (this may be a poor tennis shot)

Activities other than tennis playing!

• Using plumbing tools
• Painting
• Driving screws
• Cutting up cooking ingredients, particularly meat
• Repetitive computer mouse use
• Carpenters
• Vigorous hand shake
• Using a wrench
• Household activities causing tennis elbow specially

in women :

• Cooking
• Wringing cloth
• Making roti
• Sweeping
• Repeated Turning a doorknob

Sign and Symptoms

1. Pain:
   • Pain when performing gripping tasks
   • Pain when resisted wrist/finger extension
   • Pain when the muscles are stretched
   • Pain worse when grasping or holding an object
   • Pain when squeezing any objects
2. Tenderness over the affected area
3. Morning stiffness of the elbow with persistent aching
4. Soreness in the forearm
5. Weakness may make it difficult to
   • Shake hands or grip an object
   • Turn a doorknob
   • Hold a coffee cup
6. Weak grip strength

Stages Of tennis elbow :

Stage 1

– Immediate swelling
– Pain during activity
– Minor aching, usually after activity

Stage 2

– Constant swelling and scar development initiated pain during activity and at rest.

Stage 3

– Extensive scar tissue present
– Small tears in the tendon, sometimes leading to a large tear of the tendon
– Pain at rest, sometimes night pain
– Pain reproduced with numerous activities of daily living

Diagnosis

• A history and physical exam is usually all that is necessary to diagnose tennis elbow. Patients will describe pain in the outside of the elbow, pain with lifting objects (even as light as a cup of coffee), and pain that radiates down the forearm. There is usually no numbness or tingling associated with tennis elbow.
• During the physical exam, the physio usually tries to reproduce pain by pressing directly on this area, or ask the patient to lift the wrist and fingers against resistance. These two simple tests are usually all that is necessary to diagnose tennis elbow.
• Radiographs are not routinely obtained, but an MRI is sometimes in order to determine how much tendon degeneration there is. An MRI is typically reserved for those patients who do not get better with non-surgical treatment.

Radiological examination

Diagnostic imaging. While tennis elbow usually does not require diagnostic imaging, additional scan tests may be ordered to rule out other possible causes of the patient’s symptoms. For example:

• X-rays. While tennis elbow will not show up in X-rays, they can be used to detect other conditions, such as bone fractures, joint misalignment, or one or more types of arthritis.^1,2
• Magnetic resonance imaging (MRI). Some cases of elbow and forearm pain and tingling are actually caused by a herniated disc and/or arthritis in the neck, so doctors may perform an MRI scan to rule out these conditions.^1,2  An MRI of the elbow may show partial tears in the extensor tendon and may help rule out other problems in the elbow, such as cartilage injuries or ligament tears.
• Electromyography (EMG). If the doctor suspects that the patient’s elbow symptoms are caused by nerve compression/entrapments in the elbow or elsewhere, this test may be ordered to test nerve conduction in the area.²
• Power Doppler ultrasound. This type of ultrasound is an emerging diagnostic imaging test for tennis elbow and other types of tendon problems, and it may be used to diagnose or rule out tennis elbow.^3,4

Once tennis elbow has been diagnosed, an appropriate treatment plan can begin.

Medical Management

Non-Operative Treatment (During the Acute phase)

• The first step toward recovery is to give your arm proper rest. This means that you will have to stop participation in sports or heavy work activities for several weeks.
• The use of ice three times per day for 15 minutes is also recommended because it reduces the inflammatory response by decreasing the level of chemical activity and by vasoconstriction, which reduces the swelling. Elevation of the extremity is also indicated if an edema of the wrist or fingers is present.
• Conservative management. The use of an elbow counterforce brace can be helpful because it plays the role of a secondary muscle attachment site and relieves tension on the insertion at the lateral epicondyle. The brace is applied around the forearm (below the head of the radius) and is tightened enough so that, when the patient contracts the wrist extensors, he or she does not fully contract the muscles.

Physiotherapy Management

There are different types of therapies to treat Tennis elbow all with the same aim: reduce pain and improve function.

General Physiotherapy Management

• Education/Advice
  • Pain control
  • Modify and restrict activities
• Manual therapy
  • Mulligan – Movement with mobilization
• Exercises
  • Strengthening
  • Stretching
• Modalities
  • Ultrasound
  • Transcutaneous electrical nerve stimulation (TENS)
• Braces/Splints/Straps
• Medications
  • NSAIDs offer a short term benefit (3-4 weeks pain relief)
• Corticosteroids injection
  • Short term effect (<6 weeks)
• Sport/Occupation Specific Rehabilitation

Other Options:

Steroid Injection. Injections should be given subperiosteally to the extensor brevis origin. These injections have an early and beneficial effect. During the initial 24-28 hours, increased pain be experienced. A steroid injection should be followed by 1-2 weeks’ rest and should not be repeated more than 2 times. Steroid injection seems to be effective for about 3 months, indicating that the patient must continue with the exercise program.

 Surgical Treatment. 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.

• Open surgery.
• Arthroscopic surgery.

Rehabilitation after Surgery

1. Measures to control pain as mentioned earlier.
2. Active ROM exercises to the shoulder
3. Passive ROM exercises to shoulder, elbow, forearm and wrist.
4. Progressive RE as mentioned earlier
5. Thermotherapy helps to reduce pain

Prevention & Guideline

• The key to preventing tennis elbow is to avoid overuse.
• Stop if you feel any elbow pain during an activity.
• Stop using the wrong equipment, like a golf club or tennis racket that is too heavy or that has a grip that is too large.
• Avoid Bad technique — like using the wrong posture for a swing — can also lead to tennis elbow.
• Stretch and warm up before any sport or activity that will exercise your elbow or arm.
• Ice your elbow after exercise.

Prognosis

Untreated Tennis Elbows can last anywhere from 6 months to 2 years. You are also prone to recurrence. Studies have shown physiotherapy to be the most effective way of managing Tennis Elbow when compared to steroid injections or giving of advice alone. In a recent study, When given a 6 week course of physiotherapy comprising of 8 treatment sessions, most patients show significant improvement after 3 weeks, increasing to a 60% or greater recovery after 6 weeks of treatment. This improvement is shown to continue to around a 90% improvement at 12 months, even without further treatment. Up to 95% success rate with non-operative treatment. ⁵

Tennis elbow / lateral epicondylitisis is not strictly a sports-related injury. If you believe that you have this condition, see your physiotherapist as soon as possible. Modified exercises program and combination of different electrotherapeutic modalities are the best form of treatment. Other commonly prescribed treatments help to reduce the pain temporarily and which may recurrence the symptoms again as the underlying cause are not treated properly. Fully resolving the pain may take 3-4 weeks. Your physiotherapist will also be able to teach you how to manage your condition while on the road to recovery.

References

1. American Academy of Orthopedic Surgeons. Tennis elbow (lateral epicondylitis). September 2009: OrthoInfo. Accessed December 30, 2014.
2. Walrod, BJ. Lateral epicondylitis clinical presentation. June 13, 2014: Medscape. Accessed December 29, 2014.
3. Almekinders, L, and Matava, M. Tennis elbow. Sports Tips. Rosemont, IL: American Orthopedic Society for Sports Medicine, 2008.
4. du Toit C et al. Diagnostic accuracy of power Doppler ultrasound in patients with chronic tennis elbow. Br J Sports Med 43 (2008); 872-876. doi:10.1136/bjsm.2007.043901.
5. Chang EY, Hoenecke HR Jr, Fronek J, Huang BK, Chung CB. Humeral avulsions of the inferior glenohumeral ligament complex involving the axillary pouch in professional baseball players. Skeletal Radiol 2014;43(1):35–41.