Acute Tennis Elbow is an injury to the muscles that extend the wrist and fingers. The site of injury is typically the lateral epicondyle, a bony bump on the outside of the elbow where these muscles attach.
Tennis Elbow symptoms that have lasted more than 6 weeks are considered to be sub‑acute and beyond three months, as chronic tennis elbow.
What are Tennis Elbow Symptoms?
Typically the Tennis Elbow sufferer will experience pain when performing gripping tasks or resisted wrist/finger extension. Pain can also be present when the muscles are stretched. There will be tenderness directly over the bony epicondyle, and there may be trigger points in the wrist muscles.
Some sufferers will also have neck stiffness and tenderness, as well as signs of nerve irritation. Most elbow movements will be pain‑free, despite that being the area of pain.
What Causes Acute Tennis Elbow?
Acute Tennis Elbow is caused by damaged muscle tissue at the point it anchors to the arm bone at the elbow. It occurs when more force is applied to an area than the normal healthy tissues can handle.
Common Tennis Elbow Causes include:
Unaccustomed hand use. eg painting a fence, hammering, lots of typing.
Excessive gripping or wringing activities
Poor forearm muscle strength or tight muscles
Poor technique (this may be a poor tennis shot)
In some cases such as Chronic Tennis Elbow, this can occur due to the soft tissues being in poor health, which are easily injured. Inflammation follows the injury, which leads to swelling and elbow pain.
What Causes Chronic Tennis Elbow?
Chronic Tennis Elbow is associated with degenerative changes in the muscle tissues located at the epicondyle. Although for a long time this was thought to be related to inflammation from overuse, this is now known to be incorrect.
Testing of Chronic Tennis Elbow sufferers has shown no evidence of the chemicals normally associated with inflammation. Histochemists look at tendon biopsies under the microscope and find what they now call “angiofibroblastic hyperplasia”. This alteration in the blood supply is coupled with fibrous scar tissue development, and results in changes in the coordination of the muscles when using the hand and wrist. The histopathology of the affected musculature reveals edema and fibroblast proliferation in the subtendinous space, tendinopathy with hypervascularity (particularly involving the extensor carpi radialis brevis tendon), and spur formation with a sharp longitudinal ridge on the lateral epicondyle. You also see degenerative changes in the extensor tendon, where the tendon structure starts to break down.
There is also evidence that longstanding forearm muscle imbalances can distort your elbow joint position and result in chronic tennis elbow pain. This results in decreased ability to perform normal elbow activities and reducing elbow and grip strength.
How is Tennis Elbow Diagnosed?
Your Tennis Elbow is clinically diagnosed by your physiotherapist or doctor. After listening to your injury history and using some confirmatory clinical tests a provisional diagnosis of tennis elbow can be made.
An ultrasound scan and MRI are the two best imaging tests to identify any tendon tears or inflammation. X‑rays alone are of little diagnostic benefit, but may be helpful in ruling out many other potential causes of elbow pain.
Referred Pain from your Neck can mimic Tennis Elbow
A significant percentage of tennis elbow sufferers may feel pain in the lateral elbow, but not actually be experiencing tennis elbow. There is a high incidence of lateral elbow pain that is referred to your elbow from a cervical spine (neck) problem or injury. The most common neck level that refers to your lateral elbow is C5‑6 which transmits their pain signals along the radial nerve path to the lateral side of the elbow.
Your radial nerve may also have reduced neural mobility, which can cause symptoms similar to tennis elbow. It is extremely important to have your neck and upper limb assessed by an experienced orthopedist to confirm or exclude any neck dysfunction or neural tension. Failure to do so will result in a lack of symptom improvement and the development of chronic tennis elbow pain syndrome.
Who Suffers Tennis Elbow?
Tennis Elbow occurs commonly in the community. It is present in 40% of all tennis players (hence its name) and 15% of people working in repetitive manual trades. Certainly most people who get tennis elbow symptoms don’t even play tennis. It can occur at any age; however, sufferers are generally between the ages of 35 and 50. Predictably, the side affected is usually associated with handedness, but it can occur in the non‑dominant arm. Males and Females are affected equally.
Tennis Elbow Treatment
Physical therapy has been shown to be effective in the short and long‑term management of tennis elbow.
Physical therapy aims to achieve a:
Reduction of elbow pain.
Facilitation of tissue repair.
Restoration of normal joint range of motion and function.
Restoration of normal muscle length, strength and movement patterns.
Normalization of your upper limb neurodynamics.
Normalization of cervical joint function.
There are many ways to achieve these and, following a thorough assessment of your elbow, arm and neck, your physical therapist will discuss the best strategy for you to use based on your symptoms and your lifestyle. Results are typically measured through patient feedback and measurement of pain‑free grip strength.
Physiotherapy treatment can include gentle mobilization of your neck and elbow joints, electrotherapy, elbow kinesio taping, muscle stretches, neural mobilizations, massage, dry needling, AStim muscle abrasion, and strengthening.
When Should You Use a Tennis Elbow Brace?
A tennis elbow brace can be very effective from the moment you put it on. In these instances, the brace will dissipate the stressful gripping forces away from your injured structures.
However, a tennis elbow brace does not work in 100% of cases. In our experience, we recommend that you even consider trying a wrist splint. Although it may not make sense immediately, recognize that the muscles and tendons that flex and extend the wrist arise from the lateral elbow and are precisely the tendons affected in tennis elbow. Therefore, minimizing wrist flexion and extension may help rest the tendons affected in tennis elbow even more than a traditional tennis elbow brace.
Do Injections Help?
Injection of corticosteroid onto the tendon sheath of the extensor tendons beleagured by tennis elbow has been a main stay of treatment for decades. Excellent results can be expected in the short term, but long‑term analysis proves that there is a fairly high recurrence rate and ultimately it is no better than strict observation for complete resolution of the condition. Cortisone injections can shorten the symptomatic periods, allow athletes to participate in sports, and allow workers to continue with their work. It historically and currently maintains a roll to minimize symptoms for weeks or months at a time, but is no longer considered curative.
A second type of injection is called PRP injections. PRP stands for platelet rich plasma. In PRP therapy, a patient’s blood is drawn, separated and re‑injected into injured joints and muscles to ease pain. Platelets release special growth factors that are purported to lead to tissue healing and repair. Scientific data that has been inconclusive, with some studies supporting its use and some studies concluding it was no better than the “placebo effect”. Because of the conflicting evidence, at the time of this writing, it was not an FDA approved, considered experimental treatment, and insurance companies were not paying for this therapy.
Injections of any kind should be avoided if the overlying skin or subcutaneous tissue is infected or if bacteremia is suspected. Injection of a joint with a replacement or prosthesis in it carries a particularly high risk of infection. Lack of response to previous injections may be a relative contraindication. Warfarin anticoagulation with international normalized ratio (INR) values in the therapeutic range is not a contraindication to joint or soft‑tissue aspiration or injection.
What is Your Tennis Elbow Prognosis?
Untreated Tennis Elbows can last anywhere from 6 months to 2 years. You are also prone to recurrence.
Studies have shown rest and bracing, cortisone injection, followed by physical therapy to be the most effective way of managing Tennis Elbow when compared to benign neglect and hoping for it to go away.
Cortisone injections alone result in very good initial improvements with almost 80% reduction in symptoms after 3 to 6 weeks. But, some patients who receive cortisone injections show an increase in pain after 6 weeks if rest and appropriate activity modification is ignored.
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.
Can surgery fix tennis elbow?
Yes. Surgery is typically considered the last option, it is only employed when you the extensor tendons along the lateral side of the elbow are actually torn off the bone, or a concentrated effort of nonoperative measures have produced dissatisfactory results. The surgery is done through a small 2 inch incision, tendon edges are cleaned up, angiofibroblastic tissue is removed, and the tendons are repaired neatly to the bone. Surgery typically takes less than a half hour, is done as an outpatient, then followed by a short period of rest, range of motion stretches, and finally strengthening. Good results can be expected in over 90% of cases.