Many people are affected by Tennis elbow (aka lateral epicondylitis) is a painful condition of the elbow caused by overuse. This overuse is usually from repeating the same motions again and again. The result is damage to the tendons that join the forearm muscles to the outside of the elbow. Naturally, this causes much pain and tenderness on the outside of the elbow where these forearm muscles attach.
Movements associated with repetitive stresses from playing Tennis such as forearm supination (turning the forearm over with the palm up); and wrist extension have provided this condition with its nickname. Although many sufferers with tennis elbow have never played Tennis in their lives! Tennis Elbow symptoms that have lasted more than six weeks are considered to be sub-acute and beyond three months, as chronic tennis elbow.
Anatomy of the elbow joint
The elbow joint is comprised of three bones: your upper arm bone (humerus) and two long bones in your forearm (the radius and ulna). There are bony bumps at the distal end (base) of the humerus called epicondyles. The bony bump on the outside (lateral side) of the elbow is called the lateral epicondyle. Muscles, ligaments, and tendons attach here and hold the elbow joint together.
The tendons and muscles that lateral epicondylitis affects, involves these muscles and tendons of your forearm. In particular, the forearm muscles that extend your wrist and fingers and the forearm tendons (extensors) which attach the muscles to bone. They are each attached at the elbow onto the lateral epicondyle. The specific tendon (usually) involved in tennis elbow is known as the Extensor Carpi Radialis Brevis (ECRB).
Acute tennis elbow
When the ECRB is weakened from overuse or more force is applied to the area than normal healthy tissue can handle. Microscopic tears form in the tendon where it attaches to the lateral epicondyle. Over time these tears lead 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 friction can cause gradual wear and tear of the muscle over time.
Common tennis elbow causes can include unaccustomed hand use, for example by painting a fence; hammering; continuous typing (from those last second essays); excessive/repetitive gripping or twisting tasks. It can also result from during sporting activities due to poor forearm muscle strength, tight muscles or poor sports technique.
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.
Tennis elbow symptoms
A person will typically experience pain in the lateral epicondyles when the muscles are stretched when undertaking gripping tasks or any motion requiring wrist tension/finger movement. There will be tenderness directly over the bony epicondyle, and there may be trigger points in the wrist muscles.
The symptoms of tennis elbow develop gradually and in many cases, the pain begins as mild and then slowly worsens over the coming weeks. There is usually no specific injury associated with the start of symptoms. Other common indicators of tennis elbow include pain or burning on the outer part of your elbow and weak grip strength.
The symptoms are often worsened with further forearm activity. For example, holding heavy objects such as a hammer or supporting one’s body weight using just the hands. The dominant arm is most often affected although it is usual for both arms to be affected.
Who suffers tennis elbow?
As you may have surmised, athletes are not the only people who suffer tennis elbow (It is present in 40% of all tennis players). People working in repetitive manual trades, such as painters, plumbers, and carpenters are particularly prone to developing tennis elbow. Furthermore, studies have shown that mechanics, cooks, and butchers also get tennis elbow more often than the rest of the population. It is thought that the repetition and heavy lifting required in these occupations is what often leads to injury.
Tennis elbow can occur at any age. However, sufferers are generally between the ages of 35 and 50, with males and females being affected equally. Finally, tennis elbow occurrence can also be of unknown cause without any recognised risk factors or the case of a recognised repetitive injury, in this case, it is labelled as “insidious”.
Tennis elbow diagnosis
Tennis elbow can usually be diagnosed by a relevant professional with experience with the condition such as a physiotherapist or a doctor. After listening to the injury history, and undertaking some clinical tests a provisional diagnosis of tennis elbow can be made. An MRI scan and/or an Ultrasound scan can be used to identify any tendon tears or inflammation.
Possible differential diagnosis
Some tennis elbow sufferers 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) injury! The most common neck joint that refers to your lateral elbow is between levels C5 and 6 (which transmit their pain signals along the radial nerve of the forearm). If you have additional neck pain or additional symptoms then this should be mentioned to your doctor.
Untreated Tennis Elbows can last anywhere from 6 months to 2 years and are sadly also prone to recurrence (as well I know!).
Treating tennis elbow
Physiotherapy has been shown to be effective in the short and long-term management of tennis elbow. The aims of Physiotherapy in treating the condition are the reduction of the pain; tissue repair facilitation; restoring normal joint range of motion and function; as well as restoring normal muscle length; strength and movement patterns as quickly as possible.
Using a tennis elbow brace
A tennis elbow brace can be a very effective tool for reducing pain. The brace is designed to dissipate the stressful gripping forces away from your injured structures. So it reduces pain while protecting the healing area. Naturally, a tennis elbow brace doesn’t work if is resulting from aforementioned referred symptoms from C5-6 Vertebrae in your neck (See above).
Nonsurgical treatment options
Nonsurgical Treatment, as per any sports or occupational injury the use of PRICE (Protection; Rest; Ice Compression and Elevation) should be the first port of call with treatment. Non-steroidal anti-inflammatory medicines, as well as drugs like aspirin or ibuprofen, can be taken to reduce the pain and swelling. However, these are short-term options.
If the pain is ongoing a physiotherapist or doctor may suggest wrist stretching and strengthening exercises with the elbow extended (See below). A physiotherapist may also perform ice massage or muscle-stimulating techniques to improve muscle healing. If the condition worsens steroid injections (such as cortisone) may be considered by your doctor. These are very effective anti-inflammatory medicines.
With regards to exercising with tennis elbow. During the initial phase of the injury, stick with the PRICE techniques to allow the elbow joint sufficient time to heal. All exercise should be avoided during this time it should be noted for all you fitness junkies out there! Let it heal! No pull-ups!!
With my own personal injuries, I started out very light. This was after weeks of frustration not being able to undertake barely a single press-up without experiencing intense pain! I used isometric holds and stretches to help keep muscle tone. Although whether you would consider such options would depend on the severity of your condition and how well you are healing. Additionally, if in doubt I would consult an appropriate health professional for advice prior to undertaking any activity. Especially where stress might re-injure the affected elbow(s).
If symptoms are treated shortly after onset, improvement with conservative measures may allow for a quick return to activity. Chronic cases may require three to six months to resolve. They may again require referral to a physiotherapist or your own doctor.
Worst case scenario
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 the bone. The surgical approach for you will depend on a range of factors, including the scope of your injury; your general health; and your personal needs.
What increases the risk of developing tennis elbow?
Sports or jobs requiring repetitive and strenuous forearm and wrist movements (tennis, squash, racquetball, carpentry).
- Sports that require strenuous or repetitive forearm movement (tennis, racquetball, golf).
- Poor physical conditioning (strength and flexibility).
- Inadequate warm-up before activity.
- Resumption of activity before healing and rehabilitation and conditioning are complete.
Although there are no absolute guarantees at warding off a Tennis elbow injury. There are a number of things can be done to help reduce risks associated with the condition. For example, appropriately warming up and stretching before practice or competition; Maintaining wrist/forearm flexibility and muscle strength/endurance through regular exercise; correct technique and the use of proper equipment (i.e., racquet size/weight and grip).
Rehabilitation and Strengthening Techniques
Poor grip strength is a common symptom of tennis elbow. Improving grip strength by building the muscles of the forearm can help improve the ability to perform daily activities.
Equipment: Tennis Ball
Muscles Involved: long flexor tendons of the fingers and thumb.
- Sit at a table with your forearm resting on the table.
- Hold the tennis ball in your affected hand.
- Squeeze the ball as hard as you can and hold for 15 seconds.
- Release and repeat 10 times. Switch and do the other arm (even if not affected).
Supination with a dumbbell
The supinator muscle is a large muscle of the forearm that attaches into the elbow. It’s responsible for turning the palm upward and is often involved in movements that can cause tennis elbow.
Equipment: Light dumbbell.
Muscles Involved: Supinator Forearm muscle.
- Sit in a chair holding a light dumbbell vertically in your hand with your elbow resting on your knee.
- Let the weight of the dumbbell help rotate the arm outward, turning the palm up.
- Rotate the hand back the other direction until your palm is facing downward.
- Repeat 20 times on each side.
- Concentrate on isolating the movement to the lower arm, ensure your upper arm and elbow remain still.
The wrist extensors are a group of muscles that are responsible for bending the wrist. Like when signalling to someone to ‘talk to the hand’. These small muscles that connect into the elbow are often subject to overuse, especially during racquet sports.
Equipment: Light dumbbell
Muscles Involved: wrist extensors
- Sit in a chair holding a light dumbbell in your hand with your palm facing down. Rest your elbow comfortably on your knee.
- Keeping your palm facing down, extend your wrist by curling it towards your body. If this is too challenging, do the movement with no weight.
- Return to starting position and repeat 10 times on each side.
- Concentrate on isolating the movement to the wrist, keeping the rest of the arm still.
The wrist flexors are a group of muscles that work opposite the wrist extensors. These small muscles that connect into the elbow are also subject to overuse, leading to pain and inflammation.
Equipment: Light dumbbell.
Muscles worked: wrist flexors
- Sit in a chair holding a light dumbbell in your hand with your palm facing up and elbow resting comfortably on your knee.
- Keeping your palm facing up, flex your wrist by curling it towards your body.
- Return to starting position and repeat 10 times on each side.
- Try to isolate the movement to the wrist, keeping the rest of the arm still.
Equipment: hand towel
Muscles worked: wrist extensors, wrist flexors
- Sit in a chair holding a towel with both hands, shoulders relaxed.
- Twist the towel with both hands in opposite directions as if you are wringing out water.
- Repeat 10 times then repeat another 10 times in the other direction.