Tennis Elbow

What is 'Tennis elbow' ?

'Tennis elbow' is a condition where the outer part of the elbow becomes sore and tender. Although commonly associated with tennis and other racquet sports the condition can affect almost anybody. The condition is also known as lateral epicondylitis, although histologic studies have shown no evidence of an inflammatory process.

What symptoms does it cause?

Patients usually describe pain located towards the outer part of the arm. There is often local tenderness in the affected area (lateral epicondyle - a prominent part of the bone on the outside of the elbow). Gripping objects and movements of the wrist usually hurt (especially wrist extension and lifting movements) and some patients describe stiffness of the elbow, particularly in the morning.

Who does it usually affect ?

Lateral epicondylitis commonly occurs between the ages of 30 and 60. It is just as common in men and women and can equally affect the dominant and non dominant arm.

What causes it?

It is a degenerative, non-inflammatory condition predominantly affecting the origin of the extensor carpi radialis brevis (ECRB) muscle. In raquet sport players, it is believed to be caused by the repetitive nature of hitting a ball which leads to tiny tears in the tendon attachment at the elbow. The normal healing process does not occur. Other possible risk factors for developing the condition include taking up tennis later in life, unaccustomed physical activity and repetitive eccentric (controlled lengthening of a muscle group) contractions.

Diagnosing Tennis elbow

The diagnosis is made by clinical signs and symptoms which are usually fairly characteristic. There is usually point tenderness over the origin of the extensor carpi radialis brevis muscle on the lateral epicondyle. There should also be pain on passive flexion of the wrist flexion and with resisted wrist extension (Cozen's test). Both tests are usually performed with the elbow extended.

Investigations

An X-ray will not normally show any abnormality. An MRI typically shows fluid in the ECRB origin and there may also be a defect in this tissue.

How does the condition progress ?

Depending on the severity of the tendon injury healing may be incomplete. The condition may progress from reversible local degeneration to non-reversible changes in the origin of the ECRB muscle to rupture of ECRB muscle origin and finally secondary changes of fibrosis or calcification can occur.

What treatments are available for 'Tennis Elbow' and 'Golfers Elbow' ?

Rest is the treatment of choice when the pain first appears. If the pain is severe, short term immobilisation of the arm in a splint may be helpful in some patients. This rest aims to allow the tiny tears in the tendon attachment to heal. Non-specific symptomatic treatments that can be used include non-steroidal anti-inflammatory drugs (NSAIDs),heat or ice. A counter-force brace or "tennis elbow strap" to reduce strain at the elbow can help to limit pain and to protect against further damage. Physiotherapy, including a program of stretching, strengthening and local tissue massage may also provide some benefit.

What other treatments can be used?

A number of other treatment options are available supported by variable degrees of clinical evidence:

  • Acupuncture.
  • Injection of autologous blood or platelet-rich plasma.
  • Extra-corporeal shock wave therapy (ESWT).
  • Heat therapy.
  • Local injection of cortisone and a local anaesthetic.
  • Pulsed ultrasound to break up scar tissue, promote healing, and increase blood flow in the area.
  • Sclerotherapy .
  • Trigger point therapy.

Surgery ?

In cases which fail to resolve with other treatment modalities surgery may be indicated. Many techniques have been described. Most aim to release the strain on the affected muscle origin, remove degenerative tissue and promote healing.

Can these conditions be prevented or a recurrence avoided?

The use of appropriate coaching techniques, training regimes and equipment may be of use in reducing the risk of the condition occuring and minimising the risk of recurrence. 

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