Tennis elbow

What is tennis elbow?

Elbow joint is formed by three bones, humerus (arm bone), radius and ulna (forearm bones) supported by muscles and tendons. It is the second most mobile joint of the body. Tennis elbow is an inflammatory condition of the tendons that attach the muscles of the forearm to the bony prominence on the outside of the elbow joint. It is also called lateral epicondylitis as the inflammation of the tendons take place at their attachment to lateral epicondyle (a bony bump on the lateral or outer side) of the humerus (upper arm bone).

Lateral epicondylitis or tennis elbow is caused by repetitive strain or overuse of the forearm in sports like tennis, racquet sports, squash, weightlifting, etc and activities like carpentry, painting, typing, knitting, cleaning, house work etc.  It is the most common cause of elbow symptoms in patients with elbow ailments. It accounts for 5 % of cases of elbow problems. It affects 1 to 3 % adults every year, usually in the dominant arm. It is commonly seen in both men and women at the age of 30-50 years. Extensor carpi radialis brevis (ECRB) is a specific muscle that stabilizes the wrist when you straighten the elbow. Tennis elbow is often caused by wear and tear in the ECRB muscle. Radial tunnel syndrome is associated with 5 % cases of tennis elbow.


What are the symptoms of tennis elbow?

The common symptoms of tennis elbow are pain and tenderness on the outer side of the elbow. In the beginning, pain is mild that gets worse slowly over weeks and months. The pain may radiate to the hand and sometimes to the upper arm. Pain is felt most when you twist your hand, lift a weight and extend your wrist. Soreness in the forearm muscles and morning stiffness is also common. Weakness in the forearm becomes so severe in some that you find it difficult to do simple activities like gripping or holding small objects such as a pen or cup, shaking hands, opening the door, or lifting anything.


How is it diagnosed?

Your orthopaedic surgeon will diagnose tennis elbow after discussion of your symptoms and physical examination. He will ask for ultrasound scan/MRI scan/x-rays to study the extent of the damage to this area and plan the treatment. He may also ask you to have EMG or electromyography to check the involvement of the nerves.


What happens if nothing is done?

If tennis elbow is left untreated, it may recover by itself if the causative factor (sports, work etc) is stopped. If the activity is continued, it may lead to chronic pain, tendon tear, weakness and limited range of motion in the elbow.


How is it treated?

It can be treated both conservatively and surgically. 95% of cases of lateral epicondylitis are treated successfully with conservative or non-operative treatment. It involves rest, cold application, steroid injections, acupuncture, medications, physical therapy, PRP injections, and extracorporeal shock wave therapy.

Surgery is indicated in

  • Failure of conservative treatment (6-12 months)
  • Persistent pain
  • Associated pathology – Radial tunnel syndrome, fracture etc


What are the non-operative treatments?

The non-operative treatment involve –

  • Rest– resting your arm can be achieved by avoiding the activities that can provoke pain. This enables proper healing of the tendon without new injury or trauma.
  • Ice application– you can apply ice packs for 15 to 20 minutes at an interval of three to four times in a day. It controls the pain and swelling of the affected area.
  • Medicines– your surgeon will give you painkillers like paracetamol or codeine to reduce your pain. Anti-inflammatory medicines like aspirin and ibuprofen are also prescribed to reduce your pain and swelling however long term use can affect your stomach and kidneys.
  • Brace– your surgeon can advise you to use counterforce brace or splint for your affected arm in order to reduce strain on your muscles and tendons.
  • Physical therapy- physical therapy is necessary to regain the lost strength and range of motion and prevent stiffness in the joint. It is started with gentle stretching exercises of the elbow after immobilization in a sling. It is followed by strenuous and strengthening exercises of the elbow. It should be done under the supervision of your surgeon and physiotherapist.
  • Acupunture – This could help with the pain in early stages in some patients.
  • Steroid injections- your surgeon can inject corticosteroid directly into your tendons to reduce inflammation. However, this treatment provides instant relief but it may not last longer.
  • Plasma-rich protein injections- plasma rich protein injections are given to repair the damaged tissues of the affected site. These injections are basically derived from your own blood plasma, however the results are not promising more than steroid injection.
  • Extracorporeal shock wave therapy- shockwave therapy is used to enhance natural healing of the body through sound waves. This is still in experimental stage.


What does the operation involve?

The main goal of the operation is to relieve the symptoms, remove the damaged tissues and improve the blood supply to the affected site for proper healing. It can be done by two techniques either by arthroscopy (authors’ preferred method) or open surgery.

  • The operation is done as a day case under general anaesthetic, the skin over the affected area is cut and damaged tendon tissues are removed through the key hole. Scar tissues and bony projections if present are removed. The bone is drilled to improve blood supply and the remaining tendon is repaired back to the bone in open surgery.
  • The skin is then stitched with absorbable sutures, a bulky bandage is applied to the elbow. The operation takes 1- 2 hours and most patients are discharged on the same day.


What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • Before discharge, your physiotherapist will teach you gentle exercises of fingers, wrist, elbow and shoulder. This is necessary to prevent further stiffness and to maintain the strength of the muscles.
  • The bulky bandage could be removed in 48hrs and dressings over the wound kept clean and dry for 2 weeks
  • Heavy activities and weightlifting should be restricted for 4-6weeks to ensure safe healing. You can use your arm to do light activities (writing, using keyboard etc) that don’t cause excessive pain or discomfort.
  • The patient is reviewed at 2 weeks and referred for physiotherapy.
  • The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications and helps the scar to mature.
  • The physical therapy after tennis elbow release is paramount and is essential to start them as soon as possible after surgery. Gentle exercises as tolerated by the patient after surgery and are progressed to stretching exercises around 2-4 weeks. This will be guided by your surgeon and physiotherapists. The improvement in symptoms happens over a period of 3- 6 months and is dependent on the complexity of the primary problem and the intervention.


Are there any risks?

  • Persistent elbow stiffness
  • Infection
  • Nerve injury (Radial or ulnar)
  • Vascular injury (uncommon, brachial artery)
  • Myositis ossificans
  • Recurrence
  • Anaesthetic complications
  • Chronic Regional Pain Syndrome “CRPS”.
  • Any surgery can end up with rare complications and leave a patient worse than before surgery and is rare in this surgery


What are the results of the operation?

The outcome of the surgery is good with minimal serious complications (<1%). The outcome following this surgery depends on severity/chronicity of the injury, treatment involved and adherence to physiotherapy. However is more predictable in the author’s experience.


When can I return to driving and work?

You can get back to work in 2-4 weeks if you have a desk job, however might take upto 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3 months and you should be able to resume driving in 4-6 weeks. The above time line could vary based on the severity of injury and the treatment modality.  Your physician will be able to advise you.


Inflammation of the tendons that attach the muscles of the forearm to the bony prominence on the outside of the elbow joint


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