A Patient's Guide to Lateral Epicondylitis (Tennis
Elbow)
Introduction
Lateral epicondylitis, commonly known as
tennis elbow, is not limited to tennis players.
The backhand swing in tennis can strain the muscles
and tendons of the elbow in a way that leads to tennis
elbow. But many other types of repetitive activities
can also lead to tennis elbow: painting with a brush
or roller, running a chain saw, and using many types
of hand tools. Any activities that repeatedly stress
the same forearm muscles can cause symptoms of tennis
elbow.
This guide will help you understand
- what parts of the elbow are affected
- the causes of tennis elbow
- ways to make the pain go away
Anatomy
What parts of the elbow are affected?
Tennis elbow causes pain that starts on the outside
bump of the elbow, the lateral epicondyle. The
forearm muscles that bend the wrist back (the
extensors) attach on the lateral
epicondyle and are connected by a single
tendon. Tendons connect muscles to bone.
Tendons are made up of strands of a material called
collagen.
The collagen strands are lined up in bundles next to
each other.
Because the collagen strands in tendons are lined
up, tendons have high tensile strength. This
means they can withstand high forces that pull on both
ends of the tendon. When muscles work, they pull on
one end of the tendon. The other end of the tendon
pulls on the bone, causing the bone to move.
When you bend your wrist back or grip with your
hand, the wrist extensor muscles contract. The
contracting muscles pull on the extensor tendon. The
forces that pull on these tendons can build when you
grip things, hit a tennis ball in a backhand swing in
tennis, or do other similar actions.
Related Document: A
Patient's Guide to Elbow Anatomy
Causes
Why did I develop tennis elbow?
Overuse of the muscles and tendons of the forearm
and elbow are the most common reason people develop
tennis elbow. Repeating some types of activities over
and over again can put too much strain on the elbow
tendons. These activities are not necessarily
high-level sports competition. Hammering nails,
picking up heavy buckets, or pruning shrubs can all
cause the pain of tennis elbow.
In an acute injury, the body undergoes an
inflammatory response. Special inflammatory cells make
their way to the injured tissues to help them heal.
Conditions that involve inflammation are indicated by
-itis on the end of the word. For example,
inflammation in a tendon is called tendonitis.
Inflammation around the lateral epicondyle is called
lateral epicondylitis.
However, tennis elbow often does not involve
inflammation. Rather, the problem is within the cells
of the tendon. Doctors call this condition
tendonosis. In tendonosis, wear and tear is
thought to lead to tissue degeneration. A degenerated
tendon usually has an abnormal
arrangement of collagen fibers.
Instead of inflammatory cells, the body produces a
type of cells called fibroblasts. When this
happens, the collagen loses its strength. It becomes
fragile and can break or be easily injured. Each time
the collagen breaks down, the body responds by forming
scar tissue in the tendon. Eventually, the tendon
becomes thickened from extra scar tissue.
No one really knows exactly what causes tendonosis.
Some doctors think that the forearm tendon develops
small tears with too much activity. The tears try to
heal, but constant strain and overuse keep re-injuring
the tendon. After a while, the tendons stop trying to
heal. The scar
tissue never has a chance to fully heal, leaving
the injured areas weakened and painful.
Symptoms
What does tennis elbow feel like?
The main symptom of tennis elbow is tenderness and
pain that starts at the lateral epicondyle of the
elbow. The pain may spread down the forearm. It may go
as far as the back of the middle and ring fingers. The
forearm muscles may also feel tight and sore.
The pain usually gets worse when you bend your
wrist backward, turn your palm upward, or hold
something with a stiff wrist or straightened elbow.
Grasping items also makes the pain worse. Just
reaching into the refrigerator to get a carton of milk
can cause pain. Sometimes the elbow feels stiff and
won't straighten out completely.
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Diagnosis
How can my doctor be sure I have tennis elbow?
Your doctor will first take a detailed medical
history. You will need to answer questions about your
pain, how your pain affects you, your regular
activities, and past injuries to your elbow.
The physical exam is often most helpful in
diagnosing tennis elbow. Your doctor may position your
wrist and arm so you feel a stretch on the forearm
muscles and tendons. This is usually painful with
tennis elbow. There are also other tests for wrist and
forearm strength that can be used to detect tennis
elbow.
You may need to get X-rays of your elbow. The
X-rays mostly help your doctor rule out other problems
with the elbow joint. The X-ray may show if there are
calcium deposits on the lateral epicondyle at the
connection of the extensor tendon.
Tennis elbow symptoms are very similar to a
condition called radial tunnel syndrome. This
condition is caused by pressure on the radial
nerve as it crosses the elbow. If your pain does
not respond to treatments for tennis elbow, your
doctor may suggest tests to rule out problems with the
radial nerve.
Related Document: A
Patient's Guide to Radial Tunnel Syndrome
When the diagnosis is not clear, your doctor may
order other special tests. A magnetic resonance
imaging (MRI) scan is a special imaging test that
uses magnetic waves to create pictures of the elbow in
slices. The MRI scan shows tendons as well as
bones.
Ultrasound tests use high-frequency sound
waves to generate an image of the tissues below the
skin. As the small ultrasound device is rubbed over
the sore area, an image appears on a screen. This type
of test can sometimes show problems with collagen
degeneration.
Treatment
What can I do to make my pain go away?
Nonsurgical Treatment
The key to nonsurgical treatment is to keep the
collagen from breaking down further. The goal is to
help the tendon heal.
If the problem is caused by acute inflammation,
anti-inflammatory medications such as ibuprofen may
give you some relief. If inflammation doesn't go away,
your doctor may inject the elbow with
cortisone. Cortisone is a powerful
anti-inflammatory medication. Its benefits are
temporary, but they can last for a period of weeks to
several months.
Your doctor may suggest using ultrasound to guide a
needle into the sore area. The ultrasound gives a
clear picture of areas in the tendon that contain scar
tissue. Poking holes in the tendon breaks up scar
tissue and gets the tendon to bleed. Bleeding in the
tendon helps stimulate the healing response.
Shock wave therapy is a newer form of
nonsurgical treatment. It uses a machine to generate
shock wave pulses to the sore area. Patients generally
receive the treatment once each week for up to three
weeks. It is not known exactly why it works for tennis
elbow, but recent studies indicate that this form of
treatment can help ease pain, while improving range of
motion and function.
Doctors commonly have patients with tennis elbow
work with a physical or occupational therapist. At
first, your therapist will give you tips on how to
rest your elbow and how to do your activities without
putting extra strain on your elbow. Your therapist may
apply tape to take some of the load off the elbow
muscles and tendons. You may need to wear an elbow
strap that wraps around the upper forearm in a way
that relieves the pressure on the tendon attachment.
Your therapist may apply ice and electrical
stimulation to ease pain and improve healing of the
tendon. Therapy sessions may also include
iontophoresis, which uses a mild electrical
current to push anti-inflammatory medicine to the sore
area. This treatment is especially helpful for
patients who can't tolerate injections. Exercises are
used to gradually stretch and strengthen the forearm
muscles.
Because tendonosis is often linked to overuse, your
therapist will work with you to reduce repeated
strains on your elbow. When symptoms come from a
particular sport or work activity, your therapist will
observe your style and motion with the activity. You
may be given tips about how to perform the movement so
the elbow is protected. Your therapist can check your
sports equipment and work tools and suggest how to
alter them to keep your elbow safe.
Surgery
Sometimes nonsurgical treatment fails to stop the
pain or help patients regain use of the elbow. In
these cases, surgery may be necessary. Tendon
Debridement
When problems are caused by tendonosis, surgeons
may choose to take out (debride) only the
affected tissues within the tendon. In these cases,
the surgeon cleans up the tendon, removing only the
damaged tissue. Tendon Release
A commonly used surgery for tennis elbow is called
a lateral epicondyle release. This surgery
takes tension off the extensor tendon. The surgeon
begins by making an incision along the arm over the
lateral epicondyle. Soft tissues are gently moved
aside so the surgeon can see the point where the
extensor tendon attaches on the lateral
epicondyle.
The extensor tendon is then cut where it connects
to the lateral epicondyle. The surgeon splits the
tendon and takes out any extra scar tissue. Any
bone spurs found on the lateral epicondyle are
removed. (Bone spurs are pointed bumps that can grow
on the surface of the bones.) Some surgeons suture the
loose end of the tendon to the nearby fascia
tissue. (Fascia tissue covers the muscles and organs
throughout your body.) The skin is then stitched
together.
This surgery can usually be done on an outpatient
basis, which means that you don't have to stay
overnight in the hospital. It can be done using a
general anesthetic or a regional
anesthetic. A general anesthetic puts you to
sleep. A regional anesthetic blocks only certain
nerves for several hours. For surgery on the elbow,
you would most likely get an axillary block to
numb your arm.
View
animation of the procedure
Rehabilitation
How soon can I use my elbow again?
Nonsurgical Rehabilitation
In cases where the tendon is inflamed, nonsurgical
treatment is usually only needed for four to six
weeks. When symptoms are from tendonosis, you can
expect healing to take longer, usually up to three
months. If your tendonosis is severe, it may take at
least six months for complete healing.
After Surgery
Rehabilitation takes much longer after surgery.
Immediately after surgery, your elbow is placed in a
removable splint that keeps your elbow bent at a
90-degree angle. Your first few therapy sessions may
involve ice and electrical stimulation treatments to
help control pain and swelling from the surgery. Your
therapist may also use massage and other types of
hands-on treatments to ease muscle spasm and pain.
You will gradually work into more active stretching
and strengthening exercises. You just need to be
careful to avoid doing too much, too quickly. Active
therapy starts about two weeks after surgery. Your
therapist may begin with light isometric strengthening
exercises. These exercises work the muscles of the
forearm without straining the healing tissues. You
will use your own muscle power in active
range-of-motion exercises.
At about six weeks, you start doing more active
strengthening. As you progress, your therapist will
teach you exercises to strengthen and stabilize the
muscles and joints of the wrist, elbow, and shoulder.
You will also do exercises to improve fine motor
control and dexterity of the hand. Some of the
exercises you'll do are designed get your hand working
in ways that are similar to your work tasks and sport
activities. Other exercises will work your elbow in
ways that are similar to your work tasks and sport
activities. Your therapist will help you find ways to
do your tasks that don't put too much stress on your
elbow.
You may require therapy for two to three months. It
could take four to six months to get back to
high-level sports and work activities. Before your
therapy sessions end, your therapist will teach you a
number of ways to avoid future problems. |