Tennis Elbow

What is tennis elbow and what are the symptoms?

Tennis elbow causes pain on the outer side of the elbow. A medical term for tennis elbow is lateral epicondylitis. This is because the pain is felt around the area of the lateral epicondyle (the lower, outer, bumpy part of the humerus bone in the upper arm). In most people the pain only occurs when you use the forearm and wrist, particularly for twisting movements such as turning a door handle. However, for some people the pain is constant.

The pain may also travel down your arm from your elbow towards your wrist and it can mean that you may find it difficult to hold items such as a knife or fork, a cup or a pen. Some people find it painful and difficult to straighten their arm fully when they have tennis elbow. Some people also notice a stiffness in the affected arm.

Golfer's elbow is the name given to a similar condition that produces pain around the inner side of the elbow.

What causes tennis elbow?

The site of the pain is where some tendons from the forearm muscles attach to the bone around the elbow. The pain is thought to be due an injury, or several tiny injuries, to one or more tendons. The injury can cause a tiny tear to the tendon and inflammation and scarring of the tendon can occur as a result.

The injuries are usually caused by overuse of the forearm muscles in repeated actions such as wringing clothes or manual work (particularly with twisting movements such as using a screwdriver). Playing tennis or other racquet sports can also cause it. However, despite being called tennis elbow, racquet sports are only thought to be the likely cause in about 5 in 100 people. In most people, tennis elbow affects your dominant arm (the arm that you tend to write with).

Who gets tennis elbow?

About 5 in 1000 adults develop tennis elbow each year. It mainly occurs between the ages of 40 and 60. Women and men are affected equally.

Tennis elbow is more likely to occur if you have unfit forearm muscles. For example, if you suddenly play a lot of tennis whilst on holiday, or you do a DIY project when you are not used to strong forearm actions. However, even if you are used to heavy work, you can overdo it and injure a tendon. People whose work involves repeated twisting and gripping actions, such as carpenters and plasterers, are prone to getting tennis elbow.

However, it can sometimes be difficult to pinpoint an exact event that started your symptoms. In some people, the condition develops for no apparent reason without any prior overuse or injury to the arm.

How is tennis elbow diagnosed?

Your doctor can usually diagnose tennis elbow by talking to you about your symptoms and by examining your arms. You will typically experience pain when the doctor examines the outer part of your elbow. Your doctor may also ask you to move your wrist as this will usually bring on your pain.

Investigations are not usually needed to diagnose tennis elbow. However, if after some time your tennis elbow is not improving, your doctor may suggest that they refer you to a specialist. The specialist may suggest investigations such as an MRI scan.

What are the treatment options for tennis elbow?

Modifying activities that bring on your symptoms

You will be able to recognise which movements tend to bring on your pain and you should try to avoid these as much as possible. Typically, pain is made worse by lifting, gripping and twisting movements of the affected arm. Resting from activities that bring on pain can help to reduce inflammation so that the tendon injury can heal. In some people, just modifying their activities and cutting out repetitive movements of the arm or hand can be enough to improve tennis elbow.

You may need to discuss with your doctor and/or your employer if you feel that your job may be contributing to your tennis elbow. There may be different tasks that you can do at work while your tennis elbow is healing. It is also advisable for everyone to take regular breaks when they are working.

Anti-inflammatory and other painkillers

Anti-inflammatory painkillers such as ibuprofen are commonly used to ease pain in tennis elbow. Some anti-inflammatory painkillers also come as creams or gels which you can rub over a painful elbow. These tend to produce fewer side-effects than those taken by mouth and may give good relief of pain for tennis elbow. There are various brands which you can buy, or get on prescription. Ask your doctor or pharmacist for advice.

If you cannot take anti-inflammatory painkillers, other painkillers such as paracetamol, with or without codeine added to it, may be helpful.

Steroid injection

If the above measures do not work, or if you have severe pain and difficulty using your arm, an injection of a steroid into the painful area of the elbow may ease the pain. For some people, the pain never returns after having a steroid injection. However, often, the relief from pain is only for a short time - perhaps for a few weeks. It is worth thinking about this before deciding on trying a steroid injection. A number of studies have shown that steroid injections may be helpful in easing pain in the short-term but that pain tends to come back in many people.

Remember that even if a steroid injection has eased your pain, you still need to rest your arm and avoid any activities that may have brought on your pain previously. Build up your activities over some weeks to try to reduce the chance of your tennis elbow coming back.

A steroid injection may sometimes be repeated after some weeks if pain recurs. However, it is usual to have no more than three injections at the same site. There may also be some side effects of steroid injections, for example:

• Pain on injection.
• Atrophy of (shrinking or loss of) the fatty tissue under the skin at the injection site.
• Depigmentation (loss of colouration) of the skin around the injection site.
• Damage to the tendon around the elbow (this is very rare).

Physiotherapy

Physiotherapy has been shown to be helpful in the treatment of tennis elbow. The physiotherapist may be able to use techniques such as massage, laser therapy and ultrasound therapy as well as exercises to treat your tennis elbow. It is not certain if any of these physiotherapy treatments is better than others.

Studies have shown that physiotherapy may not be as good as a steroid injection at relieving pain in the short-term (ie within the first six weeks). But it may be superior to steroid injections in the long-term. However, there may be a wait for your physiotherapy appointment.

Other treatment options

These can include wearing a special elbow armband or bandage. This may help to give support and protection to the elbow until symptoms ease. Another option may be to wear a wrist splint which may ease pain by helping to rest the muscles that pull on the elbow. Wearing supports such as these and having physiotherapy at the same time may give you better symptom relief in the long-term.

Shockwave therapy using high-pressure low-frequency sound waves is sometimes used to treat tennis elbow. However, it is not clear exactly how well this type of treatment works. There is a small chance of side-effects, including pain and bone and tendon damage. You should discuss the pros and cons of this type of treatment with your doctor if it is offered.

If symptoms persist for some time and are really troublesome, then a specialist may advise an operation. The common operation to ease symptoms is to remove the damaged part of the tendon. Only a small number of people require surgery to relieve symptoms.

What is the prognosis (outlook) for tennis elbow?

If you rest your arm and avoid any activities that bring on your symptoms, there is a good chance that your tennis elbow will settle over time. Pain from tennis elbow usually lasts for six to twelve weeks because tendons are 'slow healers'. However, in some people pain can last for longer (for between six months and two years).

The treatments described above may ease symptoms more quickly. Unfortunately, once you have had tennis elbow, it may return.

Can tennis elbow be prevented?

You often cannot avoid a sudden overuse of the arm which can cause tennis elbow. However, if you increase the strength of your forearm muscles, it may help to prevent a further bout of tennis elbow in the future. The aim is to exercise and strengthen the muscles, but to avoid twisting movements. It is best to see a physiotherapist for advice on how to strengthen your forearm muscles.

If your tennis elbow has been brought on by playing some kind of sport, seek advice from a professional coach about your technique, racquet grip size etc.