Tennis Elbow – Symptoms, Causes and Treatments

Anatomy

The elbow joint is formed by three bones: the humerus (the upper arm bone), the ulna (the larger bone of the forearm, on the opposite side of the thumb), and the radius (the smaller bone of the forearm on the same side as the thumb).

The elbow itself is a hinge joint, meaning it bends and straightens like a hinge. There is a second joint where the end of the radius meets the humerus that allows the radius to rotate so that the hand can turn.

At the bottom of the humerus, there are bony bumps called epicondyles where muscles of the forearm attach. Specifically, the bony bump on the outside (lateral side) of the elbow is called the lateral epicondyle.

Tennis elbow or lateral Epicondyle Tendinopathy involves the muscles and tendons of the forearm that are responsible for the extension of the wrist.

The Extensor Carpi Radialis Brevis (ECRB) muscle and tendon is usually involved in tennis elbow.

Causes

Tennis elbow is a painful condition that is commonly caused by overuse. It is caused by inflammation or micro-tearing of the tendons that join the forearm muscles on the outside of the elbow. The forearm muscles and tendons become damaged from repeating the same motions again and again, leading to pain and tenderness on the outside of the elbow.

Not surprisingly, playing tennis or other sports that involve a racquet (badminton or squash for eg) can cause this condition. However, many other activities and sports can put you at risk of tennis elbow for example it can sometimes occur after banging or knocking your elbow. You may get tennis elbow if your forearm muscles are not used to doing a certain activity, such as gardening, using hand tools, or typing on the keyboard repetitively.

Symptoms

Tennis elbow commonly causes pain and tenderness on the bony knob on the outside of the elbow. This area is where the injured tendons connect to the bone. It is not uncommon for discomfort or pain to radiate into the upper and lower arm. The pain of tennis elbow is worse when you use your arm, particularly for twisting movements and repetitive wrist movements; such as extending your wrist and gripping.

Your Physiotherapist or Osteopath at Pillar Health will consider all of your symptoms and other factors when making a diagnosis. Some factors may include how your symptoms developed, occupational risk factors and recreational sports participation. During the examination you will be asked to perform a battery of tests to confirm a tennis elbow diagnosis. 

Pain and swelling around the elbow are common symptoms of tennis elbow and will occur in response to increased load which is known as reactive tendinopathy. During this phase reducing pain is essential by pain management measures and de-loading the injured site.

Treatment

Elbow pain that is experienced with Tennis Elbow generally comes from the tendon that connects the muscles of the forearm to the bone in the upper arm. For this reason, the management approach has been adapted from the general principles of tendon rehabilitation. Rehabilitation should always be personalised and multimodal to ensure best outcomes for the client. Multimodal care includes education, exercises, tissue loading management, manual therapy, taping, platelet-rich plasma injection, shockwave therapy, and if warranted, steroid injections. All of these strategies can be used and tailored depending on the client’s needs, however, exercise has been proven to be the gold standard in tennis elbow management to date.

Approximately 80 to 95% of clients with tennis elbow have success with conservative treatment. The first step towards recovery is to give your arm a proper rest from aggravating activities. This means stopping the sport, and work activities that cause pain in the elbow for several weeks.  

Medications such as non steroidal anti inflammatory drugs have been shown to be effective in reducing pain and swelling. Additionally, using a brace over the back of the forearm may also help to relieve symptoms in the elbow. These braces work by resting the muscles and tendons of the arm.

 

Client Education – Educating clients on their condition, prognosis, management options and self – management strategies is an important part of the rehabilitation process. Since tennis elbow is a degenerative disease and the first stages are considered inflammatory, treatment and recovery will depend on the general health of the body. To de-load the inflamed tendon in early stages of rehabilitation, it is important to educate the client on correct lifting techniques. This normally includes education on lifting objects with a flexed elbow and a supinated or “palm-up” forearm.

 Load Management – Tennis Elbow is a degenerative condition that is characterised by increased thickness in the extensor tendon and the presence of different wrist function particularly when gripping. Reducing the load on the tendon is an effective management strategy which goes hand in hand with building tissue resilience to allow for gradual progression of tendon rehabilitation. As a general rule, a great way to alter the load is to ensure the client is working under their pain threshold. This ensures that the client is exercising safely and not exaggerating symptoms.

The main tendon affected in tennis elbow is the Extensor Carpi Radialis Brevis which has a major role of stabilising the wrist. Exercise rehabilitation begins with exercises that have been found to have a hypoalgesic effect on the injured sites. Gradual progression of exercises is essential to increase the tolerance of the tendon to different loads. The following exercises have been outlined to progress tennis elbow rehabilitation exercises safely:

  • Elbow and forearm position: Exercises should begin in a comfortable position. Begin with the elbow bent and with the hand facing the ceiling and gradually progress the exercise by extending the elbow as performing the exercise.
  • Fingers flexing and extending to strengthen the long extensors.
  • Adding weights by incorporating resistance bands or dumbbells.
  • Functional training exercises that target the entire upper limb.
  • Sport or activity specific exercise to ensure the tendon is strong enough to tolerate the required activity.
  • Weight bearing exercises.

Platelet-rich plasma injection (PRP) is a treatment that is increasingly popular for tennis elbow rehabilitation. It involves obtaining a small sample of blood and spinning it (centrifuging it) to obtain platelets from the solution. Platelets are well known for their high concentration of growth factors which can then be injected into the affected area. While some studies have shown the effectiveness of PRP in tendon rehabilitation, some have been inconclusive.

Extracorporeal shock wave therapy for tennis elbow is a treatment modality that we offer at Pillar health. Shockwave therapy is a non-invasive method of treating soft tissue injuries. Shockwave therapy is a fast acting, long lasting treatment option and works by passing radial shockwaves through the skin to the injured part of the body through a handpiece and in doing so, causes direct mechanical vibration of the tissue. This vibration works to increase blood flow to the injured area and facilitate healing of the tissue through promoting growth factors. The average treatment time is short – around 8-10 minutes and most clients will notice pain relief immediately or soon after treatment. Normally we recommend 4-5 sessions of Shockwave Therapy to benefit from the full effects and achieve significant pain relief. In terms of treatments offered, Shockwave Therapy stacks up highly against surgery and corticosteroid injections– there is no risk of infection or complication, no down time and significantly reduced costs.

If symptoms do not respond to 6 to 12 months of conservative treatment strategies, your practitioner may recommend surgical management. Most surgical procedures for tennis elbow involve removing diseased muscle and reattaching healthy muscle back to the bone. There are two common surgical approaches to consider:

Open surgery. The most common approach to tennis elbow repair is open surgery. This involves making an incision over the elbow.

Arthroscopic surgery. Commonly known as keyhole surgery, arthroscopic surgery is performed by making two small cuts, about half a centimetre long around the elbow joint. Through these cuts, a small telescope is placed so the surgeon can examine the joint. Small surgical instruments are also inserted through the cuts to remove damaged parts of the tendon and treat problems from within the joint. This type of surgery normally allows the patient to return home on the same day.

Recovery

As mentioned, most cases of tennis elbow will heal with non surgical management. Of course, what you want to know is when you can get back to your regular activities after having tennis elbow. That depends on your individual case and the extent of damage to the tendon. People heal at different rates. What you shouldn’t do is rush your recovery. If you start pushing yourself before your tennis elbow is healed, you could do more damage to the tendon. As a general rule of thumb, you are ready to return to your former level of activity when:

  • Gripping objects or bearing weight on your arm/elbow is no longer painful.
  • Your injured elbow feels as strong as your other elbow.
  • You’re not experiencing any swelling around the elbow joint.
  • You can bend and move the elbow with no discomfort.

Following surgical management of tennis elbow, the arm will be immobilised temporarily with a splint. Approximately one week later, the splint is removed along with the sutures. At this time, gentle exercises are commenced that aim to stretch and restore the flexibility in the arm. Light and gradual strengthening exercises commence approximately two months post surgery.

 Your Physiotherapist and surgeon will tell you when you are ready to return to athletic activity. When a good rehabilitation program is performed, this is usually 4-6 months post surgery.

General complications can arise from surgical management and this can increase recovery time. Some specific complications that can occur include:

  • Bleeding into the joint
  • Infection in the elbow joint
  • Severe pain and stiffness
  • Damage to the nerves around the joint
  • Unsightly scarring of the skin from the incision.

Prevention

The key to preventing tennis elbow, is to avoid overuse of the elbow joint. If you feel any elbow pain or discomfort during an activity, you should cease the activity and have the elbow assessed by a Physiotherapist or Osteopath.

Tennis elbow can also be caused by using the wrong equipment like a golf club or tennis racquet that is too heavy or that has a grip that is too large. You should ensure that you are performing a good warm up before using your elbow for activity and after activity, ensuring that you are performing a good cool down and icing the area for 20-30 minutes if able to do so. If you would like any advice on the best warm up and cool down exercises to perform, chat to your Physiotherapist or Osteopath at Pillar Health, they will happily guide you in the right direction.

When to see a physiotherapist

Elbow, wrist and hand injuries can stem from a variety of factors, and the onset may be sudden or gradual.  The intensity and nature of symptoms can vary from minor stiffness through to a range of more significant concurrent symptoms that can affect your work, sport and daily activities.

If you would like diagnostic advice regarding your elbow, or are having trouble with managing your tennis elbow symptoms, call us on (03) 8899 6277 or book online at pillarhealth.com.au. Our Physiotherapist and Osteopath are experienced in managing all injuries of the upper limb.