February 28, 2020 By Dr Anuj Agrawal

Tennis Elbow: Common Cause of Elbow Pain

Tennis Elbow: Common Cause of Elbow Pain

Lateral epicondylitis of humerus, commonly called as “tennis elbow”, is a common cause of elbow pain in general population. Though this is usually a self-limiting condition, natural recovery might take months to years, causing significant disability in day-to-day activities. Hence, treatment is required for this condition.

In this article, you will get useful information on tennis elbow, including its symptoms, diagnosis and various treatment options.

1. Pathoanatomy: What is tennis elbow?

Tennis elbow or lateral epicondylitis is a tendinopathy (disease of string-like ends of muscles known as tendons) of extensor muscles of wrist and hand which originate from the outer side of the elbow (lateral epicondyle). It is thus a localized degenerative disease of elbow muscles occurring due to overuse or repetitive microtraumatic injury. It is an extremely common musculoskeletal disease, seen in 1-3% of the general population.

2. Causes of tennis elbow

Any repeated activity involving the use of wrist and hand muscles can cause tennis elbow. Such activity is commonly seen in sports, particularly those involving use of bats or rackets such as tennis, baseball and cricket. The condition is seen in 5-10% of tennis players, and hence the name ‘tennis elbow’. It is more commonly seen in manual laborers and craftsmen.

In general population, tennis elbow usually occurs in middle age (30-50 years), more commonly involving the dominant arm. Housewives involved in activities such as kneading dough, dusting windows, etc. are predisposed to develop this condition.

3. Diagnosis of tennis elbow

The diagnosis of tennis elbow is clinical, aided by the characteristic site of activity-related pain on the outer side of elbow, associated with decreased grip strength. A careful clinical examination by the orthopaedician further confirms the diagnosis due to characteristic site of tenderness and some other special tests. X-rays are usually normal and not ordered routinely. MRI scan may be done to confirm the diagnosis and rule out other conditions, particularly in refractory cases.

4. Treatment of tennis elbow: General measures

Initial treatment consists of giving rest to the elbow, avoiding activities which aggravate the pain. Local ice application helps to reduce pain. A compressive band (tennis elbow brace) worn at proximal forearm region reduces the stress transmitted to the elbow region, and helps reduce symptoms. Extension wrist splints are used occasionally to rest the involved muscles, but are cumbersome for regular use.

Anti-inflammatory medications (e.g. NSAIDs) are prescribed to control the inflammation in the involved tendon and relieve pain. Oral NSAIDs are used for a short period, followed by topical NSAIDs.

5. Treatment of tennis elbow: Physical therapy

Physical therapy is commonly used as an adjunctive treatment for tennis elbow. Supervised exercises are helpful to strengthen the involved muscles. Application of local ultrasound or ESWT (extracorporeal shock wave therapy) has been shown to help reduce pain. Acupuncture, laser treatment and iontophoresis are some other treatments found useful for this condition.

6. Treatment of tennis elbow: Non-biological injections

If general measures and physical therapy fail to relieve the symptoms of tennis elbow, local injections have been found to very effective in treating this condition. Corticosteroids are potent anti-inflammatory medications and work well when injected directly at the site of disease, without having systemic side-effects. Various steroid formulations, such as dexamethasone and triamcinolone, are used for injection in combination with a local anaesthetic. More than 90% of patients have significant or complete pain relief after 4 weeks of steroid injection.

There is a view that the injection technique (accurate site, direction) is more important than the drug injected. Multiple injections of just an irritating solution like dextrose (prolotherapy) have also been found useful to treat this condition.

7. Treatment of tennis elbow: Biological injections

Though steroid injections are commonly used for treatment of tennis elbow, recently use of ‘biological injections’ has become popular, which deliver growth factors from one’s own body directly into the diseased tissue to initiate the healing process. Injection of one’s own blood (autologous blood), platelet-rich plasma (a component rich in growth factors separated from one’s blood by spinning at high speeds in a machine called centrifuge) and stem cells (obtained from one’s own bone marrow, skin or muscle/tendon tissue) are the various biological injections used for tennis elbow. Autologous blood injections are the simplest and cheapest amongst these. These biological injections have been shown to result in better healing of tendon tissue and improved long term function as compared to steroid injections, which are feared to retard tendon healing.

8. Treatment of tennis elbow: Surgery

Most patients suffering from tennis elbow respond to non-surgical treatment, and surgery might be required in <5% of patients who do not respond to other treatments and rehabilitation measure, tried over a period of more than 6 to 9 months. Surgery may be done open, mini-open or even arthroscopic and involves resection or release of the diseased tendon tissue. A high rate of good to excellent results is reported after surgery.