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Getting a grip on tennis elbow

by Fiona Jacobsen MCSP

Repetitive stress or strain injury (RSI) is a common cause of elbow pain. Although often referred to as tennis elbow, in reality any repetitive motion which involves gripping or squeezing can cause inflammation of the tendons attached to the outside (lateral) of the elbow. Depending on the nature of the movement, the inflammation can also occur on the inside of the elbow and supports the diagnosis of golfer’s elbow!

Fiona Jacobsen, principal physiotherapist at Physio2go St. Albans adds to this excellent series of articles on joint health by exploring the common causes of elbow pain and discusses how this often-chronic condition may be prevented. Mr. Andrew Irwin, Consultant Orthopaedic surgeon at The Elms Consulting Rooms reviews the medical management, including some of the new treatment options available.

What is Tennis Elbow?

People who present with pain on the outside (lateral aspect) of the elbow are often found to be suffering from Tennis elbow. This is not the only possible cause of such pain and it is important to seek medical advice from your Doctor or a Physiotherapist, as conditions affecting the neck and/or shoulder may also cause similar symptoms of pain. The medical term for tennis elbow is lateral epicondylitis. The pain is usually due to inflammation at the origin of the wrist extensor muscles. These muscles straighten the wrist and fingers and arise from a small bony projection (lateral epicondyle) on the outside of the elbow, where most of the pain is concentrated. The pain may radiate up into the upper arm or down below the elbow as far as the wrist. These muscles/tendons are susceptible to repetitive micro-trauma, particularly when the wrist is flexed, pointing downwards and rotated. Ie when lifting or turning.

Causes

Although tennis elbow can be caused by a sudden violent injury, it almost all cases it results from a constant repetitive overload of the muscles and tendons of the affected forearm. You do not have to played tennis to suffer from a tennis elbow! Playing intensively when you haven’t played for months (or changing your grip) is the type of overuse that could damage the tendon. Tendon damage can occur after a single injury i.e. lifting something very heavy but it is more commonly due to repeated overuse of the hand, wrist and forearm. Common examples include gardening, using scissors or shears, and manual occupations involving repetitive twisting movements such as plumbing, bricklaying or poor workstation posture.

Symptoms

The onset of symptoms is usually gradual although occasionally patients can remember a specific injury. The patient often presents with a dull aching pain that increases with gripping, lifting or repeated wrist and forearm movements. It can be painful to simply shake hands or turn door handles. Sometimes sleeping with the wrist may aggravate the symptoms or elbow in extreme flexion causing the patient to experience increased pain upon awakening. Other symptoms can include a general feeling of weakness in the affected arm, and/or pain and stiffness in your neck and shoulders as you try and compensate for the pain in your elbow.

Treatment

If the problem is very mild then you can treat yourself. The most important part is to rest the damaged tendon by stopping or changing the activity that caused the problem.

• An Ice pack over the tender area for 10 minutes will help to reduce the pain and swelling if very acute.
• You may benefit from a non-steroidal antiinflammatory drug, such as Ibuprofen; these can have side effects so you should consult your GP or pharmacist.
• Wear a tennis elbow wrap/brace. Your physiotherapist will be able to advise you.
• If the problem was caused by a gripping activity then you should alter the grip you may find it beneficial to use a tool/ racket with a smaller grip.
• Physiotherapy to the affected tendon can be very beneficial. It may consist of deep tissue friction, ultrasound, and stretches.
• In some cases acupuncture has been shown to be very effective.

If the elbow pain does not respond, your GP may consider referring you to an orthopaedic consultant or rheumatologist. Since most patients respond well to physiotherapy, orthopaedic specialists such as Mr. Andrew Irwin (Orthopaedic Consultant specialising in upper limb conditions) usually consult on patients with the most severe and intransigent symptoms. Mr Irwin adds that “this can be a very disabling condition and the improvement in symptoms is usually gratefully received by patients.” When asked to review the current treatment plan of patients referred to him with tennis elbow/elbow pain Mr. Irwin stated: “ A multitude of treatments have been tried over the years, but at the moment (once the diagnosis has been confirmed) I favour a single local anaesthetic and cortisone injection instilled in the area of maximal tenderness. This will often give between three and six months relief. If the pain returns at that stage then the newer treatment of injecting the patient’s own harvested platelets is showing favourable outcomes. This may turn out to be a more logical treatment as it may increase concentrations of growth hormone and may lead to tendon healing or prevent further degeneration. As a last resort, in the most resistant cases, a “tendon slide” surgical procedure may be considered. This operation can now be done arthroscopically (via keyhole) and is usually 70-80% successful. It is very unlikely to leave the individual any worse off apart from the small scar over the lateral side of the elbow. The long term results of this operation are still awaited.”.

Prevention

• As tennis elbow is usually an over use injury it can be prevented by taking a few precautions.
• Warm up before doing any activity
• Take regular breaks so as not to do the same activity for prolonged periods.
• If the problem persists seek early treatment from your physiotherapist, acute problems respond faster and better than chronic!