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Mathias Masem, M.D.
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Shoulder | Elbow | Wrist | Hand

Tennis Elbow (Lateral Epicondylitis)

What is tennis elbow/lateral epicondylitis?

Lateral epicondylitis, commonly known as tennis elbow, is a painful condition involving the tendons that attach to the bone on the outside (lateral) part of the elbow. Tendons anchor the muscle to bone.

The muscle involved in this condition, the extensor carpi radialis brevis, helps to extend and stabilize the wrist. With lateral epicondylitis, there is degeneration of the tendon’s attachment, weakening the anchor site and placing greater stress on the area. This can then lead to pain associated with activities in which this muscle is active, such as lifting, gripping, and/or grasping. Sports such as tennis are commonly associated with this, but the problem can occur with many different types of activities, athletic and otherwise.

What causes tennis elbow/lateral epicondylitis?

Overuse – The cause can be both non-work and work related. An activity that places stress on the tendon attachments, through stress on the extensor muscle-tendon unit, increases the strain on the tendon. These stresses can be from holding too large a racquet grip or from “repetitive” gripping and grasping activities, i.e. meat-cutting, plumbing, painting, weaving, etc.

Trauma – A direct blow to the elbow may result in swelling of the tendon that can lead to degeneration. A sudden extreme action, force, or activity could also injure the tendon.

Who gets tennis elbow/lateral epicondylitis?

The most common age group that this condition affects is between 30 to 50 years old, but it may occur in younger and older age groups, and in both men and women.

What are the signs and symptoms of tennis elbow/lateral epicondylitis?

Pain is the primary reason for patients to seek medical evaluation. The pain is located over the outside aspect of the elbow, over the bone region known as the lateral epicondyle. This area becomes tender to touch. Pain is also produced by any activity which places stress on the tendon, such as gripping or lifting. With activity, the pain usually starts at the elbow and may travel down the forearm to the hand. Occasionally, any motion of the elbow can be painful.

What can you do to help yourself?
  • Ice for five to fifteen minutes at a time on the area which is most swollen and tender. "Over the counter" non-steroidal anti inflammatory medication (NSAID), such as aspirin, ibuprofen, or naprosyn. Check with your pharmacist regarding possible side effects and drug interactions.
  • Avoid lifting with your palms down and elbow straight. The muscle which is usually the most irritated (the extensor carpi radialis brevis) bends the elbow and pulls the wrist back. When you lift something with your palm down, you use this muscle, and when your elbow is straight, it puts much more stress on the irritated tendon.
  • A splint or brace which supports the wrist. Wait and watch.
What can a therapist do to help?
  • Provide a forearm strap or wrist brace to help protect the irritated area.
  • Help identify aggravating activities and suggest alternative postures.
  • Massage, heat, ice and other treatments aimed at making the area more comfortable.
  • Supervise a set of progressive exercises designed to gradually strengthen and recondition the irritated muscles.
What can a hand surgeon do to help?
  • Confirm that this actually is the problem.
  • Prescribe stronger NSAID medication or cortisone type medication.
  • Prescribe hand therapy and/or a custom prescription splint.
  • Give a cortisone shot into the sore area.
  • Perform surgery to remove the chronically irritated tissues, possibly shave down the bone, and possibly cut some of the small nerves which transmit pain signals from the area. The goal of surgery is pain relief, and there are several different operations currently performed for this problem.
What is the treatment for tennis elbow/lateral epicondylitis?

Conservative (non surgical):

  • Activity modification – Initially, the activity causing the condition should be limited. Limiting the aggravating activity, not total rest, is recommended. Modifying grips or techniques, such as use of a different size racket and/or use of 2-handed backhands in tennis, may relieve the problem
  • Medication – anti-inflammatory medications may help alleviate the pain.
  • Brace – a tennis elbow brace, a band worn over the muscle of the forearm, just below the elbow, can reduce the tension on the tendon and allow it to heal.
  • Hand Therapy - may be helpful, providing stretching and/or strengthening exercises. Modalities such as ultrasound or heat treatments may be helpful.
  • Steroid injections – A steroid is a strong anti-inflammatory medication that can be injected into the area. No more than (3) injections should be given.
How successful is conservative treatment?
  • Simply waiting and watching may provide satisfactory relief in as many as 4 out of 5 people, although often pain persists for months before resolving. A specific supervised therapy program may improve results and speed recovery. Recovery without surgery is less likely when the problem has developed after a sudden injury such as a blow to the side of the elbow.
  • Cortisone shots in the elbow can provide temporary help - for several months or longer. Although shots do not cure tennis elbow, they can ease pain and can be very helpful for people who are really suffering with the problem and just want some relief.
When should surgery be considered?

Surgery is only considered when the pain is incapacitating and has not responded to conservative care, and symptoms have lasted more than six months. Surgery involves removing the diseased, degenerated tendon tissue. Two surgical approaches are available; traditional open surgery (incision), and arthroscopy—a procedure performed with instruments inserted into the joint through small incisions. Both options are performed in the outpatient setting. 70-90 percent of those needing surgery have a satisfactory improvement from surgery.

Recovery from surgery includes hand therapy to regain motion of the arm. A strengthening program will be necessary in order to return to prior activities. Recovery can be expected to take 4–6 months.