What is Lateral Epicondylitis (Tennis Elbow)?
Lateral epicondylitis, more commonly known as tennis elbow, is an injury from overuse. It’s often a result of too much strain on the primary tendon that helps extend the wrist, called the extensor carpi radialis brevis (ECRB) tendon. Tennis elbow is often caused by repetitive strain due to activities that involve consistent and heavy gripping, or repeatedly extending the wrist. This condition is widespread among individuals who play tennis, squash, badminton, pickle ball, or any activity involving repeating wrist movement, specifically wrist extension, radial deviation, which is moving the wrist towards the thumb, and/or forearm supination, which is rotating the forearm to face upwards.
What Causes Lateral Epicondylitis (Tennis Elbow)?
Tennis elbow is commonly caused by repeating the same hand and wrist movements over and over again. This can happen due to tasks and activities that involve holding onto something tightly and repeatedly extending the wrist. This issue is first seen in tennis players, but can happen due to any sport like squash and badminton or activity that needs similar movements. Often, tennis elbow can be brought on by incorrect movements and techniques, or use of wrong equipment in people who play sports.
Risk Factors and Frequency for Lateral Epicondylitis (Tennis Elbow)
Tennis elbow is the most frequent reason behind elbow pain. It affects men and women equally. Generally, 1 to 3 percent of people in the United States have this condition each year. Only 10% of these patients are tennis players, but half of all tennis players will experience elbow pain at some point, with 75% of these cases being true tennis elbow. It’s more commonly found in people over 40. The chances of getting tennis elbow increase if you smoke, are overweight, do the same movement for at least two hours each day, or regularly carry heavy loads (over 20 kg). However, the condition often improves on its own, with 80 to 90% of patients recovering within one to two years.
- Tennis elbow is often the cause of elbow pain.
- It has the same impact on men and women.
- Each year, about 1 to 3% of Americans get tennis elbow.
- Just 10% of those affected are tennis players.
- It is usually found in people over 40.
- Smoking, obesity, repetitive motion for at least two hours a day, and heavy physical work increase the risk.
- But the good news is 80 to 90% of people recover on their own within one to two years.
Signs and Symptoms of Lateral Epicondylitis (Tennis Elbow)
People suffering from this condition often reveal a history of overuse or strenuous activity involving the wrist, despite not remembering a distinct incident causing the discomfort. This pain is usually felt one to three days after doing an activity they’re not used to, which involves repetitive extension of the wrist.
This condition could be a result of using new equipment, an unusually intense or long workout, or following a specific injury like lifting a heavy object or swinging the racket hard while playing tennis. The latter scenario leads to an acute-on-chronic overuse injury, where a sudden injury adds to an existing problem of overuse.
The pain is usually located over the bony bump on the outer side of the elbow and tends to get worse with activity and better with rest. The severity of the pain can range from mild discomfort while playing tennis or using hand tools repetitively, to severe pain triggered by simple tasks such as lifting a coffee cup.
During a physical check-up, the doctor will usually find the most tender point over the outer elbow, sometimes a bit further down the arm. Some discomfort might be felt across the entire tendon and the connecting muscle might feel unusually tight. The pain tends to increase during a resisted wrist extension, especially when the elbow is straight and the forearm is turned so that the palm faces down. This shows increased stress on the tendon, supporting the diagnosis. If there are symptoms such as numbness or tingling, it suggests a different problem like a trapped radial nerve, although both conditions can coexist.
Testing for Lateral Epicondylitis (Tennis Elbow)
Lateral epicondylitis, often known as “tennis elbow,” is usually diagnosed based on symptoms and physical examination, and imaging tests like X-rays or MRIs are not always necessary. However, your doctor might request an X-ray of your elbow – taking images from the front and the side – if they think you might have additional injuries or conditions. These other conditions could include age-related joint changes, fractures, growths, or inflammation of the pouches of fluid in your joint (known as bursitis).
If treatments for your tennis elbow aren’t working as expected, your doctor might consider ordering an MRI scan or an ultrasound. These imaging tests can help spot issues such as tears in your tendons, stress fractures, or damage to the cartilage and bone (osteochondral defects).
Treatment Options for Lateral Epicondylitis (Tennis Elbow)
The first approach to treating lateral epicondylitis, also known as tennis elbow, includes rest and avoiding activities that cause pain. Applying ice after activity and using oral or topical non-steroidal anti-inflammatory drugs (NSAIDs) can also help with pain management. Wearing forearm counterforce straps during activity can relieve tension at the elbow; however, some patients may find these straps uncomfortable as they may press on tender areas.
Occupational or physical therapy can be beneficial. These therapies focus on stretching and strengthening your forearm and improving the strength of the extensor tendon, which is commonly affected in tennis elbow. If pain persists despite these conservative measures, advanced or invasive techniques might be considered. These include topical nitrates, botulinum toxin, platelet-rich plasma therapies, and dextrose prolotherapy (a form of therapy that stimulates the body’s healing processes).
Surgery is viewed as a final option when dealing with lateral epicondylitis. Non-surgical management should be attempted for an extended period (6-12 months) before thinking about surgery. The surgical procedures for tennis elbow vary and often include different extents of debridement and/or release of the origin of the tendons at the lateral elbow. With debridement, abnormal tissue is removed to promote the healing process. If the Extensor Carpi Radialis Brevis (ECRB, a muscle in the forearm) is not detached, a thorough debridement should be performed at the ECRB origin. This is to stimulate a healthy, bleeding, bed of tissue at the elbow to encourage healing.
What else can Lateral Epicondylitis (Tennis Elbow) be?
When a doctor is trying to diagnose lateral epicondylitis (tennis elbow), they have to consider other conditions that might be causing the symptoms. These include:
- Elbow bursitis (inflammation in the elbow)
- Cervical radiculopathy (a pinched nerve in the neck)
- Posterolateral elbow plica (a fold of tissue in the elbow joint)
- Posterolateral rotatory instability (a type of elbow instability)
- Radial nerve entrapment (pressure on a nerve in the arm)
- Radial tunnel syndrome, which is identified by:
- feeling for a specific point 3 to 4 cm in front of and below the bony bump on the outside of the elbow (lateral epicondyle)
- pain when extending the third finger
- pain when turning the forearm to face palm upward (supination)
- Hidden (occult) fractures
- Capitellar osteochondritis dissecans (a joint condition in the elbow)
- Triceps tendinitis (inflammation of the triceps tendon)
- Radiocapitellar osteoarthritis (a form of arthritis affecting the elbow)
- Shingles
Remember that a professional health care provider will perform tests to accurately diagnose the condition.
What to expect with Lateral Epicondylitis (Tennis Elbow)
The outlook for lateral epicondylitis, often known as tennis elbow, is usually positive. Most people experience relief from pain within a year of starting non-invasive treatment, which includes rest, ice, and anti-inflammatory medicines. If the initial treatment doesn’t provide relief, physical and occupational therapies are other effective options.
It’s crucial to stick to the therapy plan given, because people who do not complete their treatment often see their symptoms return.
Possible Complications When Diagnosed with Lateral Epicondylitis (Tennis Elbow)
Possible complications from lateral epicondylitis, often known as tennis elbow, may include a recurrence of the injury once normal activities are resumed. Rupture of the tendons due to repeated steroid injections and failure to improve despite conservative treatment are also potential adverse effects.
There can also be complications after surgery which may include:
- Not addressing the main cause of symptoms. Patients could report poor outcomes and no improvements if the main cause of their symptoms isn’t addressed during surgery. Potential risks include infection, blood loss, injury to nerves or blood vessels, continued pain, stiffness, or continued or worsening overall dysfunction.
- Entrapment of the radial nerve, which can be overlooked in up to 5% of patients being treated for lateral epicondylitis.
- Iatrogenic injury to the Lateral Ulnar Collateral Ligament (LUCL). This risk increases if the surgical dissection goes beyond the midpoint of the radial head. This can lead to iatrogenic posterolateral rotatory instability (PLRI), if the extension or LUCL compromise is significant.
- Iatrogenic neurovascular injury.
- Radial nerve injury.
- Heterotopic ossification. The risk of this can be reduced through thorough saline irrigation following decortication and debridement.
- Infection.
Preventing Lateral Epicondylitis (Tennis Elbow)
Patients should be educated on how to move properly to prevent any strain or excessive use of the forearm and elbow. Key instructions to keep in mind are:
* Try to avoid moving your elbow to its full range in both extension (straightening) and flexion (bending).
* If your work involves repetitive hand and wrist movements, remember to take breaks when needed.
* Avoid holding heavy items with your arm fully extended; instead, try to keep your elbow slightly bent when carrying heavy weights.
* When handling heavy tools, it’s safer to use both hands; similarly, if you’re playing tennis, consider using a two-handed backhand.
* Limit repeated actions that involve grasping and gripping.
* If a certain movement brings back the pain, avoid it and let your healthcare provider know.
The idea behind these guidelines is to assist you in avoiding unnecessary strain on your elbow and forearm.
