Tennis Elbow: An Overview

Tennis elbow (lateral epicondylitis) is an overuse injury. It develops in one of the tendons that connects the muscles of the forearm to the humerus (upper arm bone) at the lateral epicondyle (a knobby portion of bone where the extensor muscles of the elbow originate). Over time, strain on the tendon gradually pulls it away from the bone, causing microscopic tears. Despite the popular term for this condition, most patients who develop this condition do not play tennis. Most patients are over 40, because aging tendons are more vulnerable to repetitive stress.

Illustration, the origin of extensor muscles at the elbow, courtesy of The Journal of Musculoskeletal Medicine. 

The primary symptom of tennis elbow is pain. However, the mechanism that causes the pain is not well-understood. Generally, patients can point out the precise site where they are experiencing pain and describe which of their physical actions make the pain worse. Orthopedic surgeons use physical examination and information obtained through magnetic resonance imaging (MRI) to confirm the diagnosis and to rule out other conditions, such as nerve compression or a tumor. (Interestingly, some patients who are undergoing MRI for other reasons may be found to have evidence of tendon failure, even though they have no associated pain.) 

"A number of people with this condition try alternative treatments," says Robert N. Hotchkiss, MD, Associate Attending orthopedic Surgeon. "A wide range of remedies are reported to offer relief, including acupuncture, herbal remedies or splinting, but it’s difficult to say how successful these treatments really are. In my practice, I see patients for whom they have not been useful." 

In patients whose symptoms are not severe, an orthopedic surgeon may advise a "wait-and-see" approach. These patients are also advised to modify their activities, reducing or stopping altogether any activity that aggravates the condition. For those who do play tennis, modifications in the way they play can be helpful – including restringing or changing rackets, getting a larger grip, or using a different backhand (the tennis stroke that places the greatest stress on the wrist). For all patients, use of over-the-counter anti-inflammatory drugs such as ibuprofen and the application of ice can also reduce pain. Physical therapy may also provide some relief by strengthening surrounding muscles. Although strengthening the wrist using weights is advocated by some therapists, this particular exercise may aggravate the patient’s pain.

Some studies indicate that, in most patients, pain in the outer elbow may clear up on its own over a period of a year or two. However, Dr. Hotchkiss points out, these studies don’t show whether patients adapted to their condition by changing the way they used their arms or by giving up certain activities. It’s also unclear whether the study populations included a significant number of patients who are disabled on a daily basis.

Patients whose symptoms persist, or who do not achieve adequate relief from these measures, may be candidates for an injection of cortisone (a potent anti-inflammatory agent). As with the mechanism that causes pain, the mechanism for pain relief provided by these injections is unclear – particularly in the absence of a significant number of inflammatory cells. Some orthopedists have suggested that insertion of the needle breaks up some loose tissue in the area that is causing pain. Patients' responses to these injections vary. Some patients experience a period of pain relief lasting from a few weeks to a few months, while others feel no benefit.

For patients who are truly disabled by tennis elbow (many experience difficulty with such simple daily functions as lifting a cup of coffee, writing, or shaking hands) and have not benefited from conservative treatments, surgery may be advised. Two surgical techniques are available – open surgery and elbow arthroscopy. Open surgery requires a larger incision and affords a number of options. A little chip of bone can be removed, which may increase blood flow to the area and therefore promote healing and reduce pain. Alternatively, a small portion of the tendon can be released by severing its connection to the bone. This reduces pain but leaves most of the tendon still attached to the bone and functional so that there is virtually no loss of mechanical strength. The tendon also can be repaired by debriding, which means cutting away the unhealthy portion of the tendon and reattaching the healthy portion to the bone.

In arthroscopic surgery, two small cuts are made: one on the medial (inner) side and one on the lateral (outer) side of the elbow. The surgeon uses an arthroscope to clean out all of the torn-off tissue (in essence, cutting off a small portion of the tendon). In general, no bone is removed. However, some surgeons roughen the surface of the bone with a motorized tool to generate more blood flow to that area.

At HSS, both types of surgery are performed as same-day procedures, usually using a regional anesthetic technique that permits the patient to be awake and comfortable with only the arm and elbow numb. Some patients prefer to be more sedated.

Following surgery, patients who have arthroscopic treatment are not splinted, but simply have the elbow covered and wear a sling. They may begin gentle stretching exercises of the wrist and elbow in the immediate postoperative period as tolerated. Supervised physical therapy is initiated if the patient is failing to regain adequate motion or strength in the month following treatment.

For patients who have the open debridement, the wrist is usually splinted in extension for three to six weeks to allow healing of the repaired and reattached tendon. The patient then begins gentle stretching and strengthening with supervision of a physical therapist or hand therapist.

Although pain relief is usually significant, the pain of tennis elbow can return. Surgical patients are advised to guard against any old habits that may have caused or exacerbated their condition. In the case of tennis players, the orthopedic surgeon may suggest they do specific exercises to improve shoulder strength and foot speed and/or consult a tennis instructor before they return to the sport. Because tennis elbow can be bilateral (up to 20% of the tennis elbow patients Dr. Hotchkiss sees have some evidence of the condition in both arms), caution should be exercised to protect the untreated elbow.