What is it?
Tennis elbow is a common and self-limiting condition which gives rise to pain over the outer aspect of the elbow. It usually presents in patients between the ages of 40-60, although not exclusively so. The condition is known as an Enthesopathy.
What is an Enthesopathy?
As the body ages, changes are seen within the tendons at the point where they insert onto bone. Enthesopathy is the term given to the type of change seen as a normal part of the ageing process. This starts with reactive changes in the tendon, and leads to myxoid degeneration of the tendon. Although it is commonly also termed ‘degenerative‘ change, it is a normal part of the ageing process and does not represent a harmful disease process.
The common extensor origin is the name given to the tendinous attachment of the main bulk of muscles to the outer aspect of the elbow. Next to the common extensor origin, the origins of another two muscles arise – the two powerful muscles that extend the wrist joint or pull the wrist joint back. One of these, the Extensor Carpi Radialis Brevis muscle (ERCB), is thought to be the tendon most commonly involved in the enthesopathy of tennis elbow.
What provokes the onset of Tennis Elbow?
Although many people report no provoking factors, the onset of symptoms in tennis elbow can be related to:
Unusual or strenuous repetitive use of the arm: Tennis elbow is no more common in people with heavy jobs than in people with relatively light jobs, so it does not seem to be related to occupation. It is likely, however, to be provoked by unusually strenuous use of the arm in the presence of the changes of enthesopathy.
A knock or bang to the elbow: Although there may be a history of trauma to the arm, this may represent tendon injury rather than tennis elbow, and the recommendations for management may be different.
What are the symptoms?
If you have tennis elbow, you will usually experience:
- pain on the outside of your upper forearm, just below your elbow – the pain may also travel down your forearm towards your wrist
- pain when lifting or bending your arm
- pain when writing or gripping small objects – for example, when holding a pen
- pain when twisting your forearm – for example, when turning a door handle or opening a jar
- pain and stiffness when fully extending your arm
How is it diagnosed?
In many cases the diagnosis can usually be made based on patient symptoms and examination. X-rays are sometimes performed but these are usually normal.
What is the natural history?
Tennis elbow is a self-limiting condition, which means it will eventually get better without treatment. An episode of tennis elbow will usually last between 6 months and 2 years, but can last longer. However, the majority of people (90%) will make a full recovery within a year.
What is the treatment?
Historically, doctors and therapists have always worked on the premise that they should help patients by doing things to relieve the pain of tennis elbow. As a result of this philosophy, there are many many treatments described for this condition, with no strong evidence to support the usefulness of the treatment. It is therefore worth considering whether or not any treatment is worthwhile.
Since pain is the body’s mechanism for signalling danger, it is natural for people who have a painful condition to associate this pain with danger or harm. This is not the case with tennis elbow, which is a harmless condition. The pain mechanism is misplaced in this condition, and does not signify a major problem. People who have pain usually report two concerns regarding their pain:
1) If my elbow is as painful as this now, then what will they be like in a year or two?
The pain is most likely to be either gone, or significantly improved, as the natural history is that the condition is self-limiting.
2) If it is painful to use my elbow, am I doing any harm by using it, and should I rest it? Actually, there is no harm in using the arm and hand normally. Normal use of the arm and hand does not cause the condition to worsen, but may simply provoke pain where not using the arm or hand would not produce pain.
So, it is very safe to use the elbow normally and not worry about the pain. There are, however, many described measures for easing the pain of tennis elbow, and we have made a list of the more common and our recommendations regarding these measures:
Simple measures: Avoiding heavy use of the arm or hand will usually result in less pain. This is common sense, and it is often worth modifying the way you do things to avoid un-necessary pain. You should not worry if you are unable to avoid use of the arm, because this will not cause harm.
Painkillers and Anti-inflammatories: Painkillers or non steroidal anti-inflammatory drugs are often prescribed by Doctors who want to help relieve pain. It is unusual, however, for patients to report that they are effective, with most patients stating that they do not help. Doctors then tend to escalate the strength of drugs used. All drugs have side effects and there is a risk involved in using painkillers regularly. Since the tennis elbow is harmless and carries no risk, our advice is to avoid painkillers and use them on an occasional basis only. Topical anti-inflammatories applied to the area of pain around the elbow may help to reduce symptoms without causing some of the side effects.
Physiotherapy: This may be beneficial in severe cases or those with persistent symptoms. Your physiotherapist may use manual therapy techniques, such as massage and manipulation, to relieve pain and stiffness, and encourage blood flow to your arm. They can also show you exercises you can do to keep your arm mobile and strengthen your forearm muscles.
Splints and braces (orthoses): These probably help by applying pressure to the elbow. Because the sensation of pressure is transmitted via the same nerve fibres as pain, the brain registers the pressure in preference to pain. This is a method well understood by anyone who has caught a fingertip in a door!
Steroid injections: Steroid injections have traditionally been used to treat tennis elbow by dampening pain through a poorly understood mechanism. Although very effective for relieving pain, steroids are generally not good for tendons, and repeated use can cause direct harm. Current best evidence does not support the use of steroids for tennis elbow. Although short term symptom relief is usually good, steroid tends to interfere with the natural history by prolonging the course of the condition.
Shockwave therapy: This is a treatment, where high-energy acoustic or sound waves are passed across the skin to help relieve pain. Although safe, it can cause minor side effects, including bruising and reddening of skin in the area being treated. There is no strong evidence to suggest that this treatment is of value, and we do not offer it in Fife.
Platelet rich plasma (PRP) injections: This involves taking a sample of your blood and separating the platelets (the blood cells that promote healing) from the plasma and injecting it to the affected area. The long-term effectiveness is not yet known. This is not currently offered in Fife.
Surgery: Surgery is again controversial when used in tennis elbow, since there is no strong evidence that it does anything other than act as a placebo. Individual cases, however, particularly where there has been an associated injury to the elbow, can benefit from surgery with full understanding of the risks, and shared decision making with the surgeon.
© Fife Hand Service 2021