Tennis elbow: symptoms, signs and treatment

INTRODUCTION

What causes tennis elbow?

Tennis elbow, also known as ‘lateral epicondylitis’, is caused by inflammation in the tendons on the outside of the elbow:

• PRP Injection – containing blood products such as ‘platelet-rich plasma’, these injections have been demonstrated as an effective alternative to surgery in difficult-to-treat tennis elbow.
• Hyaluronan gel injection – more commonly used in osteoarthritis, preliminary studies have shown some benefit of these, with a potential role in improving tendon healing.
• Botulinum injection – another alternative to surgery, these injections will temporarily paralyse the muscles for the third and fourth fingers and must be followed by gradual ‘re-loading’ and physiotherapy for effective relief of tennis elbow.
• Shock wave therapy – this technology is mainly used to break down small kidney stones made of calcium compounds. In cases where there is calcification of the tendon, shock wave treatments can be theoretically useful, but they do not help in the majority of cases of tennis elbow.
• Acupuncture – as an alternative form of pain relief, acupuncture has been shown to give short-term benefit in the case of tennis elbow, and can be used in combination with other treatments (topical NSAIDS, physiotherapy etc.).

This is commonly caused by repetitive forearm extension (straightening the arm, similar to a back-hand shot in tennis) resulting in elbow and upper forearm pain. More specifically, tennis elbow results from the repetitive use or overuse of ‘extensor carpi radialis’; a muscle in the forearm.

What are the symptoms?

The main symptom of tennis elbow is pain, ranging from a mild discomfort to a more severe, debilitating problem where pain can be felt even when you are resting your arm. The main problem area is usually the outside of the elbow, but you can also experience pain in the forearm and back of the hand. It is often worsened by movement (particularly in twisting movements), and the joint can be tender to touch.

Who gets tennis elbow?

Tennis elbow is often seen in tennis players due to the repetitive movements during matches (hence its name), however, this condition does not only occur in tennis players. Tennis elbow can occur in anyone who gets lateral elbow pain due to muscle-tendon overuse. Tennis elbow affects mainly those in the age group of 40-60 years, most commonly in women, with a prevalence in the general population of 1-1.3% in men and 1.1-4% in women. This makes tennis elbow more common than ‘golfer’s elbow’, a similar condition causing pain on the inside (medial aspect) of the elbow, caused by repeated forearm flexion.

I’VE GOT ELBOW PAIN – WHAT NOW?

There are many causes of elbow pain, of which tennis elbow is only one. If you have elbow pain lasting for more than a few weeks, it is advised to see your GP. If you have any of the following symptoms or circumstances, you should attend A&E rather than waiting to see a GP:

• Recent trauma or dislocation to the elbow joint
• Swollen, red joint and a fever
• Any change in sensation in the arm, particularly in the hand (on the side of the affected elbow)
• The joint becomes extremely painful and difficult to move
• Very fast swelling of the joint
• Any central chest pain/heaviness

To diagnose tennis elbow, the doctor will ask you several questions about the pain, precisely where it hurts and what kinds of movements make the pain worse, as well as examining the joint and painful areas. This will distinguish tennis elbow from many other causes of elbow pain, such as:

• Golfer’s elbow
• Elbow arthritis
• Fracture in the elbow joint
• Radial tunnel syndrome
• Referred pain from a shoulder/wrist problem
• Fibromyalgia
• Cervical root entrapment (nerve damage in the neck)

n most cases, this is all that is needed to diagnose tennis elbow. In some instances, additional imaging may be required such as X-ray and ultrasound to rule out other causes if the cause is not clear on examination. Occasionally MRI or EMG (looking at electrical activity in muscles) may also be required to determine the cause.

Following definitive diagnosis, the doctor will discuss the available treatment options with you and put together a plan moving forward, taking your own circumstances into consideration.

TREATING TENNIS ELBOW
What’s the prognosis?
The average episode of tennis elbow can last anywhere between 6 months and 2 years, but a vast majority (90% of cases) are resolved within 1 year. Recurrence of tennis elbow is seen in 8.5% of cases and these often require further treatments such as surgery.

What are the treatment options?
Tennis elbow is sometimes referred to as a ‘self-limiting’ disease, meaning that it often resolves on its own without the need for specific treatments. This means that the first line strategy for managing tennis elbow focuses on pain relief and restoring physical function as soon as possible (i.e. conservative treatment).

Pain relief
The key to early mobilisation and effective physiotherapy is successful pain relief. The most commonly used method for tennis elbow is the application of topical NSAIDs (gels containing non-steroidal anti-inflammatory drugs, like ibuprofen), which has been shown to give some benefit in the short term. ‘Off-label’ prescription of GTN patches (usually used for pain related to heart problems) has also been shown to give short-term benefit in pain relief. However, these patches are associated with side effects and are not commonly used in the first instance for tennis elbow.

Physiotherapy
Some studies have shown that physiotherapy confers long-term benefit for pain relief. Physiotherapy based on simple exercises that help to strengthen the muscles around the joint has been shown to be particularly helpful in rehabilitating tennis elbow. Eccentric exercises have also been shown to reduce pain, improve function and maintain range of movement in the joint.

Supports
It is often recommended to use orthotic straps and splints as support alongside physiotherapy, with the idea that reducing the muscle activity and offloading the painful part of the joint helps to provide symptom relief. However, many studies do conclude that there are no additional benefits from wearing a support when looking at long-term outcomes.

Steroid Injections
Steroid injections are commonly used to treat joint problems, including arthritis. Use of steroid injections for tennis elbow has been shown to provide symptom relief in the short term (up to 6 weeks), which may allow for more effective physiotherapy-based treatments. However, longer term, steroid injections are associated with a poorer outcome and greater chance of recurrence.

Surgery
Surgical management of tennis elbow is often not recommended unless you are still experiencing symptoms after 1 year of conservative treatments (pain relief, physiotherapy etc.), as the majority of cases resolve by this time. The surgery itself looks to remove the damaged portion of the tendon, followed by rest and gradual ‘reloading’ of the tendon. Whilst surgical intervention can improve function, it can take over 6 months for the joint to return to normal.

Recent developments in the surgical management of tendon-based problems have led to a new technique known as ‘ultrasound-guided tendon fenestration’, an alternative to the classic surgical procedure. There are trials ongoing to determine which procedure is more effective in the long term.

Other therapies
There are several alternative therapies for tennis elbow, but these are not used in the first instance and are only indicated where conservative treatments fail and surgery is unsuitable or unsuccessful. For more information on any of these, you should speak to your doctor.

• PRP Injection – containing blood products such as ‘platelet-rich plasma’, these injections have been demonstrated as an effective alternative to surgery in difficult-to-treat tennis elbow.
• Hyaluronan gel injection – more commonly used in osteoarthritis, preliminary studies have shown some benefit of these, with a potential role in improving tendon healing.
• Botulinum injection – another alternative to surgery, these injections will temporarily paralyse the muscles for the third and fourth fingers and must be followed by gradual ‘re-loading’ and physiotherapy for effective relief of tennis elbow.
• Shock wave therapy – this technology is mainly used to break down small kidney stones made of calcium compounds. In cases where there is calcification of the tendon, shock wave treatments can be theoretically useful, but they do not help in the majority of cases of tennis elbow.
• Acupuncture – as an alternative form of pain relief, acupuncture has been shown to give short-term benefit in the case of tennis elbow, and can be used in combination with other treatments (topical NSAIDS, physiotherapy etc.).