Definition
Tennis elbow is an inflammation of several structures of the elbow. These include muscles, tendons, bursa, periosteum, and epicondyle (bony projections on the outside and inside of the elbow, where muscles of the forearm attach to the bone of the upper arm). This condition is also called epicondylitis, lateral epicondylitis, medial epicondylitis, or golfer's elbow, where pain is present at the inside epicondyle.
Description
The classic tennis elbow is caused by repeated forceful contractions of wrist muscles located on the outer forearm. The stress, created at a common muscle origin, causes microscopic tears leading to inflammation. This is a relatively small surface area located at the outer portion of the elbow (the lateral epicondyle). Medial tennis elbow, or medial epicondylitis, is caused by forceful repetitive contractions from muscles located on the inside of the forearm. All of the forearm muscles are involved in tennis serves, when combined motions of the elbow and wrist are employed. This overuse injury is common in adults between ages 20–40.
People at risk for tennis elbow are those in occupations that require strenuous or repetitive forearm movement. Such jobs include mechanics, assembly line work, house painting, or carpentry. Sport activities that require individuals to twist the hand, wrist, and forearm, such as tennis, throwing a ball, bowling, golfing, and skiing, can cause tennis elbow. Individuals in poor physical condition who are exposed to repetitive wrist and forearm movements for long periods of time may also be prone to tennis elbow.
Causes & Symptoms
Tennis elbow pain originates from a partial tear of the tendon and the attached covering of the bone. It is caused by chronic stress on tissues attaching a group of forearm muscles known as extensor muscles to the elbow area. Individuals experiencing tennis elbow may complain of pain and tenderness over either of the two epicondyles. This pain increases with gripping or rotation of the wrist and forearm. If the condition becomes long-standing and chronic, a decrease in grip strength can develop.
Diagnosis
Diagnosis of tennis elbow includes the individual observation and recall of symptoms, a thorough medical history, and physical examination by a physician. Diagnostic testing is usually not necessary unless there may be evidence of nerve involvement from underlying causes. X rays are usually always negative because the condition is primarily soft tissue in nature, in contrast to a disorder of the bones. However, magnetic resonance imaging (MRI) has been shown to be helpful in diagnosing cases of early tennis elbow because it can detect evidence of swelling and tissue tears in the common extensor muscle group.
Treatment
Heat or ice is helpful in relieving tennis elbow pain. Once acute symptoms have subsided, heat treatments are used to increase blood circulation and promote healing. The physician may recommend physical therapy to apply diathermy or ultrasound to the inflamed site. These are two common modalities used to increase the thermal temperature of the tissues in order to address both pain and inflammation. Occasionally, a tennis elbow splint may be useful to help decrease stress on the elbow throughout daily activities. Routine exercises are very important to improve flexibility to all forearm muscles, and will aid in decreasing muscle and tendon tightness that has been creating excessive pull at the common attachment of the epicondyle.
Massage therapy also has been found to be beneficial if symptoms are mild. Massage techniques are based primarily on increasing circulation to promote efficient reduction of inflammation. Manipulation, acupuncture, and acupressure have been used as well. Contrast hydrotherapy (alternating hot and cold water or compresses, three minutes hot, 30 seconds cold, repeated three times, always ending with cold) applied to the elbow can help bring nutrient-rich blood to the joint and carry away waste products. Botanical medicine and homeopathy may also be effective therapies for tennis elbow. For example, cayenne (Capsicum frutescens) ointment or arnica, wintergreen, or rue oil applied topically may help to increase blood flow to the affected area and speed healing.
Allopathic Treatment
The physician may also prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and pain. Injections of cortisone or anesthetics are often used if physical therapy is ineffective. Cortisone reduces inflammation, and anesthetics temporarily relieve pain. Physicians are cautious regarding an excessive number of injections as they have been found to weaken the tendon's integrity. In addition, a significant number of patients experience a temporary increase in pain following corticosteroid injections.
A newer method of treatment for tennis elbow is shock wave therapy, in which pulses of high-pressure sound are directed at the injured part of the tendon. The "shock" refers to the high pressure, which breaks down scar tissue and stimulates the regrowth of blood vessels in healthy tissue. Shock wave therapy sessions take about 20 minutes and have been reported to have a success rate of 80%. Shock wave therapy has very few side effects; one group of German physicians found that temporary reddening of the skin or small bruises were the most commonly reported side effects.
Botulinum toxin, or Botox, is also being tried as a treatment for tennis elbow as of late 2003. Although further research needs to be done, Botox appears to relieve pain in chronic tennis elbow by relaxing muscles that have gone into spasm from prolonged inflammation.
Surgery
If conservative methods of treatment fail, surgical release of the tendon at the epicondyle may be a necessary form of treatment. Although surgical intervention is relatively rare in the treatment of tennis elbow, it is completely succesful in about 70% of cases.
Expected Results
Tennis elbow is usually curable; however, if symptoms become chronic, it is not uncommon for treatment to continue for three to six months.
Prevention
Until symptoms of pain and inflammation subside, activities requiring repetitive wrist and forearm motion should be avoided. Once pain decreases to the point that return to activity can begin, the playing of such sports as tennis for long periods should not occur until excellent condition returns. Many times, choosing a different size or type of tennis racquet or tool may help. Frequent rest periods are important despite what the wrist and forearm activity may be. Compliance to a stretching and strengthening program is very important in helping prevent recurring symptoms and exacerbation. In some cases, the patient may be advised to change his or her occupation to prevent further injury.
Resources
Books
Hertling, Darlene, and Randolph M. Kessler. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. 2d ed. Philadelphia: J.B. Lippincott Company, 1990.
Norkin, Cynthia C., and Pamela K. Levangie. Joint Structure and Function: A Comprehensive Analysis. Philadelphia: F.A. Davis Company, 1992.
Periodicals
Altay, T., I. Gunal, and and H. Ozturk. "Local Injection Treatment for Lateral Epicondylitis." Clinical Orthopedics 398 (May 2002): 127-130.
Das, D., and N. Maffulli. "Surgical Management of Tennis Elbow." Journal of Sports Medicine and Physical Fitness 42 (June 2002): 190-197.
de Seze, M. P., M. de Seze, P. Dehail, et al. "Botulinum Toxin A and Musculoskeletal Pain." [in French] Annales de réadaptation et de médecine physique 46 (July 2003): 329–332.
Haake, M., I. R. Boddeker, T. Decker, et al. "Side-Effects of Extracorporeal Shock Wave Therapy (ESWT) in the Treatment of Tennis Elbow." Archives of Orthopaedic and Trauma Surgery 122 (May 2002): 222-228.
Mackay, D., A. Rangan, G. Hide, et al. "The Objective Diagnosis of Early Tennis Elbow by Magnetic Resonance Imaging." Occupational Medicine (London) 53 (August 2003): 309–312.
Melikyan, E. Y., E. Shahin, J. Miles, and L. C. Bainbridge. "Extracorporeal Shock-Wave Treatment for Tennis Elbow. A Randomised Double-Blind Study." Journal of Bone and Joint Surgery, British Volume 85 (August 2003): 852–855.
Rompe, J. D., M. Buch, L. Gerdesmeyer, et al. "Musculoskeletal Shock Wave Therapy—Current Database of Clinical Research." [in German] Zeitschrift Orthopädische Ihre Grenzgebiet 140 (May-June 2002): 267-274.
Smith, A. M., J. A. Castle, and D. S. Ruch. "Arthroscopic Resection of the Common Extensor Origin: Anatomic Considerations." Journal of Shoulder and Elbow Surgery 12 (July-August 2003): 375–379.
Walther, M., S. Kirschner, A. Koenig, et al. "Biomechanical Evaluation of Braces Used for the Treatment of Epicondylitis." Journal of Shoulder and Elbow Surgery 11 (May-June 2002): 265-270.
Wang, A. A., E. Whitaker, D. T. Hutchinson, and D. A. Coleman. "Pain Levels After Injection of Corticosteroid to Hand and Elbow." American Journal of Orthopedics 32 (August 2003): 383–385.
Organizations
American College of Occupational and Environmental Medicine (ACOEM). 1114 North Arlington Heights Road, Arlington Heights, IL 60004. (847) 818-1800. .
American College of Sports Medicine. PO Box 1440, Indianapolis, IN 46206–1440 or 401 W. Michigan St., Indianapolis, IN 46202. (317) 637–9200. Fax: (317) 634–7817. .
[Article by: Kathleen D. Wright; Rebecca J. Frey, PhD]
