Anatomy of the Elbow
The elbow is basically a hinge joint, connecting the upper arm (humerus) to the forearm (radius and ulna). It also allows rotational motion of the forearm with its connection with the head of the radius. Many muscles cross the elbow and attach near the joint; some of which move the elbow, some move the forearm, and some move the wrist and fingers. Overuse or repetitive use of the wrist and hand can cause tendon problems around the elbow, the most common of which are lateral and medial epicondylitis – commonly known as tennis elbow and golfer’s elbow.
Description of Lateral Epicondylitis (Tennis Elbow)
Most patients with tennis elbow have either never played tennis or have not played in years. It is a common condition in which the tendons that attach on the lateral side of the elbow start to become degenerative. A similar condition on the medial side of the elbow is called medial epicondylitis or golfer’s elbow. Initially it was thought to be a tendinitis, or inflammatory problem, but research has shown that the tendon actually starts to degenerate and change at the cellular level. It usually causes pain on the lateral side of the elbow where these tendons attach, at a bony prominence called the lateral epicondyle. Severe cases can cause severe and debilitating pain and can make it difficult to even lift a coffee cup. The symptoms can start suddenly after an injury or stressful activity, or they can build up slowly over time.
Causes of Lateral Epicondylitis (Tennis Elbow)
Any activity that repeatedly stresses the same forarm muscles can cause symptoms of lateral epicondylitis. Some of these activities include the backhand stroke in tennis (hence the name), painting, using power tools, pruning shrubs, lifting heavy buckets, and hammering nails. For medial epicondylitis, the activities may be a golf swing or bowling stroke. Initially the area around the lateral epicondyle may become inflamed, but the actual problem of tennis elbow involves chronic changes in the tendon called tendinosis. In tendinosis, wear and tear on the tendon causes changes of the collagen fibers and the tendon is easily injured. The body responds by forming scar tissue, and eventually the tendon becomes thickened and stiff. The tendon never really has a chance to fully heal due to continued use, leaving the injured tendon weak and painful.
Symptoms of Lateral Epicondylitis (Tennis Elbow)
The most common symptoms of lateral epicondylitis are:
- Tenderness over the lateral epicondyle (bony bump on outer part of elbow)
- Pain when lifting objects, especially with the elbow straight and palm facing downward (palm upward for medial epicondylitis)
- Weakness in grip strength
- Pain that radiates from lateral elbow sometimes down entire forearm to hand
A burning sensation over the lateral elbow with activity
Diagnosis of Lateral Epicondylitis
Your doctor will consider many factors in making your diagnosis, including the history of your symptoms, risk factors, activities, and previous injuries. The physical exam is very helpful in diagnosing tennis elbow, and may involve several exam tests and maneuvers to help identify the problem. X-rays are useful in ruling out other sources of elbow pain such as arthritis or calcific tendinitis. Occasionally, if symptoms of instability are also present, an MRI may be helpful to identify collateral ligament degeneration that can be associated with lateral epicondylitis. A condition called radial tunnel syndrome can mimic symptoms of tennis elbow, and if this is suspected or if you don’t respond to standard treatments, nerve tests to evaluate the radial nerve may be ordered.
Treatment Options for Lateral Epicondylitis (Tennis Elbow)
The important thing to remember about tennis elbow is that in most cases it is a self-limiting process and the symptoms will eventually go away, but this can take many months or longer. Treatment can help alleviate the symptoms more quickly, and most of the time this condition can be treated without surgery.
Non-surgical Treatment of Lateral Epicondylitis (Tennis Elbow)
Stretching and strengthening exercises are the main non-operative treatments for tennis elbow. A physical therapist can help initially guide you in these stretches and exercises, sometimes employing techniques like flex-bar exercises or iontophoresis to help relieve your pain. A small orthotic device called a counter-force strap can help offload the injured area of tendon when worn during activities, and can be a valuable tool during your treatment. Cortisone injections in or around the tendon can actually weaken the tendon and lead to tendon rupture, so they are not suggested as a routine treatment for this problem. Newer treatments such as PRP injections have shown some promise in treating tennis elbow but more study needs to be done before these become standard treatment.
Surgical Treatment of Lateral Epicondylitis (Tennis Elbow)
Surgery is reserved for chronic cases that have failed all other treatments. One common surgical technique involves debriding, or removing, the diseased tissue from the affected tendon. This can be done through a small open incision over the lateral elbow or with the arthroscope.
Complications of Surgery
As with all surgeries, infection is always a risk but for tennis elbow procedures the infections rates are below 1%. Since there are important structures (lateral collateral ligament, radial nerve branches) near the lateral epicondyle, they are at risk for injury during this surgery. The tendon can be weakened with this procedure, so tendon rupture can occur if the tendon is stressed too early. Elbow stiffness is perhaps the most common complication of this procedure, and can usually be avoided with early rehab.
After surgery, you will have either a bulky dressing or sometimes a splint on the elbow. Motion exercises will generally begin at 1-2 weeks, and strengthening will begin after full range of motion is achieved. Some patients may do these exercises on their own, but sometimes a physical therapist will help guide your rehab.
- How long should I wait before considering surgery for tennis elbow?
Most cases will resolve on their own over time, but severe pain that limits activity for several months may be an indication for surgery. Ultimately, the decision is up to you and depends on how severe and limiting your symptoms are and how you respond to other treatments.
- When can I return to work after tennis elbow surgery?
Most people can return to work at a desk job after about one week, but more labor-intensive jobs may take 4-6 weeks.
- Are there ways to prevent tennis elbow?
Avoiding repetitive activities involving the wrist can help prevent symptoms of tennis elbow. When lifting heavy objects on a regular basis, remember to lift with the palms facing up. This helps avoid undue stress on the lateral tendons. If you have a problem with medial epicondylitis, the opposite is true and you should lift with the palms facing down.
If you have more questions, please call my office at 502-394-6341.