Tennis Elbow is a common term for a condition caused by over-use of arm, forearm, and hand muscles that results in elbow pain. Tennis elbow is caused by either abrupt or subtle injury of the muscle and tendon area around the outside of the elbow. Tennis elbow specifically involves the area where the muscles and tendons of the forearm attach to the outside bony area (called the lateral epicondyle) of the elbow. Medical practitioners may call this condition lateral epicondylitis.
You don’t play tennis, you say?
You don’t have to play tennis to get this injury, but the term came into use because it can be a significant problem for some tennis players. Tennis elbow affects 1% to 3% of people and as many as 50% of tennis players during their careers. Less than 5% of all tennis elbow diagnoses are related to actually playing tennis.
Let’s break it down, starting at the elbow
The elbow is one of the largest joints in the body. In conjunction with the shoulder joint and wrist, the elbow gives the arm much of its versatility, as well as structure and durability. The elbow is a simple hinge joint that swings 180 degrees in one direction and allows bending (flexion) and straightening (extension); it also helps turn the forearm at the point where the parallel bones in the forearm meet.
The elbow joint occurs at the junction of the humerus or upper arm bone, the ulna which is the larger of the two forearm bones and the radius bone. Joints are held together by a network of ligaments. Ligaments are made of tough, flexible connective tissue. In addition to their role of holding joints together, ligaments can also connect bones and cartilages. The major ligaments that connect the bones of the elbow include the ulnar collateral ligament, radial collateral ligament, and annular ligament. Several major muscles and tendons (fibrous bands that join muscles to bone or muscles to other muscles) meet at the elbow. These include the biceps, triceps, brachioradialis, and extensor carpi radialis longus tendons.
The resting angle of the elbow prevents the arms from hitting the sides of your body as you walk. This is also known as the“carrying angle.” The elbow is frequently used as a fulcrum¹ for seated activities that involve the hands, such as writing or using a keyboard. The elbow can be easily put under stress, as it is a major joint in one of the most active regions of the human body. It is put under extreme pressure as the point of injury or trauma.
How do I know I have Tennis Elbow?
Symptoms of tennis elbow include:
- Pain slowly increasing around the outside of the elbow. Less often, pain may develop suddenly.
- Pain is worse when shaking hands or squeezing objects.
- Pain is made worse by stabilising or moving the wrist with force. Examples include lifting, using tools, opening jars, or even handling simple utensils such as a toothbrush or knife and fork.
It is usually diagnosed by the description of pain you provide to your physiotherapist and certain findings from a physical exam. Since many other conditions can cause pain around the elbow, it is important that you see your physiotherapist so the proper diagnosis can be made. Your physiotherapist can then prescribe the appropriate treatment. Tennis elbow usually is successfully treated by medical means, such as physical therapy, forearm bracing to rest the tendons, topical anti-inflammatory gels, topical cortisone gels, and cortisone injections by medical doctors. It only rarely requires surgery.
What can I do now?
The goals of treatment are to reduce pain or inflammation, promote healing, and decrease stress and abuse on the injured elbow. To reduce the pain and inflammation of tennis elbow, try:
- Rest and avoid any activity that causes pain.
- Apply ice to the affected area.
- Take nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen.
- Physiotherapy to assist with pain management and correct the cause of the Tennis elbow
- Cortisone-type medication may be put on topically by you or injected into the sore area by your doctor.
Is there anything else I can do?
This step begins a couple of weeks after the pain of Tennis Elbow has been reduced or eliminated. It involves specific physical-therapy exercises to stretch and strengthen muscles and tendons around the injured elbow. Any activity that aggravates the pain must be avoided.
To help lessen the continued stress and abuse on tennis elbow:
- Use the proper equipment and technique in sports and on the job.
- Use of a counter-force brace, an elastic band that wraps around the forearm just below the injured elbow (tendon) may help to relieve pain in some people.
- Avoid tight gripping and overuse of the wrist.
- Pay attention to the movements that cause pain.
The “super 7” exercises are an important part of treatment for tennis elbow. They are designed to strengthen the muscles in the forearm and increase flexibility through stretching. In most cases, these exercises will help relieve elbow pain in about 4 to 6 weeks. Each stretching exercise should be held for 15 seconds and repeated 2 or 3 times.
To stretching the muscles that extend the wrist (extensor muscles): Straighten the arm out fully and push the palm of the hand down so you feel a stretch across the top of the forearm.
To stretch the muscles that flex the wrist (flexor muscles): straighten the arm out fully (palm side up), and push the palm downward to stretch.
Thereafter, strengthening exercises must be done twice a day after you have done the stretching exercises. To do these, sit in a chair with your elbow supported on the edge of a table or on the arm of the chair with your wrist hanging over the edge. Use a light weight such as a hammer or can of soup/food when performing the strengthening exercises. Repeat the exercises 30 to 50 times, twice a day, but do not push yourself beyond the point of pain. To strengthen wrist extensor muscles: Hold the weight in the hand with the palm facing down. Extend the wrist upward so that it is pulled back. Hold this position for 2 seconds and then lower slowly.
To strengthen wrist flexor muscles: Hold the weight in the hand with the palm up. Pull the wrist up, hold for 2 seconds and lower slowly.
Strengthening the muscles that move the wrist from side to side (deviator muscles): Hold the weight in the hand with the thumb pointing up. Move the wrist up and down, much like hammering a nail. All motion should occur at the wrist.
Strengthening the muscles that twist the wrist (pronator and supinator muscles): Hold the weight in the hand with the thumb pointing up. Turn the wrist inward as far as possible and then outward as far as possible. Hold for 2 seconds and repeat as much as pain allows, up to 50 repetitions.
Massage is performed over the area of soreness. Apply firm pressure using 2 fingers on the area of pain and rub for 5 minutes.
If exercise aggravates any of your symptoms, contact a doctor or physical therapist. These exercises can be used to prevent or rehabilitate injuries caused by repetitive forearm work.
Overall, 90% to 95% of people with tennis elbow will improve and recover with the treatment plan described. However, about 5% of people will not get better with conservative treatment and will need surgery to repair the injured muscle-tendon unit around the elbow. For 80% to 90% of people who have surgery, it results in pain relief and return of strength.
¹A fulcrum is the point on which a lever rests or is supported and on which it pivots; a thing that plays a central or essential role in an activity.
Brukner, P. & Khan,K. 2007(Third edition) Clinical sports medicine. McGraw publications.
Tim L. Uhl, P.T., A.T.,C.- https://www.hughston.com/hha/a.seven.htm
American Academy of Orthopaedic Surgeons .(1995-2016)