tenniselbow

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ELBOW INJURIES

Lateral epicondylitis

Doctors first identified tennis elbow (or lateral epicondylitis) more than 100 years ago. Today nearly half of all tennis players will suffer from this disorder at some point. Interestingly though, tennis players actually account for less than 5 percent of all reported cases making the term for this condition something of a misnomer.

There are 2 additional strain related conditions which are often mistaken for Tennis Elbow. These being Golfer’s Elbow & Bursitis. Before we delve into the details of what Tennis Elbow actually is and options that are available for relieving & preventing the pain...let’s look at the distinguishing characteristics of each of these 3 ailments.

Tennis Elbow
(lateral epicondylitis)
Outside of Elbow
Cause & Symptoms

The onset of pain, on the outside (lateral) of the elbow, is usually gradual with tenderness felt on or below the joint's bony prominence. Movements such as gripping, lifting and carrying tend to be troublesome.

Golfer’s Elbow
(medial epicondylitis)
Inside of Elbow
Cause & Symptoms

The causes of golfer's elbow are similar to tennis elbow but pain and tenderness are felt on the inside (medial) of the elbow, on or around the joint's bony prominence.

Bursitis
Back of Elbow
Cause & Symptoms

Often due to excessive leaning on the joint or a direct blow or fall onto the tip of the elbow.
A lump can often be seen and the elbow is painful at the back of the joint.

Symptoms Of Tennis Elbow

Recurring pain on the outside of the upper forearm just below the bend of the elbow; occasionally, pain radiates down the arm toward the wrist.
Pain caused by lifting or bending the arm or grasping even light objects such as a coffee cup.
Difficulty extending the forearm fully (because of inflamed muscles, tendons and ligaments).
Pain that typically lasts for 6 to 12 weeks; the discomfort can continue for as little as 3 weeks or as long as several years.

The damage that tennis elbow incurs consists of tiny tears in a part of the tendon and in muscle coverings. After the initial injury heals, these areas often tear again, which leads to hemorrhaging and the formation of rough, granulated tissue and calcium deposits within the surrounding tissues. Collagen, a protein, leaks out from around the injured areas, causing inflammation. The resulting pressure can cut off the blood flow and pinch the radial nerve, one of the major nerves controlling muscles in the arm and hand.

Tendons, which attach muscles to bones, do not receive the same amount of oxygen and blood that muscles do, so they heal more slowly. In fact, some cases of tennis elbow can last for years, though the inflammation usually subsides in 6 to 12 weeks.

Many medical textbooks treat tennis elbow as a form of tendonitis, which is often the case, but if the muscles and bones of the elbow joint are also involved, then the condition is called epicondylitis. However, if you feel pain directly on the back of your elbow joint, rather than down the outside of your arm, you may have bursitis, which is caused when lubricating sacs in the joint become inflamed. If you see swelling, which is almost never a symptom of tennis elbow, you may want to investigate other possible conditions, such as arthritis, infection, gout or a tumor.

Relief Of Tennis Elbow

The best way to relieve tennis elbow is to stop doing anything that irritates your arm — a simple step for the weekend tennis player, but not as easy for the manual laborer, office worker, or professional athlete.

The most effective conventional and alternative treatments for tennis elbow have the same basic premise: Rest the arm until the pain disappears, then massage to relieve stress and tension in the muscles, and exercise to strengthen the area and prevent reinjury. If you must go back to whatever caused the problem in the first place, be sure to warm up your arm for at least 5 to 10 minutes with gentle stretching and movement before starting any activity. Take frequent breaks.

Conventional medicine offers an assortment of treatments for tennis elbow, from drug injections to surgery, but the pain will never go away completely unless you stop stressing the joint. Re-injury is inevitable without adequate rest.

For most mild to moderate cases of tennis elbow, aspirin or ibuprofen will help address the inflammation and the pain while you are resting the injury, and then you can follow up with exercise and massage to speed healing.

For stubborn cases of tennis elbow your doctor may advise corticosteroid injections, which dramatically reduce inflammation, but they cannot be used long-term because of potentially damaging side effects.

Another attractive option for many sufferers, especially those who prefer to not ingest medication orally, is the application of an appropriate and effective topical ointment. CT Cream with A.C.P. was specifically designed to reduce inflammation and does so by taking advantage of well known elements Arnica, Choline and Vitamin B₆.

If rest, anti-inflammatory medications, and a stretching routine fail to cure your tennis elbow, you may have to consider surgery, though this form of treatment is rare (fewer than 3 percent of patients). One procedure is for the tendon to be cut loose from the epicondyle, the rounded bump at the end of the bone, which eliminates stress on the tendon but renders the muscle useless. Another surgical technique involves removing so-called granulated tissue in the tendon and repairing tears.

Even after you feel you have overcome a case of tennis elbow, be sure to continue babying your arm. Always warm up your arm for 5 to 10 minutes before starting any activity involving your elbow. And if you develop severe pain after use anyway, pack your arm in ice for 15 to 20 minutes and call your doctor.

Prevention

To prevent tennis elbow:

Lift objects with your palm facing your body.
Try strengthening exercises with hand weights. With your elbow cocked and your palm down, repeatedly bend your wrist. Stop if you feel any pain.
Stretch relevant muscles before beginning a possibly stressful activity by grasping the top part of your fingers and gently but firmly pulling them back toward your body. Keep your arm fully extended and your palm facing outward.

Caution!

To prevent a relapse:

Discontinue or modify the action that is causing the strain on your elbow joint. If you must continue, be sure to warm up for 10 minutes or more before any activity involving your arm, and apply ice to it afterward. Take more frequent breaks.
Try strapping a band around your forearm just below your elbow. If the support seems to help you lift objects such as heavy books, then continue with it. Be aware that such bands can cut off circulation and impede healing, so they are best used once tennis elbow has disappeared.

Call Your Doctor If....

The pain persists for more than a few days; chronic inflammation of the tendons can lead to permanent disability.

The elbow joint begins to swell; tennis elbow rarely causes swelling, so you may have another condition such as arthritis, gout, infection or even a tumor.

Tennis elbow, or lateral epicondylitis, is one of the most common elbow problems seen by an orthopedic surgeon.

It is actually a tendinitis of the muscle called the extensor carpi radialis brevis which attaches to the lateral epicondyle of the humerus.

It may be caused by a sudden injury or by repetitive use of the arm. Many doctors feel that micro tears in the tendon lead to a hyper-vascular phenomenon resulting in pain. The pain is usually worse with strong gripping with the elbow in an extended position, as in a tennis back hand stroke, but this problem can occur in golf and other sports as well as with repetitive use of tools.

Before surgery is considered a trial of at least six months of conservative treatment is indicated and consists of a properly placed forearm brace and modification of elbow activities. I have not found anti-inflammatory medication or physical therapy to be of any value. If the above treatment is not helpful, a cortisone injection can be beneficial but no more than three injections are recommended in any one location in a year.

Conservative treatment is in two phases and after Phase I (Pain relief) has been successful, Phase II, (Prevention of recurrence) is equally as important and involves stretching and then later strengthening exercises, so the micro tears will not occur in the future.

When conservative treatment has failed, then surgery is indicated. Many procedures have been described. Procedures as simple as percutaneous release of the tendon off of the bone have been described and more recently arthroscopic procedures or other procedures involving the joint and resection of a ligament as well have been described.

The most popular procedure today is a simple excision of diseased tissue from within the tendon, shaving down the bone and re-attachment of the tendon. This can be performed as an outpatient procedure with regional anesthesia (where only the arm goes to sleep) and through a relatively small incision of approximately 3” long. 85-90% of patients with this technique are typically able to perform full activities without pain after a recuperation of two to three months. Approximately 10-12% of patients have improvement but with some pain during aggressive activities and only 2-3% of patients have no improvement.

Text prepared by David M. Auerbach, MD
Southern California Orthopedic Institute

Tennis Elbow (Lateral Epicondylitis)

Tennis Elbow or Lateral Epicondylitis is a condition when the outer part of the elbow becomes painful and tender, usually as a result of a specific strain, overuse, or a direct bang. Sometimes no specific cause is found.

Tennis Elbow is similar to Golfer's Elbow which affects the other side of the elbow.

Symptoms

The outer part of the elbow is painful and tender to touch. Movements of the elbow, and also movements which involve lifting, with the hand on top, hurt.

Causes

Although called tennis elbow, lateral epicondylitis is much more commonly seen in people who are over using their arm doing something else. It could equally well be called "plasterer's elbow" or "mechanic's elbow" or "painter's elbow".

The most common cause is over use of the muscles which are attached to the bone at this part of the elbow. That is to say, the muscles which pull the hand backwards (the wrist extensors). All the extensor muscles of the hand attach to the elbow at the outer part (the lateral epicondyle). If they are strained or over used they become inflamed, which means they are swollen, painful and tender to touch.

Sometimes the inflammation is caused by a direct injury or bang. Sometimes, especially when the cause is direct injury or strain, the muscles are actually partially torn.

Rarely the inflammation comes on without any definite cause, and this may be due to an arthritis, rheumatism or gout. Sometimes the problem is partly or completely due to a neck problem, which is causing pain in the elbow via the nerves from the neck.

Diagnosis

The doctor or physiotherapist will test for tenderness over or near to the bony bump on the outside of the elbow. He or she will also test to see whether the pain gets worse when you bend the wrist back (extend it) against resistance. In the event of both these signs being present, it is likely that you have tennis elbow.

Your doctor may also examine your neck, as this may be the cause, or part of the problem. After all many of the things that might strain your elbow might also put a strain on your neck.

Treatment

Rest helps, with avoidance of the activities which over use the elbow.
Physiotherapy treatments, which may include heat or ultrasound therapy
Use of anti inflammatory drugs and ordinary pain killers (analgesics).
The doctor may suggest an injection of a small dose of steroid to the affected area. This is not the sort of steroid banned for athletes. If used it can last for up to three months, and although it may need to be repeated you seldom need more than two or possibly three injections.
You can buy a brace from a sports shop or pharmaceutical supplier, which can be helpful. This is probably largely because it reduces the amount you can use your elbow.

Tennis Elbow

Tennis elbow is somewhat of a misnomer since many people with this diagnosis don't play tennis. There is usually no history of trauma and repetitive use seems to make the pain worse. Discomfort is most often located over the outside or lateral bony prominence of the elbow, (called the epicondyle), with a similar but less frequent condition seen on the inside or medial joint area, just in front or anterior to the "funny bone." This problem area over the outside of the elbow is where a large tendon attaches to bone. Functionally, it helps lift your wrist up (extension).

You can usually reproduce the symptoms by forcefully extending the wrist joint against resistance. X-rays are of very little benefit and treatment is best implemented with a trial of NSAIM, ice massage, and physical therapy modalities. I believe cortisone shots should be delayed until more conservative measures are tried, since frequently patients get relief without the injection, which can be very uncomfortable.

Although some physicians are quick to splint people with tennis elbow, or stop their activities, I find this only temporarily masks the pain which almost immediately returns with use. Therefore, my recommendation is that the patient cut back on the offending source causing the pain while simultaneously undergoing treatment and then work back to the initial level of activity, slowly.

Tennis elbow bands wrapped around the area below the joint may be helpful but care must be taken to avoid putting these on too tight and possibly compromising circulation. In my experience, less than five percent of patients with this annoying problem come to surgery, although many people with this aggravating problem have gotten significant relief from this small out-patient procedure that carries with it very little risk. You won't play tennis or many other sports for two to three months.

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