Tennis elbow is very common. It occurs most commonly on the outer side of your elbow, but may also occur on the inner side, and occasionally even in the back of the elbow. When it occurs on the inner side of the elbow it’s called “golfer’s elbow,” but it’s really the same problem. The problem is tendon over-use, leading to tendon breakdown. This is called tendinosis, which means tendon degeneration. We used to call it tendinitis, which means tendon inflammation, but we now know that this is incorrect. The pain comes from the breakdown and degeneration of overused tissue, not from inflammation.
Any activity that stresses these tendons, including tennis, golf, sports and manual labor (heavy lifting, etc) can lead to tennis elbow. Despite its name, up to 95 percent of cases of “tennis elbow” occur in non-tennis players. Musicians, carpenters, assembly line workers, and many others who subject themselves to repetitive stresses may develop tennis elbow.
Treatment
Even though the involved tendons are located around the elbow, they are attached to the muscles that move your wrist and forearm. Therefore, it is overuse of the wrist and forearm muscles, not elbow muscles, that leads to tennis elbow. It is necessary to understand this to know how to avoid and treat tennis elbow.
There is a balance between the stresses you apply to your arm and the strength of the small muscles to handle these stresses. As long as muscle strength is greater than or equal to the applied stress, you’re ok. But once stresses become too high or too frequent, you experience pain and injury. If damage occurs at a rate that is too rapid for your body to heal, tendon degeneration occurs. Therefore, to get rid of your pain and avoid future injury you have two options: 1) Improving the strength of your tissues, or 2) Reduce the stresses you place on them.
Maybe the painful activity isn’t that important to you. You could give it up. But many don’t want to give up tennis, golf, sports, or the painful activity. For sports, proper technique is very important in minimizing the stresses placed on your arm. You’re supposed to generate the force to swing the racket or club, throw the ball, etc. from the large muscles of your legs and trunk. The shoulder and elbow are simply supposed to transfer these forces to the ball, club or racket. If you’re trying to generate significant force from your shoulder or elbow, your form is incorrect and you’re putting yourself at risk of overuse injuries. You can greatly reduce the amount of stress that your forearm tendons are subjected to, and reduce your chance of injury or speed your recovery, simply by improving your sport-specific mechanics. At work, utilizing proper mechanics and avoiding provocative activities can be helpful.
“Counterforce” bracing has also been shown to be effective in reducing the stresses to your forearm muscles. Counterforce bracing reduces the tendon’s load by: 1) preventing full contraction of your muscles. In this way maximal force cannot be generated, and the tendon will not be injured, and 2) by absorbing some of the stresses so that the tendon doesn’t have to.
Limiting your activities, proper technique, proper equipment, and counterforce bracing will help to decrease the stress load on the origins of your forearm muscles. The other side of the coin is to increase the quality of those tissues. This is done through rehabilitative exercises. The muscle groups worked are the wrist extensors, wrist flexors and the forearm rotators. I prefer to have my patients use an elastic resistance for strengthening, such as an isotube, rather than a dumbbell weight
The Six Tennis Elbow Exercises
Exercise should not cause pain. Pain means you could be further injuring the already damaged tissue. The idea is to strengthen the weakened muscles, not to over-stress them. Wear your counterforce brace while exercising to further reduce the stresses on the tendons as you’re strengthening the muscles. If pain occurs during strengthening, you’re either using too much resistance or doing them too many times. To start, I recommend only one set of 10-12 repetitions per day for each exercise.
Steroid injections provide temporary pain relief in approximately 50% of cases. Unfortunately, steroid injections cannot provide a permanent cure and are no better than placebo at 3 months. However, if pain is preventing you from performing your strengthening exercises, an injection may provide decrease pain enough that you can perform the exercises. And it’s always nice to have less pain, even if it’s just for a while.
If the injection site hurts the night after injection, put ice on it for 15-20 minutes.
Steroid injections should be placed deep to the tendons. Injections into the tendons should be avoided, as they may further damage the already injured tendon. Injections not placed deep enough may dissolve the fat just below your skin, leaving a permanent dimple, thinner skin and less padding over your sensitive bone and tendons.
The repeated use of cortisone injections is inappropriate. There is no advantage, and considerable disadvantage, in having more than two such injections. Repetitive injections may weaken the surrounding normal tissues, potentially leading to further damage.
Rehabilitative exercises, combined with appropriate bracing, successfully treats about 75-95% of patients with tennis elbow. The others continue to have pain that limits their activities. This occurs because the amount of tissue damage is too great for their body to repair. If you’re in this situation, then you have a choice to make. Either 1) accept your condition and limit your activities accordingly, or 2) undertake a surgical solution.
Surgery
The vast majority of patients with tennis or golfer’s elbow get better without surgery, using the exercise protocol outlined above. However, when nonoperative treatment fails to solve the problem, there is a simple surgical solution that is approximately 97% effective. It involves a small incision, only about 2″ long, through which the damaged, abnormal, unhealthy tendon is removed.
However, there are other, older surgeries still used that tried to “release” the origin of the tendons from the bone, repair the tendon, or take out the bone itself. Not only does this not work well, but it hurts a lot, can lead to stiffness and residual pain and can weaken the forearm muscles. Some of these operations leave some damaged and degenerated tissue behind. In addition, releases may damage the elbow ligaments located directly beneath the tendons, which may lead to further pain and elbow instability. And once you’ve had an unsuccessful surgery, the chances that an appropriate surgery can help you decreases to about 84%.
The take home message is this: tennis elbow is relatively common, but can be minimized by using proper techniques, both during athletics and at work. The vast majority of tennis elbows can be treated with a counterforce brace and a good muscle strengthening program. And for the minority of patients who do come to surgery, modern techniques of tennis elbow excision have an excellent rate of success.
