Tennis Elbow

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, who subject themselves to repetitive stresses may develop 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. Once the applied stresses become too much, injury and pain can occur. Therefore, to get rid of your pain and avoid future injury you can either decrease the stresses on your elbow or increase the strength of the forearm muscles about the elbow.

For sports, proper technique is very important. For golf, tennis, throwing, etc. you’re supposed to generate the force to swing the racket or club, or throw the ball 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 using your shoulder or elbow to generate power, your form is incorrect and you’re putting yourself at risk of overuse injuries. 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 braces absorb some of the stress so that the tendons don’t have to.

The more important treatment is to increase the strength quality of your muscles and tendons. This is done through rehabilitative strengthening exercises. The muscle groups that you need to strengthen are the wrist extensors, wrist flexors and the forearm rotators. For strengthening, I prefer an elastic resistance, such as an isotube, rather than a dumbbell or free weight.

Exercise should not cause pain. If pain occurs during strengthening, you’re either using too much resistance or doing them too many times. The idea is to strengthen the weakened muscles, not to over-stress them. Wear the counterforce brace while exercising. To start, I recommend only one set of 10-12 repetitions per day for each exercise. During exercises, the elbow should be bent and the forearm supported.

Steroid injections provide temporary pain relief in over 50% of cases. Unfortunately, steroid injections do not provide a permanent cure, and are no better than placebo at 3 months. However, injections are useful to decrease pain enough so that you can perform the exercises better. Understand that 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 the body to repair. If you’re in this situation, then you can either accept the condition and limit your activities accordingly, or elect to undergo 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.

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 do these not work well, but they can hurt a lot, lead to stiffness and/or 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 people with tennis elbow 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.