10%-50% of people who engage in racquet sports regularly will at some point during their careers experience symptoms of a tennis elbow. However with improvement in racquet technology, it is seen less commonly in tennis players. It is also seen in a host of other sports and in many recreational activities and occupations. It is now commonly seen with the use of the mouse and keyboard in computer work. It is most commonly seen in people between the ages of of 30 and 50 years.
What is it?
It initially occurs as micro tears of the tendons (part of the muscle that attach to the bone) on the outside of the elbow. There is ingrowth of fibrous and vascular tissue. There is the formation of granulation tissue with the presence of free nerve endings thus making the area very sensitive to touch.
Pain is the main symptom and it is felt on the outside of the elbow but can radiate down to the wrist and up the arm. Simple activities such as shaking hands, picking up a packet and carrying a case may cause severe pain. The elbow may be very sensitive to touch and just simple bumping the prominent bone on the outside of the elbow may be excruciating. There may be the feeling of weakness in the forearm. In severe cases the elbow may not be able to be straightened fully. The diagnosis is fairly simple and is made from the history and examination; where there is tenderness in a very specific site and pain is reproduced by lifting the wrist up against resistance.
A period of stretching of the forearm muscles prior to partaking in sport will greatly help in preventing the condition.
Most tennis elbows will respond to simple treatment. The treatment is aimed at relief of pain and inflammation followed by the promotion of healing.
Initial treatment includes rest, splinting of the wrist and anti-inflammatory medication. Physiotherapy is extremely important with stretching followed by strengthening of the forearm and hand muscles.
If it does not respond to these measures then an injection with local anaesthetic and steroid can give dramatic relief and a cure. Once the local anaesthetic wears off then there may be quite severe discomfort in the elbow for a day and you may need to take pain killers and anti-inflammatoires. The cortisone takes approximately 24 to 48 hours to work. A number of steroid injections may be required over a period of time to effect a cure.
Other substances have also been injected; simply blood taken from the patient or plasma enriched with platelets (PEP). This is obtained from the patient’s blood sample which is spun down in a centrifuge to separate the platelet enriched plasma layer. Recent reports have shown that this PEP injection lasts longer than a cortisone injection. This PEP injection however is far more costly than a cortisone injection.
A support band or counterforce brace around the forearm muscles may be worn when partaking activities or sport. This compresses the muscle and takes some of the force off the tendon; it also absorbs vibration protecting the tendon at it’s insertion onto the bone.
Changing or adjusting sports equipment may be necessary (i.e. racquet handle size, racquet weight and string tension) and even changing playing technique. These measures may help in preventing the condition from recurring.
The above non-operative methods of treatment will result in cure rates of 85%-95%. The majority of tennis elbows will settle down within a year of the onset of symptoms.
Surgery is indicated when there is persisting pain, which is debilitating in spite of a well-managed non-operative programme which has been tried for at least 6 months if not a year.
This is done arthroscopically (‘keyhole surgery’). The advantage of this is that the joint is inspected for any other abnormalities. The affected tendon is released from the bone. It is done as a day case and a splint may be worn on the wrist for 2 weeks. The bandage is taken off after 2 days and waterproof dressings are applied to the wound so you can shower or bath. The hand can be used normally as pain allows.
This varies between patients, though most patients will feel improvement by 6 weeks and complete recovery with no pain at 12 weeks. In a few patients, it may take up to 6 months for a full recovery. The elbow may be stiff post operation but usually the full movement returns by 6 weeks.