Tennis Elbow
Tennis elbow is the most common condition which affects the elbow.
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.
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Diagnosis
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.
Treatment
Prevention
A period of stretching of the forearm muscles prior to partaking in sport will greatly help in preventing the condition.
Non-operative
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.
Counterforce brace
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.
Operative
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.
Recovery
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.
Surgery procedure
Elbow Arthroscopy
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.
Anaesthesia
The anaesthetist will see you in the ward prior to the operation or in the reception room in theatre. If you have medical problems; eg: heart condition, previous cardiac surgery, chest disease (eg: emphysema), you will be referred to a physician for an assessment and may see the anaesthetist a few days prior to the operation. A premed is sometimes given prior to theatre which will make you a little drowsy and relaxed. In theatre you will sit on the theatre table and make yourself comfortable prior to the induction of anaesthesia. A drip will be inserted into your arm through which the anaesthetic drugs are administered. Gases will be given by a mask and once you are asleep a tube will be inserted into your throat, this is why you may have a sore throat for a short time after the operation.
The anesthetic is a general anaesthetic with a regional block. It can be done with a block alone but you are placed into a seated position on the operating table which can be uncomfortable and thus a general anaesthetic is preferred. The block is done with local anaesthetic injected into the side of the neck where the nerves to the arm are passing (essentially an epidural of the arm). This provides excellent pain relief during the operation thus less anaesthetic drugs are required; you tend to wake up quickly and are quite refreshed afterwards. The block provides excellent relieve of pain after the operation and lasts for between 8 and 24 hours. The arm may be completely dead and you may not even be able to move your fingers initially. Care must be taken not to put anything hot on the arm as this will not be felt and a burn may occur. In approximately 1% of cases there may be a persisting area of numbness in the arm, forearm or hand after the block has worn off. This numbness will usually disappear within 3 months. Occasionally neuralgia (nerve pain) may occur after the block and may require medication till it settles of its own accord. Although extremely rare, permanent nerve damage has been reported.
You tend to wake up very quickly after the operation and may eat soon afterwards. The drip will be taken down when you are back in the ward. The block provides excellent pain relief for between 8 and 24 hours but pain killers and anti-inflammatories are started before the block wears off so that they are already working when the pain starts. Patients vary in the amount of pain killers that they need; some don’t need to take any whereas others may need to take them for up to 6 weeks.
