As a sports medicine orthopedic surgeon, you may often see patients with complaints at their elbow – one of the more common diagnoses is lateral epicondylitis also known as tennis elbow. Heads up: most patients with this condition might not even play tennis.
What is tennis elbow?
Tendons are tissues that hold muscle to the bone and tendons in our bodies are very tough and stretchy, kind of like rubber bands. But, like rubber bands, they can weaken over time. Wear and tear on these tendons as we go about our daily activities can eventually lead to micro tears, and instead of being a smooth bundle of stretchy fibers, the tendons become “tangled” by the process of tearing and re-healing.
If it leads to inflammation of the tendons on a part of the body called the epicondyle, it causes lateral epicondylitis. That is why the tennis elbow pain location is in the bony bump on the outside of the elbow and may also be felt on the forearm, wrist, and back of the hand.
The question ‘what is the difference between tennis elbow and tendonitis’ might arise and that is because tennis elbow is actually a type of tendonitis.
Also, golfer's elbow vs tennis elbow main difference is that it occurs on the medial epicondyle tendon (inner part of the elbow) instead of the lateral epicondyle.
What causes tennis elbow?
Tennis elbow falls under the category of a repetitive strain injury. This is due to the fact that is caused by overusing the forearm muscles due to a repetitive or strenuous activity that overloaded the tendons.
As said in the beginning, athletes aren't the only people who develop tennis elbow. The name comes from the fact that tennis demands the repetitive use of the backhand stroke being the main cause for tennis players to be susceptible to this pathology.
But people whose jobs feature repetitive motions of the wrist and arm, for example, plumbers, painters, carpenters, and butchers, are also at risk. Even repetitive computer mouse use can be a cause.
This condition can occur in men or women. Anyone over the age of 40 is more at risk, with the likelihood rising as people age. As you must know, most people have not only a dominant hand but a dominant arm. Since this arm is used for tasks more often, this is the arm most likely to fall prey to tennis elbow.
What are the tennis elbow symptoms?
The main symptom is the presence of forearm pain, so lateral epicondylitis hurt with pronation. Any grip or arm movement from handshaking, holding something, or even turning a doorknob could create a discomforting pain.
This creates a weakened grip with a loss of range of motion and stiffness when extending the arm. There could also be tenderness in the elbow joint due to swelling.
Tennis elbow diagnosis test
To understand if this pathology is present, you should do lateral epicondylitis tests, more specifically: Mill’s elbow test, Cozen test, Maudsley’s test, The coffee cup test, and the Chair test.
More in-depth methods might be needed to better diagnose tennis elbow, such as:
- X-rays to rule out pathologies like broken bones, arthritis, or calcifications;
- Imaging tests, such as Ultrasound, MRI, or CT scans, to assess the level of muscle and tendon damage;
- Electromyography to exclude nerve compression by measuring muscle and nerve electrical activity.
What are the tennis elbow treatments?
The most important treatment advice for healing and preventing the recurrence of tennis elbow is slow, steady, and most importantly consistent healing. Repetitive re-injury of inflamed tendons leads to the kind of scarring that can make tennis elbow very hard to eliminate.
Here you can find some examples of the types of exercises and non-invasive treatments that are often recommended:
- If the inflammation and tenderness are mild, a course of rest and NSAIDs (non-steroidal anti-inflammatories such as ibuprofen) may be adequate. Preventing tennis elbow before it takes hold is always the best plan of action.
- A tennis elbow brace compresses the muscles of the forearm, relieving the pressure on the injured tendon and allowing it to heal while reducing pain.
- Physical therapy for tennis elbow can also be a good option. Rehab exercises that increase forearm strength and provide support for the tendons at the epicondyle will help reduce strain and inflammation. The “Tyler Twist” exercises are a great example of this, as they exercise muscles that don’t typically get a lot of use, providing better support for the elbow and its tendons.
- Lateral epicondyle injection made of steroidal can help reduce inflammation, and thus pain, and allow efficient blood flow to resume, promoting the body’s natural healing processes. However, some studies show that while there may be short-term relief, there may be a negative effect beyond that. For that reason, some doctors avoid giving these altogether.
- Platelet-rich plasma or PRP injections are injections of plasma spun down from the patient’s blood. The platelets and the concentration of growth factors are thought to speed up the healing process.
- A new type of treatment gaining traction is shock wave therapy, which uses sonic waves at the site of pain and inflammation. While studies are still being done about the effectiveness of this treatment, and how exactly it helps with tennis elbow, there is some evidence that it can be good therapy, perhaps in concert with other more traditional treatments.
- Percutaneous tenotomy, which is minimally invasive, aims to promote the body’s healing response by removing any degenerative scar tissue from the tendon with a needle through the skin under ultrasound guidance. This may be an alternative to a larger surgical procedure and only uses local anesthesia.
Lateral epicondylectomy surgery
If for some reason there is no improvement with the treatments above after 6 months, surgery may be the only option.
Lateral epicondyle debridement (or lateral epicondyle release) means that you carefully dissect down, just below the epicondyle, until you can see the point where the ligaments attach to the bone and muscle. The most common type is open surgery where the surgeon makes a small incision over the elbow. Another approach is an arthroscopic surgery that uses miniature instruments and small incisions.
Broken-down tissue and scarring can be seen as slightly greyish tissue, compared to the pure white of the ligament. The diseased tissue is cut away to allow the ligament to heal more cleanly, thus reducing future irritation, swelling, and pain in the epicondyle.
The CPT code for lateral epicondyle release is 24359 (Repair, Revision, and/or Reconstruction Procedures on the Humerus (Upper Arm) and Elbow).
According to the American Academy of Orthopaedic Surgeons, the tennis elbow surgery success rate is between 80-90% with a common loss of strength. Considering how often tennis elbow surgery is done (1 in 10 patients), it is understood how it is seen as a last resort.
Final notes: how to prevent it
Tennis elbow is a quite common repetitive strain injury that affects 1-3% of the American population. It is important to beware and try to prevent tendon damage and possible tearing. For athletes, it is crucial to check the equipment for proper fit and warm up correctly. For the overall population, arms and wrist stretches help reduce the risk of lateral epicondylitis.