Tennis Elbow – Mr Hasan A Ahmed – Consultant Shoulder Surgeon

Elbow Conditions

TENNIS ELBOW (lateral epicondylitis)

What is tennis elbow?

This is a common condition which affects 1 to 3% of the population. It used to be called “writer’s cramp”. It is more common in people who participate in sports and those with occupations requiring repetitive movements of the hand and wrist. It is seen most commonly between the ages of 35 and 55 years.

Why does it occur?

No one knows, but it is thought to be due to inflammation or degeneration of the extensor muscles of the hand and wrist which attach to the outer side of the elbow (see Fig.1).

These are the muscles used while playing a backhand stroke in tennis, hence the term tennis elbow.

What are the symptoms?

There is a gradual onset of pain over the outer side of the elbow (see Fig.2).

The pain can radiate from the elbow into the forearm muscles. Activities such lifting a chair or even holding a cup of coffee can result in elbow pain.

How is it diagnosed?

The diagnosis is usually made from the history and the clinical examination. Occasionally x-rays or a scan may be ordered to exclude other conditions.

How is it is treated?

Tennis elbow is always treated non-operatively to start with. Your doctor may advise rest and modification of activities, anti-inflammatory tablets, and a special elbow support. Physiotherapy is also useful in many patients. Physiotherapy may include acupuncture, pulsed ultrasound, deep friction massage and a home exercise program

A forearm strap (counterforce brace) can be worn just below the elbow to limit the stress on the muscles (see Fig.3).

If none of the above measures work then a steroid injection given in the region of maximum tenderness can resolve the symptoms. It may be a few days before the symptoms improve. The steroid does not produce any harmful effects in the rest of the body.

Recently the use of PRP (Platelet Rich Plasma) injections has become more popular. This involves taking a blood sample and spinning it at high speeds in a centrifuge for a few minutes. This separates the blood into a number of layers. The layer containing growth factors and special cells called platelets that promote healing is then injected into the painful area. Some studies have shown good results in the treatment of tennis elbow comparable or superior to the results obtained with steroid injections.

Will an operation be required?

If symptoms persist despite trying all the above measures then an operation is advised. The operation is usually performed using a small incision under a general anaesthetic. A keyhole technique has also been recently described but is not yet in common use in the UK. On average 85% of patients will get complete relief of their symptoms, 10% get some relief but 5% see no benefit.

How long does it take to recover from the operation?

The operation is done as a day case, so you will be able to go home the same day. You will be given painkillers to use once the local anaesthetic wears off. You will wear a sling for the first few days in order to keep your hand elevated, thus avoiding swelling and stiffness. The physiotherapist will show you finger and wrist exercises to do. You will have a bulky wool and crepe dressing on the elbow which you can remove 2 to 3 days after the operation. The smaller underlying adhesive dressings should be left alone. You will need to keep your dressing/wound dry. You will be seen for a follow up about 10 to 14 days after the operation for wound inspection and suture removal (however sometimes absorbable sutures are used). At this stage you can start bathing as long as your wound is completely healed with no wet/oozy areas. The physiotherapist will then see you. Physiotherapy is a vital part of the post-operative recovery.

Complications

Complications from this procedure are rare. Watch for any signs of infection; if you experience any of the following you should seek help:

Increasing pain in the wound after the obvious initial discomfort.
Increasing redness and/or swelling.
Unpleasant discharge.

Swelling is normal and will generally settle down on its own with elevation and appropriate physiotherapy.

Returning to Work/ Driving

Your comfort level should be your guide for returning to work. Most people are able to return to work within one to two weeks, but it does depend on the kind of work you do. If you have a heavy manual job then you may need to be off work for three weeks or more. Patients are normally advised not to drive for one week; driving is only allowed once you feel that you can control the car and you can turn the steering wheel in an emergency.

Sports Activities

You will need to avoid playing sports for a certain time after the operation. This time can be anything up to 12 weeks after your operation, depending upon your sport.

It may take up to 3 to 6 months for the elbow to return back to normal following the operation.

Are there any other methods of treating tennis elbow?

Ultrasonic shockwave therapy has been tried. However this method is still experimental and its benefit is yet to be proved.

Can Tennis elbow be prevented?

To prevent tennis elbow from reoccurring, it is important to make sure you perform various exercises to strengthen and stretch the extensor muscles (see Fig.4).

You must use the proper form while playing sports such as tennis and when doing any heavy lifting in the gym etc. Warming up before starting to use the muscle will also help prevent the condition. After exercising, you may want to ice and stretch the elbow and arm muscles. This will be explained in detail by the physiotherapist.