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Tennis Elbow - A Guide

Tennis elbow is a painful condition that often occurs as a result of strenuous overuse of the muscles and tendons of the forearm and around the elbow joint. As its name suggests, tennis elbow can sometimes be caused by playing tennis, but it can also occur as a result of a number of other physical activities

Introduction
Symptoms of tennis elbow
Causes of tennis elbow
Diagnosing tennis elbow
Treating tennis elbow
Preventing tennis elbow

See also: Elbow Supports


Introduction

The main symptom of tennis elbow is pain and inflammation on the outside of the elbow. The medical name for tennis elbow is lateral epicondylitis. This is because the pain usually occurs on the bony lump on the outside of the elbow, known as the lateral epicondyle.

Symptoms can also sometimes occur on the inner side of the elbow. This is often referred to as golfer's elbow.

How does the elbow joint work?

The elbow joint is surrounded by muscles that move your elbow, wrist and fingers. The tendons in your elbow join the bones and muscles together, and control the muscles of your forearm that are located around the lateral epicondyle.

Tennis elbow occurs when one or more of the tendons in your elbow becomes inflamed. The pain occurs at the point where the tendons of your forearm muscle attach to the bone. If this area becomes inflamed, certain movements that use the forearm can be painful. For example, twisting movements, such as turning a door handle, may be particularly painful.

Who is affected by tennis elbow?

Tennis elbow usually occurs in adults. Each year, in the UK, approximately five in 1,000 adults are affected by tennis elbow. The condition occurs mostly in those who are between 30 and 50 years of age.

Outlook

In most cases of tennis elbow the symptoms will clear up regardless of whether the patient receives treatment or not.

Anti-inflammatory painkillers can often help to reduce mild pain and inflammation that is caused by tennis elbow. However, if your pain is severe or prolonged a cortisone (steroid) injection may be recommended. (See the treatment section for more information).

Occasionally, surgery may be used to treat very severe and persistent cases of tennis elbow.

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Symptoms of tennis elbow

The main symptom of tennis elbow is pain and tenderness on the outside of the elbow. You may also experience pain and in your forearm as well. The pain is often worse when you use your arm and elbow, particularly for twisting movements.

The symptoms of tennis elbow can vary in severity, but you will usually experience those that are listed below.

  • Recurring pain on the outside of your upper forearm, just below the bend of the elbow. Sometimes, pain may also be felt down your arm towards the wrist.
  • Pain that is caused by lifting, or bending, your arm.
    Pain when writing, or when gripping small objects, such as a pen.
  • Pain when twisting your forearm - for example, when turning a door handle.
  • Difficulty extending your forearm fully.

The pain that is caused by tennis elbow usually lasts for between 6-12 weeks. However, some people have pain for as little as three weeks, while others may experience discomfort in their elbow joint for several years.

The pain can range from mild discomfort when using your elbow, to severe pain that can be felt even when your elbow is still, or when you are sleeping. You may have stiffness in your arm, which gets progressively worse as the damage to your tendon increases.

As your body tries to compensate for the weakness in your elbow, you may also experience pain, or stiffness, in other parts of the affected arm, the shoulder, or neck.

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Causes of tennis elbow

Tennis elbow occurs as a result of small tears in the tendon which then become inflamed. Excessive, or repeated, use of the muscles that straighten your wrist can injure the tendons in your arm and elbow. If these injuries are not allowed to heal fully, they can tear again, leading to the formation of rough tissue.

A protein called collagen leaks out from around the injured areas, causing inflammation. The inflamed tendon can cut off blood flow and pinch the radial nerve, which is one of the major nerves that control the muscles in your arm and hand. This causes pain when you use your arm.

Tennis elbow commonly occurs after doing an activity where the forearm muscles are heavily used, without having used them much before. However, even if you use your forearm muscles frequently, it is still possible for you to develop the condition.

Activities that can cause tennis elbow

The tendons in your elbow can be injured by overuse of the forearm muscles in repeated actions such as:

  • using scissors, or shears,
  • gardening,
  • sports that involve lots of throwing,
  • swimming,
  • manual work that involves repetitive turning, or lifting of the wrist, such as plumbing, or bricklaying,
  • typing, and
  • racquet sports.

Your risk of getting tennis elbow is increased if you play racquet sports, such as tennis, or squash, regularly, or if you play after not playing for a long time. The condition can also occur if you use a lot of backhand, or if your backhand technique is not very good.

Tennis elbow can also occur if you play golf frequently, and golfers can also sometimes get golfer's elbow which affects the inside of the arm.

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Diagnosing tennis elbow

To diagnose tennis elbow, your GP will examine your affected arm and discuss your symptoms with you. They will check for pain in the area around your elbow by pressing on it, and will bend your hand upwards to see if this causes pain.

X-ray

Tennis elbow itself cannot be seen on an X-ray. However, in some cases, your GP may recommend that an X-ray is taken in order to rule out other conditions, such as arthritis, or an injury inside your elbow joint.

MRI or ultrasound scan

Your GP will also want to make sure that the pain is not being caused by pressure on a nerve. If you have severe tennis elbow that has failed to heal, you might need to have a magnetic resonance imaging (MRI) scan, or an ultrasound scan. This will produce a more detailed image than an X-ray, as it includes the soft tissues, muscles, and tendons inside your arm.

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Treating tennis elbow

The pain that is caused by tennis elbow can persist for some time. As tendons are slow to heal, the symptoms can last for a number of weeks, or months, or, in some cases, they can persist for up to a year. However, tennis elbow is a ‘self-limiting’ condition, which means that it will eventually clear up by itself.

Painkillers

If you have tennis elbow, you should rest the affected arm as much as possible and avoid any activities that put more stress on the tendons.

If you have mild pain, taking over-the-counter (OTC) painkillers, such as paracetamol may help to reduce it. Ibuprofen may also be particularly effective at treating the symptoms of tennis elbow because it is an anti-inflammatory painkiller, which means that it will help to reduce inflammation as well as treating pain. Children under 16 years of age should not take aspirin.

As well as tablets, anti-inflammatory painkillers are also available in the form of creams and gels which you can rub into the affected area. Research has suggested that anti-inflammatory creams and gels may be more effective at providing pain relief from tennis elbow compared with tablets.

Some anti-inflammatories are available over-the-counter (OTC) at pharmacists, while others are only available on prescription. Ask your GP, or pharmacist, for advice about which product is most suitable for you to use. 

Cortisone steroid injections

If your tennis elbow symptoms are particularly painful, and the condition is making movement difficult, a steroid injection may be recommended. Cortisone is the steroid that is usually used because it helps to reduce inflammation.

If you have a cortisone injection, cortisone will be injected into the tender spot in your elbow using a fine needle. It will usually be combined with an anaesthetic so that it is not painful. Most people who have a cortisone injection find that their pain improves significantly, or disappears completely, within four weeks of the treatment.

However, for some people who have a cortisone injection, pain relief is only temporary and it returns after a few weeks. In such cases, two, or three, steroid injections may be needed over the course of a number of weeks. The risk of developing side effects after having a cortisone injection is small, but you may experience some increased discomfort at the site of the injection for up to 48 hours.

Before deciding whether or not to have a steroid injection you should carefully consider the possible implications. For example, a large-scale study which compared patients who had a steroid injection with those who did not, found that although 90% were pain free in the short term, only 70% were pain free one year following treatment.

After having a steroid injection (or injections), you should take care to rest your arm and avoid putting too much strain on it too quickly. As with any injury, you should gradually build up to your normal level of activity in order to prevent the problem reoccurring. 

Physiotherapy 

If your tennis elbow symptoms are particularly severe, or persistent, your GP may refer you to a physiotherapist. A physiotherapist will be able to show you exercises to help stretch and strengthen your forearm muscles. They may also recommend wearing a bandage, or wrist splint, in order to help support your elbow and to encourage the tendons to heal. 

Surgery 

In rare cases of severe, persistent tennis elbow, surgery may be recommended. The operation involves removing the damaged part of the tendon in order to relieve the symptoms of pain.

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Preventing tennis elbow

It is often difficult to avoid the sudden onset of tennis elbow. However, not putting too much stress on the tendons of your elbow will help you to avoid developing the condition, as well as preventing your symptoms from getting worse if you already have the condition.

Self care advice

Below are a number of measures that you can take which may help to prevent tennis elbow from developing, or prevent it from reoccurring.

  • If you have tennis elbow, stop doing the activity that is causing you pain, or find an alternative way of doing it that does not place stress on your tendons.
  • Rather than using your wrist and elbow more than the rest of your arm, try spreading the load to the larger muscles of your shoulder and upper arm.
  • If you play a sport that uses repetitive movements, such as tennis, it may be a good idea to get some professional advice about your technique, so that you do not strain your elbow.
  • Before playing a sport that involves repetitive arm movements, such as tennis, or squash, warming up beforehand and gently stretching your arm muscles will help you to avoid injury.
  • Using lightweight tools, or racquets, and enlarging their grip size, will help prevent putting excess strain on your tendons.
  • Wearing an arm brace, or a wrist splint, when you are using your arm, and taking it off while you are resting, or sleeping, can help prevent further damage to your tendons. Ask your GP, or physiotherapist, for advice about the best type of brace, or splint, for you to use.
  • Increasing the strength of your forearm muscles can help to prevent tennis elbow from occurring. A physiotherapist will be able to advise you about suitable exercises that will help build up the muscles of your forearm.

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