What is Tennis Elbow?
Tennis elbow, also known as lateral epicondylitis, is a condition in which the outer part of the elbow becomes painful and tender. The pain may also extend into the back of the forearm and grip strength may be weak. The onset of symptoms is generally gradual. Golfer’s elbow is a similar condition that affects the inside of the elbow.
It is due to excessive use of the muscles of the back of the forearm. Typically this occurs as a result of work or sports, classically racquet sports. The diagnosis is typically based on the symptoms with medical imaging used to rule out other potential causes. It is more likely that pain increases when a subject tries to bend back the wrist when the wrist is held in a neutral position. It is classified as chronic tendinosis, not tendinitis.
Treatment involves decreasing activities that bring on the symptoms together with physical therapy. Pain medications such as NSAIDs or acetaminophen may be used. A brace over the upper forearm may also be helpful. If the condition does not improve corticosteroid injections or surgery may be recommended. Many people get better within one month to two years.
Despite its name, “tennis elbow”, does not solely occur in tennis players. Tennis elbow is actually the most common condition seen in patients experiencing elbow pain and is thought to be due to small tears of the tendons that attach forearm muscles to the arm bone at the elbow joint.
The diagnosis of tennis elbow is made through a medical history and physical examination. Additional tests may be ordered to rule out other health conditions that cause lateral elbow pain.
Treatment of tennis elbow is conservative and usually involves rest, wearing a forearm brace, and taking an anti-inflammatory medication.
Tennis elbow occurs when there is a problem with the tendon (called the extensor carpi radialis brevis muscle tendon) that attaches to the outside part of the elbow bone called the lateral epicondyle, thus giving tennis elbow the medical name ‘lateral epicondylitis. This tendon is the attachment site of the muscle that functions to cock the wrist back (called wrist extension).
It’s important to note that tennis elbow is not simply a tendon “inflammation.” Rather, as a result of repetitive use, experts believe that incompletely healed microscopic tears develop within the tendon. This leads to a degenerative (“wear and tear”) process and subsequent pain and tenderness felt at the outside of the elbow.
While tennis elbow may occur on its own, there are two groups of people that are especially vulnerable to developing this condition:
- Sports Participants: Athletes, especially racquet sport players, are prone to developing tennis elbow. About a third of amateur tennis players experience tennis elbow at some point in their careers. In addition to racquet sports, tennis elbow is seen in golfers, fencers, and other sports participants.
- Manual Laborers: People who work with their hands are at greater risk of developing tennis elbow. Jobs that may lead to tennis elbow include plumbers, painters, gardeners, and carpenters.
Besides activities that require repetitive gripping and grasping, trauma (in the form of a direct hit to the elbow which leads to tendon swelling) can also cause tennis elbow; although, this is a less common culprit.
Tennis elbow usually develops over time. Repetitive motions — like gripping a racket during a swing — can strain the muscles and put too much stress on the tendons. That constant tugging can eventually cause microscopic tears in the tissue.
Tennis elbow may also result from:
- Weight lifting
It can also affect people with jobs or hobbies that require repetitive arm movements or gripping such as:
Medical History and Physical Examination
In addition to inquiring about the characteristics of your elbow pain (e.g., location and severity), your doctor will ask you about any potential risk factors, like whether you have participated in a certain job or sports-related activities or experienced a recent elbow injury or trauma.
Your doctor will also ask you about your medical history, like whether you have a history of rheumatoid arthritis or elbow nerve entrapment.
During the physical exam, your doctor will press on your elbow at various sites to evaluate for tenderness. With tennis elbow, there is usually tenderness about one centimeter from the lateral epicondyle itself.
Your doctor will also move (flex and extend) your wrist while your arm and elbow are held out to see if this increases or reproduces your pain.
The most common symptoms of tennis elbow are:
- An aching or burning pain over the outside of the elbow that is worsened by gripping or lifting
- Pain starts at the elbow but then may spread to the forearm
- Weak grip strength
The pain associated with tennis elbow usually has a gradual onset, but it may also come on suddenly. Pain can be highly variable too, ranging from very mild to severe and debilitating.
The symptoms of tennis elbow include pain and tenderness in the bony knob on the outside of your elbow. This knob is where the injured tendons connect to the bone. The pain may also radiate into the upper or lower arm. Although the damage is in the elbow, you’re likely to hurt when doing things with your hands.
Tennis elbow may cause the most pain when you:
- Lift something
- Make a fist or grip an object, such as a tennis racket
- Open a door or shake hands
- Raise your hand or straighten your wrist
Tennis elbow is similar to another condition called golfer’s elbow, which affects the tendons on the inside of the elbow.
To diagnose your tennis elbow, your doctor will do a thorough exam. He or she will want you to flex your arm, wrist, and elbow to see where it hurts. You may also need imaging tests, such as an X-ray or MRI (magnetic resonance imaging) to diagnose tennis elbow or rule out other problems.
During the physical exam, your doctor may apply pressure to the affected area or ask you to move your elbow, wrist, and fingers in various ways.
In many cases, your medical history and the physical exam provide enough information for your doctor to make a diagnosis of tennis elbow. But if your doctor suspects that something else may be causing your symptoms, he or she may suggest X-rays or other types of imaging tests.
Factors that may increase your risk of tennis elbow include:
- Age. While tennis elbow affects people of all ages, it’s most common in adults between the ages of 30 and 50.
- Occupation. People who have jobs that involve repetitive motions of the wrist and arm are more likely to develop tennis elbow. Examples include plumbers, painters, carpenters, butchers, and cooks.
- Certain sports. Participating in racket sports increases your risk of tennis elbow, especially if you employ poor stroke technique.
Tennis elbow often gets better on its own. But if over-the-counter pain medications and other self-care measures aren’t helping, your doctor may suggest physical therapy. Severe cases of tennis elbow may require surgery.
If your symptoms are related to tennis, your doctor may suggest that experts evaluate your tennis technique or the movements involved with your job tasks to determine the best steps to reduce stress on your injured tissue.
A physical therapist can teach you exercises to gradually stretch and strengthen your muscles, especially the muscles of your forearm. Eccentric exercises, which involve lowering your wrist very slowly after raising it, are particularly helpful. A forearm strap or brace may reduce stress on the injured tissue.
Surgical or other procedures
- Injections. Your doctor might suggest injecting platelet-rich plasma, Botox, or some form of an irritant (prolotherapy) into the painful tendon. Dry needling — in which a needle pierces the damaged tendon in many places — can also be helpful.
- Ultrasonic tenotomy (TENEX procedure). In this procedure, under ultrasound guidance, a doctor inserts a special needle through your skin and into the damaged portion of the tendon. Ultrasonic energy vibrates the needle so swiftly that the damaged tissue liquefies and can be suctioned out.
- Surgery. If your symptoms haven’t improved after six to 12 months of extensive non-operative treatment, you may be a candidate for surgery to remove damaged tissue. These types of procedures can be performed through a large incision or through several small incisions. Rehabilitation exercises are crucial to recovery.
For most people, one or more of the following treatments are effective for treating tennis elbow:
- Rest and Activity Modification: Stopping or significantly limiting activities that trigger and/or aggravate the condition (oftentimes for several weeks) is a key first step to healing.
- Medication: Under the guidance of your doctor, taking a nonsteroidal anti-inflammatory drug (NSAID), can ease inflammation and pain.
- Brace: Wearing a tennis elbow brace (a band worn over the back of your forearm muscle just below your elbow) can ease the stress on the tendon and muscle.
- Physical Therapy: Performing exercises that stretch and strengthen your forearm muscles, as well as various techniques like ice massage, heat, or ultrasound, can help improve muscle function and speed up healing.
- Steroid Injection: In certain cases, your doctor may opt to inject cortisone (a strong anti-inflammatory medication) into the area near your lateral epicondyle.
Lifestyle and home remedies
Your doctor may recommend the following self-care measures:
- Rest. Avoid activities that aggravate your elbow pain.
- Pain relievers. Try over-the-counter pain relievers, such as ibuprofen (Advil, Motrin IB) or naproxen (Aleve).
- Ice. Apply ice or a cold pack for 15 minutes three to four times a day.
- Technique. Make sure that you are using the proper technique for your activities and avoiding repetitive wrist motions.
Icing the elbow is one of the simplest and easiest ways to reduce pain and swelling. Ice may also help to prevent the progression of the condition. Instead of ice, you can also use a frozen pea bag.
- Wrap some ice cubes in a thin towel.
- Rest your elbow on a pillow or other cushioned area.
- Place the towel gently on the affected area.
- Leave it on for 10 to 15 minutes.
- Repeat several times a day until the pain is gone.
Note: Never put ice directly on the skin.
Contrast hydrotherapy, which means alternating hot and cold compresses on the affected area, is another good remedy for tennis elbow. While the heat will increase blood circulation and reduce pain, the cold will reduce inflammation as well as swelling.
- Wrap a hot water bottle in a thin towel and wrap some ice cubes in another towel.
- Place the hot compress on the affected area for about three minutes.
- Remove the compress and immediately put a cold compress on the affected area for about one minute.
- Continue alternating compresses as noted for 15 to 20 minutes.
- Follow this remedy a few times daily until you get relief.
Turmeric contains curcumin, which works as an anti-inflammatory agent as well as a natural painkiller. Furthermore, turmeric is rich in antioxidants that eliminate free radicals and speed up healing time.
- Mix one teaspoon of turmeric powder in one cup of milk. Heat it over low heat. Add a little honey and then drink this twice a day, at least for a few weeks.
- Another option is to take 250 to 500-milligram turmeric capsules three times daily but consult with your doctor first.
Ginger has strong anti-inflammatory properties that help a lot in alleviating the symptoms of tennis elbow.
- Cut a small piece of ginger root and boil it in two cups of water for 10 minutes. Strain and add a little honey. Drink it slowly, three times daily until the pain is gone.
- Applying a ginger poultice to the affected area will also help. Take four tablespoons of freshly grated ginger and wrap it tightly in a cotton bag. Put the bag in hot water for less than one minute and allow it to cool. Put it on the affected area for 15 minutes. Repeat the process several times daily until there is an improvement.
Massaging the affected area with calendula oil or avocado oil is another effective home remedy for tennis elbow. Both calendula oil and avocado oil can give relief from inflammation and pain. Plus, massaging improves blood circulation and soothes sore muscles.
- Apply oil to the affected area. Do friction massage by rubbing your thumb back and forth over the sore tendon.
- Another option is to go for a trigger-point massage using firm, long strokes.
You must massage two or three times daily until the pain is gone.
St. John’s Wort
Due to its anti-inflammatory properties, St. John’s wort can also help heal a tennis elbow. Additionally, it works as an analgesic for pain relief.
- Mix two teaspoons of dried St. John’s wort in a cup of hot water. Cover and steep it for 10 minutes. Strain and add a little honey. Drink two cups of this herbal tea daily until you get the desired result.
- Alternatively, you can apply St. John’s wort oil on the affected area several times a day for a few days.
Note: Do not use this herb if you are taking any prescription medication.
Fenugreek has anti-inflammatory properties that can help reduce swelling and inflammation. This in turn will speed up the recovery time.
- Grind one to two tablespoons of fenugreek seeds along with enough milk to make a paste. Apply this paste to the affected part and leave it on for one or two hours. Rinse it off with warm water.
- You can also eat one teaspoon of finely ground fenugreek seeds along with a glass of lukewarm water daily in the morning.
Follow both these remedies once daily until the pain is gone.
Being rich in sulfur and selenium, garlic is also very helpful in the treatment of tennis elbow. Garlic can relieve pain as well as inflammation.
- Heat four crushed garlic cloves in two tablespoons of mustard oil until they turn dark brown. Strain and allow the oil to cool until it is comfortably warm. Apply the oil to the affected area. Massage gently for a few minutes and then leave it on for a few hours. Follow this remedy twice daily for several days.
- Also, eat two or three raw garlic cloves daily. If you are deterred by the smell or taste of garlic, consider taking garlic supplements but only after consulting your doctor.
White Willow Bark
Another effective herbal remedy for tennis elbow is white willow bark. Due to the presence of a compound known as salicin, white willow bark works as a natural painkiller.
- Add one teaspoon of dried white willow bark to a cup of boiling water.
- Cover and steep for 15 minutes.
- Strain and drink this tea while it is still warm.
- Do this daily until you feel better.
There are certain chemicals in comfrey leaves that aid the body’s natural healing abilities. Also, these leaves work as a mild painkiller.
- Soak comfrey leaves in hot water until they become soft.
- While they are still warm, press the soft leaves on the affected joint.
- Wrap a cloth around it to hold the leaves in place.
- Leave it on overnight.
- Follow this remedy daily until the swelling and inflammation are gone.
After that, you can rub comfrey oil gently on the affected area twice daily for several weeks.
It is often difficult to prevent getting tennis elbow. However, there are certain tips that will help you avoid the condition or prevent the symptoms from getting worse.
- Rest the affected arm as much as possible for the first two weeks.
- Rest your arm on a few pillows to keep it elevated above your heart.
- An elbow wrap or brace can be used to promote healing while alleviating pain.
- Try some simple stretching exercises for rehabilitation.
- Perform a range of motion exercises to reduce stiffness and increase flexibility.
- Try adding more omega-3 fatty acids to your diet.
- Before playing a sport, warm up properly and gently stretch your arm muscles to prevent injury.
In most cases, these home treatments will help reduce pain, swelling, and inflammation. But if you have a severe case of tennis elbow that doesn’t respond to these home treatments, consult your doctor. Some cases may even require surgical treatment.
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