What is Lateral Epicondylitis (Tennis Elbow)?
In regards to elbow pain, the number one reason people see their physician is for lateral epicondylitis, also known as tennis elbow. Why is this injury so common?
First off, you don’t have to play tennis to have this injury. The injury occurs from repetitive or sustained gripping, especially with the thumb, index, and middle fingers. Also, a poor mechanical technique with keyboard typing can be a culprit too. To understand how this occurs, a basic understanding of the elbow anatomy is needed.
Your elbow is a hinge joint, meaning its main function is to bend and extend; however, because of the design of the joint, your elbow also assists with forearm rotation, which is called supination (palm up) and pronation (palm down).
The elbow is made up of three bones that form the joint. The humerus, ulna, and radius bones which allow us to bend, extend, and rotate the forearm. The upper arm is called the humerus. At the bottom of that bone, is the top part of the elbow joint. It is the largest bone of the three and can is easily felt on the inside of the arm at the elbow.
The humerus has two bony projections called epicondyle. In anatomical position, the arm is straight on the side, and the palm is facing forward. In this position, the medial epicondyle is the bony prominence nearest your body. The lateral epicondyle is towards the outside of the elbow.
The ulna is the second largest elbow bone that extends down to the wrist. You can feel the ulna in two spots; the first is the olecranon which is the pointy part of your elbow. The second is on your wrist; it is the bone that is rounded and sticks out on the medial side of your hand (pinky finger side).
The third bone is the radius. It is the smallest of the joint bones, and it too extends down to the wrist. The radius bone starts on the outside of the elbow and extends down towards your thumb. Each of the three bones fit together to form three joints within the elbow-humeroulnar, humeroradial, and radioulnar joints. Each of these joints is cushioned by cartilage to protect the bones and joint space.
Muscles, tendons, and ligaments aide with moving the elbow as well as to stabilize the joint. Muscles are rich in blood supply and pliable, meaning they can be stretched, at least to a point. Tendons help muscles attach to the bones. They have less blood supply and therefore commonly take longer to heal when injured. Together the muscles and tendons function as movers of the joint.
Ligaments, on the other hand, attach bone to bone and their primary job is to stabilize the joint. The ligaments prevent unwanted movement within the joint by way of keeping the bones that make up the joint aligned. Ligaments are not meant to be stretched, so when they do get stretched, they are injured. They have a little blood supply so healing can be slow.
Lateral epicondylitis occurs when the extensor muscles and tendons are affected. The main muscle and tendon involved in tennis elbow are called the Extensor Carpi Radialis Brevis (ECRB). It functions to allow for wrist extension and abduction (moving the wrist towards the thumb side).
With repetitive, or sustained, gripping, the EBRC tendon over time becomes irritated, inflamed, and can breakdown. Once injured, this causes tenderness and pain at the lateral side of the elbow. It also affects the ability to grip or hold items firmly.
What causes tennis elbow?
There are some incidences where the cause of lateral elbow pain is unknown; the medical term used these cases is called insidious; however, often the cause of tennis elbow is related to repetitive overuse.
Repetitive activities may cause the EBRC to be irritated, inflamed, or even cause it to breakdown over time. Some of those activities are:
- Carpentry work (e.g. hammering)
- Dental hygiene work (e.g. holding firmly tools)
- Hairdresser (e.g. blow drying)
- Keyboard typing
- Playing musical instruments
- Weaving, crocheting, or knitting
On occasion, tennis elbow can occur from a traumatic event like a fall, lifting a heavy object, forceful pulling like a lawn mower cord, or possibly work related.
Tennis elbow affects daily activities. Simple things like shaking someone’s hand, opening a door, or lifting a milk carton can be painful and disrupt your life, which can be frustrating because even with rest, tendons recovery slowly.
Symptoms of Lateral Epicondylitis (Tennis Elbow)
Symptoms occur at the lateral part of the elbow and may radiate down to the wrist and thumb area. The most common symptoms of tennis elbow are:
- Burning, outer part of elbow
- Elbow joint stiffness
- Painful grip
- Tenderness, outer part of elbow
- Weak grip
- Weak forearm, wrist, or hand
How is tennis elbow diagnosed?
Tennis elbow is commonly diagnosed by your physician or physical therapist (PT) through a medical history review, symptoms review, and a physical exam of the affected elbow, wrist, and hand.
On rare occasions, imaging is ordered by your physician. Often, imaging such as an X-Ray or MRI (magnetic resonance imaging) are order to rule out other medical conditions. X-Rays will provide an image of bones which would be necessary if there is suspect of fracture. MRIs will provide an image of bones and soft tissue. An MRI can check for tears, worn out cartilage, or soft tissue damage.
Treatment of Lateral Epicondylitis (Tennis Elbow)
Early diagnosis and treatment is key to successful conservative treatment. If you are experiencing lateral elbow pain, start with rest, ice, and gentle compression. Rest the affected elbow from activities causing symptoms to increase. Apply ice with gentle compression to help with pain and inflammation.
In most cases, symptoms advance because we are unable to rest the affected elbow, which is where a PT or occupational therapist (OT) can help manage your symptoms if they do not go away with self-management. The goal of therapy is to reduce symptoms, swelling, and return to functional activities.
Occasionally, your therapist may provide you with an elbow counterforce brace which provides gentle pressure directly on the EBRC. This gentle pressure allows the EBRC to rest. Some people respond well to this brace as it helps minimize, or alleviate, symptoms during functional activities.
When symptoms are so severe or tolerance to therapy is poor, medications or an injection may be needed in combination with PT or OT treatment. Medications and injections do not cure mechanical problems that caused the injury; therefore, continuing with therapy in conjunction with these treatments is necessary.
During PT or OT treatment, your therapist will manage your symptoms and begin gentle range of motion and strengthening exercises. Sometimes friction massage is used with tendinitis, such as tennis elbow. The therapist is reintroducing “trauma” to the area to allow for your body’s natural healing processes to kick-in. The therapist is not further damaging the tissue, he or she is simply trying to get your body to work with you, instead of against you, during the healing process.
As symptoms improve and gains in strength are made, your therapist will work with you on proper ergonomics of gripping during functional activities. The goal is to return you to normal activities without re-aggravating the elbow.
In rare cases, surgery may be needed. When conservative treatment, injections, or medications do not work, and you have experienced severe, or debilitating, pain for more than 6-12 months, then surgery may be indicated.
The lateral epicondyle release surgery is not a quick fix. Recovery is typically 4-6 months’ post-surgery. The surgeon makes a small incision in the area and removes the degenerative, or damaged, tendon tissue. The surgeon then reattached the repaired tendon.
PT or OT will be prescribed after surgery. Your therapist will help you manage swelling, pain, and over time he or she will help you regain movement and strength. As you progress through rehabilitation, your PT or OT will education you on proper positioning, or mechanics, of the wrist during functional activity. The goal is to prevent reinjury.
Early intervention to elbow pain is important. The sooner you address your symptoms, the more likely conservative care will work for you. As a consumer of health care, you have a choice in finding the right provider for you. Do your homework and search for a health care provider, like a physical or occupational therapist, with excellent outcomes, great customer reviews, and can provide you the care you need for a reasonable cost.
In most states, you can be seen by a PT first, without a physician’s order. To determine if your state has direct access, please visit the American Physical Therapy Association’s website Physical Therapy Direct Access By State.
Occupational therapists are commonly seen after a visit with your physician. Each state varies on direct access laws. Your physician will prescribe OT services if indicated.
To get started with conservative care today, you can find a highly qualified PT or OT in your area. There are many qualified PTs and OTs, so to find one near you, please click on Find A Clinic. This link will help you find a PT or OT that has top national rankings for treating the elbow.