Tennis elbow is the common term for lateral epicondylitis, a degenerative condition of the tendon that connects the extensor muscles of the lower arm to a bony prominence on the outside of the elbow called the lateral epicondyle. The condition causes pain at the point where the tendon attaches to the epicondyle. The pain may radiate to the forearm and wrist, and in severe cases, grip strength may lessen. It can become difficult to perform simple actions like lifting a cup, turning a key, or shaking hands.
According to the American Academy of Orthopaedic Surgeons, as many as half of all people who play racket sports have the condition. One common cause is poor body mechanics while hitting backhand shots.
But most people who have tennis elbow didn’t acquire it by playing tennis, squash, or racquetball. It can result from any activity that involves twisting or gripping motions in which the forearm muscles are repeatedly contracted against resistance, such as pruning bushes or pulling weeds, using a screwdriver, or playing a violin. Tennis elbow (and a related disorder, golfer’s elbow, which affects the epicondyle on the inside of the elbow) is an occupational hazard for professional gardeners, dentists, and carpenters.
There are many treatments for tennis elbow but not much high-quality evidence about their effectiveness or how they stack up against one another. Some new studies are helping fill this gap.
What goes wrong in tennis elbow?
Chronic overuse stresses the extensor muscles, causing tiny tears in the tendons (see “Anatomy of tennis elbow”) that result in inflammation, tenderness, and pain. Overuse can also cause tissue degeneration in the tendon, a condition called tendinosis.
Tendons are made up of parallel strands of collagen lined up in side-by-side bundles. When strains and tears disrupt this arrangement, the body responds by deploying fibroblasts (cells that help make new fibrous tissue) and other substances to form scar tissue that helps shore up the area. Repetitive injury prevents the scar tissue from healing properly, so it remains weak and painful.
Treatments abound, but what works?
Studies haven’t come to any firm conclusions about the management of tennis elbow. Many treatments relieve the pain, but in most cases only temporarily, especially if you continue to perform the motions that caused the problem in the first place. Sometimes, the best approach is to simply give the elbow a rest.
A trial published in the British Medical Journal (Nov. 4, 2006) randomly assigned 128 patients with tennis elbow to receive six weeks of physical therapy (a total of eight 30-minute sessions), two corticosteroid injections, or a “wait and see” approach in which participants were told to modify their daily activities and use heat, cold, pain-relieving drugs, and braces as needed. During the one-year follow-up, researchers assessed various outcomes, including pain-free grip strength, pain severity, and overall improvement.
At six weeks, 78% of patients receiving corticosteroid injections had improved, compared with 65% in the physical therapy group and only 27% in the “wait and see” group. But the benefits of the injections faded quickly, with recurrences developing in 72% of recipients. Over the next few months, physical therapy performed significantly better than corticosteroid injections – and somewhat better than the “wait and see” approach. By year’s end, improvement was roughly equivalent in the physical therapy and “wait and see” groups, while the corticosteroid group was worse off – possibly because the rapid early reduction of pain led to increased activity and overuse. On average, tennis elbow in this study lasted 6 to 12 months, a finding that’s consistent with clinical observations.
In one of the most comprehensive reviews of tennis elbow treatments to date, Australian researchers examined 28 randomized clinical trials involving various nonsurgical interventions, including physical therapy, bandaging, steroid injections, ultrasound, and acupuncture. They found that the studies were either too brief or too poorly designed to shed any light on long-term outcomes – or even to support the short-term use of most treatments, although acupuncture showed some advantage over placebo at two to eight weeks. Extracorporeal shockwave therapy, a noninvasive treatment that uses sound waves to stimulate healing, was not useful. Results were published in the July 2005 issue of the British Journal of Sports Medicine.
The Cochrane Collaboration, an international group of researchers who conduct systematic reviews of scientific data, found that there was not enough evidence either to recommend or to discourage acupuncture, taping or braces (orthotics), or surgery.
What to do?
Here are some strategies that may help you prevent further injury to the tendon, relieve pain and inflammation, and preserve or restore function.
Initial treatment. Cut back on movements and activities that cause pain in the affected elbow, forearm, and wrist. For additional pain relief, apply ice to the epicondyle for 15 to 20 minutes every four to six hours for the first day or so. Oral over-the-counter pain relievers (ibuprofen, naproxen, aspirin, and acetaminophen) may also help, but because of the risk of side effects, patients shouldn’t take them for more than four weeks (be sure to follow the package directions). Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are also effective, but unfortunately, they’re not yet available in the United States. Topical capsaicin, the active ingredient in red chili peppers, produces a burning sensation where it’s applied, and is thought to reduce the transmission of pain signals. It’s been shown to reduce osteoarthritis pain, but there are no data on its use in treating tennis elbow. Some people find that it helps to wear an orthotic (a brace, band, splint, or strap) around the forearm.
Intermediate steps. If symptoms persist, patients may benefit from a corticosteroid injection. This often provides immediate relief, but they shouldn’t take that as a go-ahead to return to activities that aggravate tennis elbow. After the injection, they should follow a program that includes rest, ice, and acetaminophen, followed by physical therapy. Repeated injections can cause tissue atrophy, so clinicians usually recommend no more than two to four, even in cases of chronic pain. Botulinum toxin (Botox) injections have shown promise as an alternative to corticosteroids, but larger studies are needed to assess their long-term safety and effectiveness.
Other measures. Surgery is an option in rare cases when the symptoms have lasted more than a year despite rest and other efforts to relieve pain and restore function. It’s usually done on an outpatient basis and involves trimming the damaged tendon or removing it and reattaching normal tendon tissue to the lateral epicondyle.
An experimental treatment under development at Stanford University uses injected blood cells to restore tendon tissue. Researchers injected the injured tendons of 15 chronic tennis-elbow sufferers with a single dose of concentrated blood platelets from the patients’ own (autologous) blood. (Earlier studies have shown that platelet-rich plasma helps improve healing in various tissues.) After two months, symptoms improved by 60% in the treated group, compared with 16% in a control group that received a local anesthetic instead. After two years, 93% of the autologous platelet recipients reported “complete satisfaction” with the results. Most had returned to their usual work or sports. Results were published in the November 2006 issue of the American Journal of Sports Medicine. This is just one preliminary study, but it suggests that autologous treatment should be further investigated as a possible alternative to surgery.
Tennis elbow occurs when repetitive stress causes small tears in the tendon that connects the extensor muscles — which run between the wrist and elbow — to the lateral epicondyle.
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