Tennis Elbow

Tennis Elbow

Article by John Miller

What is Tennis Elbow?

Acute Tennis Elbow is an injury to the muscles that extend the wrist and fingers. The injury site is typically the lateral epicondyle, a bony bump on the outside of the elbow where these muscles attach. Tennis Elbow symptoms lasting more than six weeks become sub-acute and beyond three months, as chronic tennis elbow.

Tennis Elbow Symptoms?

Typically the Tennis Elbow sufferer will experience pain when performing gripping tasks or resisted wrist/finger extension. There will be tenderness directly over the bony epicondyle, and there may be trigger points in the wrist muscles. Pain can also be present when the muscles overstretch.

Some sufferers will also have neck stiffness and tenderness, as well as signs of nerve irritation. Most elbow movements will be pain-free, despite that being the area of pain.

What Causes Acute Tennis Elbow?

Acute Tennis Elbow is caused by damaged muscle tissue when it anchors to the arm bone at the elbow. It occurs when more force is applied to an area than normal healthy tissues can handle.

Common Tennis Elbow Causes include:

  • Unaccustomed hand use, e.g. painting a fence, hammering, lots of typing.
  • Excessive gripping or wringing activities
  • Weak forearm muscle strength or tight muscles
  • A poor technique (this may be a poor tennis shot)

In some cases, such as Chronic Tennis Elbow, this can occur due to the soft tissues being in poor health, which are easily injured. Inflammation follows the injury, which leads to swelling and elbow pain.

What Causes Chronic Tennis Elbow?

Chronic Tennis Elbow is associated with degenerative changes in the muscle tissues located at the epicondyle. Historically, chronic tennis elbow was related to inflammation from overuse. However, this is now known to be incorrect.

Chronic Tennis Elbow is NOT due to INFLAMMATION!

Testing of Chronic Tennis Elbow sufferers has shown no evidence of the chemicals usually associated with inflammation. Instead, there is an increase in chemicals associated with pain transmission in the nerves. This toxic chemical mix is coupled with changes in the blood supply and changes in the coordination of the muscles when using the hand and wrist. You also see degenerative changes in the extensor tendon, where the tendon structure starts to break down.

There is now evidence that longstanding forearm muscle imbalances can distort your elbow joint position and result in chronic tennis elbow pain. A muscle imbalance results in your decreased ability to perform normal elbow activities and reducing elbow and grip strength.

For diagnostic advice regarding your tennis elbow, please seek the advice of your trusted elbow physiotherapist or doctor.

How is Tennis Elbow Diagnosed?

Your physiotherapist or doctor clinically diagnoses your Tennis Elbow. After listening to your injury history and using some confirmatory clinical tests, they may determine a provisional diagnosis of tennis elbow.

An ultrasound scan or MRI are the best tests to identify any tendon tears or inflammation. X-rays are of little diagnostic benefit.

Referred Pain From Your Neck Can Mimic Tennis Elbow.

A significant percentage of tennis elbow sufferers may feel pain in the lateral elbow but not be experiencing tennis elbow. A high incidence of lateral elbow pain is referred to your elbow from a cervical spine (neck) injury.

The most common neck joint that refers to your lateral elbow is C5/6, which transmit pain signals along the radial nerve.

Your radial nerve may also have reduced neural mobility, which can cause symptoms similar to tennis elbow.

It is imperative to assess your neck and upper limb neurodynamics. An experienced elbow physiotherapist will confirm or exclude any neck dysfunction or neural tension. Failure to do so will result in a lack of symptom improvement and the development of chronic tennis elbow pain syndrome.

Who Suffers Tennis Elbow?

Tennis Elbow occurs commonly in the community. It is present in 40% of all tennis players (hence it’s named) and 15% of people working in repetitive manual trades. It can occur at any age. However, sufferers are generally between the ages of 35 and 50.

Predictably, the side affected is usually associated with handedness, but it can occur in the non-dominant arm. Males and Females are affected equally.

Tennis Elbow Treatment

Physiotherapy is helpful in the short and long-term management of tennis elbow.

Physiotherapy aims to achieve a:

  • Reduction of elbow pain.
  • Facilitation of tissue repair.
  • A restoration of your normal joint range of motion and function.
  • A restoration of your standard muscle length, strength and movement patterns.
  • The normalisation of your upper limb neurodynamics.
  • The normalisation of cervical joint function.

There are many ways to achieve these and, following a thorough assessment of your elbow, arm and neck, your physiotherapist will discuss the best strategy for you to use based on your symptoms and your lifestyle. Results typically increase your pain-free grip strength.

Physiotherapy treatment may include gentle mobilisation of your neck and elbow joints. Other treatment options available include elbow kinesio taping, muscle stretches, neural mobilisations, massage and strengthening.

In some instances, a tennis elbow brace may be beneficial. Your physiotherapist will discuss what treatment options are most suitable for you.

When Should You Use a Tennis Elbow Brace?

A tennis elbow brace can be beneficial from the moment you put it on. In these instances, the brace will dissipate the stressful gripping forces away from your injured structures.

tennis elbow brace

However, a tennis elbow brace does not work in 100% of cases. In our experience, we recommend that you seek physiotherapy assistance in these cases. In stubborn cases, you have a very high likelihood of referred symptoms from your C5/C6.

Only a thorough examination of your neck, shoulder, elbow and upper limb nerve structures will confirm your diagnosis and direct which treatment options will assist you the quickest.

What is Your Tennis Elbow Prognosis?

Untreated Tennis Elbow can last anywhere from 6 months to 2 years. You are also prone to recurrence.

Studies have shown physiotherapy to be the most effective way of managing Tennis Elbow when compared to steroid injections or giving of advice alone. In a recent study, when given a 6-week course of physiotherapy comprising of 8 treatment sessions, most patients show significant improvement after three weeks, increasing to a 60% or more significant recovery after six weeks of treatment. This improvement continues to around a 90% improvement at 12 months, even without further treatment.

By comparison, provision of advice only resulted in a recovery of 60% or higher being delayed a further six weeks, to three months. Over more extended periods, patients given good advice did recover, and by six months had achieved similar gains to the treatment groups. These trends were maintained over time and continued to improve.

Cortisone injections resulted in excellent initial improvements, with an almost 80% reduction in symptoms after 3 to 6 weeks. BUT (and it’s a big one) patients who received cortisone injections showed an increase in pain after six weeks, and by three months had fallen well below both the physio treatment groups AND the advice only groups in terms of their recovery. This deterioration was followed by delayed healing, resulting in the cortisone injected group, having almost 30% more pain after 12 months than if they had followed advice alone.

For this reason, researchers do not recommend cortisone injections as a stand-alone treatment for Tennis Elbow.

Further research is currently underway to assess the effectiveness of cortisone injections combined with physiotherapy management to see if the initial early gains can be better maintained.

For more advice about tennis elbow, please ask your elbow physiotherapist.

Elbow Pain Causes

Please visit the links below for some of the more common sources of elbow pain.

Elbow-Related Arm Pain

Neck-Related Arm Pain

Muscle-Related Arm Pain

Other Sources of Arm Pain

Common Treatments For Elbow Pain

With accurate assessment and early treatment, most elbow pain responds extremely quickly to physiotherapy that will allow you to resume pain-free and normal activities of daily living quickly. Some conditions may require diagnostic investigations such as X-rays, Ultrasound, MRI or CT scans. Fractures, dislocations and some severe or chronic injuries may require surgical opinion or intervention.

Please ask your physiotherapist for their professional treatment advice.