© Cambridge Fracture Clinic - Mr Lee Van Rensburg - Cambridge; United Kingdom
Cambridge Elbow

Tennis Elbow

Lateral sided elbow pain (pain on the outside of your elbow) is often diagnosed as tennis elbow. This is often

correct as it is the most common cause for pain on the outside of the elbow in an adult.

 There are however other causes of lateral sided elbow pain, most pretty rare but need to be considered:

Posterior interosseous nerve compression (radial tunnel syndrome)

Problems inside the elbow joint (Arthritis of the radio-capitellar joint, plica, synovitis, osteochondritis)

Hyperextension valgus overload

Elbow instability (posterolateral rotatory instability, PLRI).

Referred pain (nerve compression in the neck)

Tennis elbow pain is often worse after use and is not only confined to tennis players. Any work that requires strong extension of the fingers and wrist,

can aggravate the symptoms.

When you flex the fingers and hold something tight you still tense the common extensor muscles.

 The reason we get tennis elbow is because all the strong muscles that extend your fingers and wrist all attach onto a fairly small area of bone (lateral

epicondyle or common extensor origin).

 Initially we thought it was an inflammatory condition hence term epicondylitis.

 It has been shown to not be an inflammatory condition.

 It is thought to be more a degenerative condition.

 Tendinous microtearing is followed by an incomplete healing response, leading to a tendinopathy.

 Diagnosis

 The diagnosis is mostly clinical a history of pain on the lateral aspect of the elbow that gets worse with use and better with rest.

 

 There is often an area of point tenderness over the common extensor origin and pain is increased with resisted extension of the wrist.

 

 It is important to exclude other causes of lateral elbow pain.

 I often get an X ray of the elbow to exclude other problems with the bones and joints.

 In slightly atypical cases further investigation may be needed eg. MRI scan.

 

 Treatment

 

 Tennis elbow can be very difficult to treat and fully resolve. Treatment in the first instance is non operative this includes:

 • Rest ( RELATIVE REST,  doing absolutely nothing is just as bad as doing too much)

• Activity modification (change the way you do things, avoid those things that aggravate your elbow, look at the size and weight of your racquets)

• Analgesia ( see pain killers, predominantly the NSAIDS)

• Splints (counterforce bracing – this helps spread the load)

 ◦ There are thousands of different tennis elbow braces in my opinion none have been shown to be superior, in essence you want a clasp or strap

that goes around the forearm. Use it at all times if you have a lot of pain. Then gradually wean yourself to a point where you use it only at the times

of increased stress on your arm.

• Physiotherapy (see below)

 ◦ No single set of stretches or exercises has thus far been shown to be superior to another.

 1. Classically focus has been placed on stretching and concentric strengthening.

 2. Eccentric muscle training is gaining more interest in dealing with tendon problems. In theory eccentric strengthening leads to strengthening of the

musculotendinous unit. It has however not conclusively been shown to be better than stretches and concentric strengthening

 

• Injections

 ◦ Steroid injections have been shown to help in the short term, but in the long term may make things worse.

 I would avoid repeated injections.

 Steroids although good for reducing inflammation are not good for tendon healing and repeated injections can damage the tendon.

◦ Other:

 Several different substances have been tried, including:

 ( blood, stem cells, growth factors, hyaluronic acid, botox) none so far have become mainstream treatment.

 Platelet rich plasma is showing some promise.

• Acupuncture, shock wave therapy and low intensity ultrasound has been tried but the evidence thus far does not conclusively support its use.

Surgery

 

 Surgery is not a miracle cure and is usually only considered after 6 to 12 months of symptoms and failure to improve with non operative treatment

methods.

 Surgery often improves the elbow but does not totally eliminate the symptoms, improving it by 60-80%

 Several types of surgery are available broadly in 3 groups:

 • Percutaneous release

• Open debridement

• Arthroscopic or keyhole surgery

Percutaneous release

 

 This involves a 5mm cut in the skin and the tendons are released from the common extensor origin.

 It is a day case procedure, the surgery itself taking about 5 minutes.

 The surgery and the blood from the surgery initiates a fresh healing response. After the operation I do not use any splints or casts.

 You will have a bulky bandage and sling for comfort if you need it.

 You will be advised to use your elbow gently, lifting nothing heavier than a cup of tea for a few weeks, usually 3 weeks.

 No strength work or heavy lifting for 6 weeks and then a graduated increase in activities to the 3 month mark.

 Use your counterforce brace at times of increased stress initially. Tendons that are gently stressed while healing will heal ultimately stronger than

tendons not stressed while healing.

 

 Open surgery

 A 4cm incision is made through the skin, the common extensor origin is released and the degenerative tendon tissue is removed.

 The remaining healthy tendon is then reattached.

 If this is a revision procedure, or your case slightly atypical consideration will be given to decompressing the posterior interosseous nerve (see other

causes of lateral elbow pain)

 Arthroscopic surgery

 

 It is possible with the keyhole method to release the common extensor origin from the inside of the joint.

 Further benefits of looking into the joint, is it allows me to address other intra articular possible causes of lateral elbow pain (see above).

 The down side, is the potential for complications is higher for arthroscopic elbow surgery versus percutaneous or open surgery.

 

 

References

Management of Lateral Epicondylitis: Current Concepts; Ryan P. Calfee, Amar Patel, Manuel F. DaSilva, and Edward Akelman; J. Am. Acad. Ortho. Surg.,

January 2008; 16: 19 - 29.

 A comparison of open and percutaneous techniques in the surgical treatment of tennis elbow;P. D. Dunkow, M. Jatti, and B. N. Muddu;  J Bone Joint

Surg Br, Jul 2004; 86-B: 701 - 704.

“We conducted a prospective, randomised, controlled trial of 45 patients (47 elbows), with tennis elbow, who underwent either a formal open release

or a percutaneous tenotomy. All patients had pre- and post-operative assessment using the Disability of Arm, Shoulder and Hand (DASH) scoring

system. Both groups were followed up for a minimum of 12 months. Statistical analyses using the Mann-Whitney U test and repeated measured

ANOVA showed significant improvements for patient satisfaction (p = 0.012), time to return to work (p = 0.0001), improvements in DASH score (p =

0.001) and improvement in sporting activities (p = 0.046) in the percutaneous group. Those patients undergoing a percutaneous release returned to

work on average three weeks earlier and improved significantly more quickly than those undergoing an open procedure. The percutaneous

procedure is a quicker and simpler procedure to undertake and produces significantly better results”

 

 

Physiotherapy for tennis elbow

  

 

 Stretching

 Extend the elbow fully turn your palm down to the floor and flex your wrist and hand towards the floor, hold for 20-30 seconds and repeat 5-10

times, at least twice a day. Stretch gently increasing the stretch slowly with time. Do not stretch to the point of pain that reproduces your symptoms.

 

 Strengthening

 

 Concentric exercises

 Bend the elbow, support your forearm on your leg/ table. Hold a 1 lb. weight in hand with palm facing downward (pronated). Raise wrist/hand up

slowly (concentric contraction), and lower slowly (eccentric contraction).

 

Eccentric exercises

 

 Use a theraband place one end under your foot, hold the other in your hand.

 Place your elbows straight as possible over your knee and let your wrist fall to the floor. Cock your hand and wrist up with your free hand. It is

important your free hand does all the work cocking up the wrist. Let go with the free hand and resist the theraband while slowly letting your wrist go

straight towards the floor.  Repeat this 15  times rest for a minute then repeat 15, rest again for a minute and then repeat 15. Do this twice a day.

 Start the exercises allowing wrist to straighten slowly at start with the band quite loose. It is normal to feel moderate pain in your elbow towards the

end of the exercise session.

 Shorten the band or use a stiffer band to make the exercise harder as the pain reduces.

 Work a little more quickly once you can do a whole session with a stiff band with no pain.

 Be patient it may take 2 to 3 months to feel the benefit.

 

 

Back to physiotherapy

Last updated 04/04/2012ea .

© Advanced Nerve Blocks

Tennis Elbow

Lateral sided elbow pain (pain on the outside of your elbow) is often

diagnosed as tennis elbow. This is

often correct as it is the most

common cause for pain on the

outside of the elbow in an adult.

 There are however other causes of

lateral sided elbow pain, most

pretty rare but need to be

considered:

Posterior interosseous nerve

compression (radial tunnel

syndrome)

Problems inside the elbow

joint (Arthritis of the radio-

capitellar joint, plica,

synovitis, osteochondritis)

Hyperextension valgus overload

Elbow instability (posterolateral rotatory instability, PLRI).

Referred pain (nerve compression in the neck)

Tennis elbow pain is often worse after use and is not only confined to

tennis players. Any work that requires strong extension of the fingers

and wrist, can aggravate the symptoms.

When you flex the fingers and hold something tight you still tense the

common extensor muscles.

 The reason we get tennis elbow is because all the strong muscles that

extend your fingers and wrist all attach onto a fairly small area of bone

(lateral epicondyle or common extensor origin).

 Initially we thought it was an inflammatory condition hence term

epicondylitis.

 It has been shown to not be an inflammatory condition.

 It is thought to be more a degenerative condition.

 Tendinous microtearing is followed by an incomplete healing response,

leading to a tendinopathy.

 Diagnosis

 The diagnosis is mostly clinical a history of pain on the lateral aspect of

the elbow that gets worse with use and better with rest.

 

 There is often an area of point tenderness over the common extensor

origin and pain is increased with resisted extension of the wrist.

 

 It is important to exclude other causes of lateral elbow pain.

 I often get an X ray of the elbow to exclude other problems with the

bones and joints.

 In slightly atypical cases further investigation may be needed eg. MRI

scan.

 

 Treatment

 

 Tennis elbow can be very difficult to treat and fully resolve. Treatment in

the first instance is non operative this includes:

 • Rest ( RELATIVE REST,  doing absolutely nothing is just as bad as doing

too much)

• Activity modification (change the way you do things, avoid those things

that aggravate your elbow, look at the size and weight of your racquets)

• Analgesia ( see pain killers, predominantly the NSAIDS)

• Splints (counterforce bracing – this helps spread the load)

 ◦ There are thousands of different tennis elbow braces in my opinion

none have been shown to be superior, in essence you want a clasp or

strap that goes around the forearm. Use it at all times if you have a lot of

pain. Then gradually wean yourself to a point where you use it only at

the times of increased stress on your arm.

• Physiotherapy (see below)

 ◦ No single set of stretches or exercises has thus far been shown to be

superior to another.

 1. Classically focus has been placed on stretching and concentric

strengthening.

 2. Eccentric muscle training is gaining more interest in dealing with

tendon problems. In theory eccentric strengthening leads to

strengthening of the musculotendinous unit. It has however not

conclusively been shown to be better than stretches and concentric

strengthening

 

• Injections

 ◦ Steroid injections have been shown to help in the short term, but in

the long term may make things worse.

 I would avoid repeated injections.

 Steroids although good for reducing inflammation are not good for

tendon healing and repeated injections can damage the tendon.

◦ Other:

 Several different substances have been tried, including:

 ( blood, stem cells, growth factors, hyaluronic acid, botox) none so far

have become mainstream treatment.

 Platelet rich plasma is showing some promise.

• Acupuncture, shock wave therapy and low intensity ultrasound has

been tried but the evidence thus far does not conclusively support its

use.

Surgery

 

 Surgery is not a miracle cure and is usually only considered after 6 to 12

months of symptoms and failure to improve with non operative

treatment methods.

 Surgery often improves the elbow but does not totally eliminate the

symptoms, improving it by 60-80%

 Several types of surgery are available broadly in 3 groups:

 • Percutaneous release

• Open debridement

• Arthroscopic or keyhole surgery

Percutaneous release

 

 This involves a 5mm cut in the skin and the tendons are released from

the common extensor origin.

 It is a day case procedure, the surgery itself taking about 5 minutes.

 The surgery and the blood from the surgery initiates a fresh healing

response. After the operation I do not use any splints or casts.

 You will have a bulky bandage and sling for comfort if you need it.

 You will be advised to use your elbow gently, lifting nothing heavier than

a cup of tea for a few weeks, usually 3 weeks.

 No strength work or heavy lifting for 6 weeks and then a graduated

increase in activities to the 3 month mark.

 Use your counterforce brace at times of increased stress initially.

Tendons that are gently stressed while healing will heal ultimately

stronger than tendons not stressed while healing.

 

 Open surgery

 A 4cm incision is made through the skin, the common extensor origin is

released and the degenerative tendon tissue is removed.

 The remaining healthy tendon is then reattached.

 If this is a revision procedure, or your case slightly atypical consideration

will be given to decompressing the posterior interosseous nerve (see

other causes of lateral elbow pain)

 Arthroscopic surgery

 

 It is possible with the keyhole method to release the common extensor

origin from the inside of the joint.

 Further benefits of looking into the joint, is it allows me to address other

intra articular possible causes of lateral elbow pain (see above).

 The down side, is the potential for complications is higher for

arthroscopic elbow surgery versus percutaneous or open surgery.

 

 

References

Management of Lateral Epicondylitis: Current Concepts; Ryan P. Calfee,

Amar Patel, Manuel F. DaSilva, and Edward Akelman; J. Am. Acad. Ortho.

Surg., January 2008; 16: 19 - 29.

 A comparison of open and percutaneous techniques in the surgical

treatment of tennis elbow;P. D. Dunkow, M. Jatti, and B. N. Muddu;  J

Bone Joint Surg Br, Jul 2004; 86-B: 701 - 704.

“We conducted a prospective, randomised, controlled trial of 45 patients

(47 elbows), with tennis elbow, who underwent either a formal open

release or a percutaneous tenotomy. All patients had pre- and post-

operative assessment using the Disability of Arm, Shoulder and Hand

(DASH) scoring system. Both groups were followed up for a minimum of

12 months. Statistical analyses using the Mann-Whitney U test and

repeated measured ANOVA showed significant improvements for patient

satisfaction (p = 0.012), time to return to work (p = 0.0001),

improvements in DASH score (p = 0.001) and improvement in sporting

activities (p = 0.046) in the percutaneous group. Those patients

undergoing a percutaneous release returned to work on average three

weeks earlier and improved significantly more quickly than those

undergoing an open procedure. The percutaneous procedure is a

quicker and simpler procedure to undertake and produces significantly

better results”

 

 

Physiotherapy for tennis elbow

  

 

 Stretching

 Extend the elbow fully turn your palm down to the floor and flex your

wrist and hand towards the floor, hold for 20-30 seconds and repeat 5-

10 times, at least twice a day. Stretch gently increasing the stretch slowly

with time. Do not stretch to the point of pain that reproduces your

symptoms.

 

 Strengthening

 

 Concentric exercises

 Bend the elbow, support your forearm on your leg/ table. Hold a 1 lb.

weight in hand with palm facing downward (pronated). Raise wrist/hand

up slowly (concentric contraction), and lower slowly (eccentric

contraction).

 

Eccentric exercises

 

 Use a theraband place one end under your foot, hold the other in your

hand.

 Place your elbows straight as possible over your knee and let your wrist

fall to the floor. Cock your hand and wrist up with your free hand. It is

important your free hand does all the work cocking up the wrist. Let go

with the free hand and resist the theraband while slowly letting your

wrist go straight towards the floor.  Repeat this 15  times rest for a

minute then repeat 15, rest again for a minute and then repeat 15. Do

this twice a day.

 Start the exercises allowing wrist to straighten slowly at start with the

band quite loose. It is normal to feel moderate pain in your elbow

towards the end of the exercise session.

 Shorten the band or use a stiffer band to make the exercise harder as

the pain reduces.

 Work a little more quickly once you can do a whole session with a stiff

band with no pain.

 Be patient it may take 2 to 3 months to feel the benefit.

 

 

Back to physiotherapy

Last updated 04/04/2012ea .

Cambridge Fracture Clinic