Q: I started having pain by my elbow and I saw my doctor. She said I had tennis elbow even though I have never played tennis. How is this possible?
A: The elbow is the joint where the upper arm bone (the humerus) meets the forearm bones (the radius and ulna). The muscles in the upper arm (the biceps and triceps) are responsible for movement at the elbow. The muscles in the forearm are responsible for movement of the wrist and fingers. Muscles anchor into bones by means of tendons, which are strong, inelastic fibrous tissues that connect the muscles to the bones. The tendons from the muscles that help you lift up your wrist and fingers (extensor carpi radialis brevis and longus) anchor into the epicondyle of the humerus (the rounded end of the upper arm bone), which is by the lateral part of the elbow (the outside part away from your body).
Lateral epicondylitis is the fancy medical term for tennis elbow. This condition occurs when there is swelling and inflammation around the epicondyle of the humerus. This is believed to happen from injury (strain or possibly even small tears) of the tendons and/or muscles that anchor into the epicondyle, and is thought to be due to repetitive stress injury to these structures.
Tennis elbow is very common, and although it can affect either arm (or even both) it is most common in a patient's dominant arm. Epicondylitis is most common in people in their 30s to early 50s. More than 50 percent of people who play tennis regularly will get at least some symptoms of this at some time in their playing careers, and hence the name. However, only about 5 percent of all people diagnosed with tennis elbow get it from playing tennis. Other repetitive motions such as frequent hand shaking (such as in politicians running for re-election), other sports (such as a ``wristy'' backhand in squash), gripping tools tightly (such as in many construction or manufacturing jobs) or any other twisting or hand turning motions can contribute to this problem. Many people get this condition with no identifiable risk factors.
Tennis elbow is diagnosed by the patient's history, as well as an exam by their health care provider that will reveal tenderness by the lateral epicondyle as well as pain reproduced by extending (lifting up away from the palm) the wrist and/or fingers. No X-rays or other tests are typically needed at this point.
Patients with tennis elbow typically go to their doctor because of the elbow pain, often noting that it is worsened by gripping things in their hand or with certain lifting movement with their hand. They will sometimes describe it as a weakness, although it is not common for there to be true weakness, just limitation of use of the affected muscles due to pain. It will not usually limit the patient's range of motion (except as limited by the pain it causes), and elbow movement will not usually worsen the pain. The pain can be severe, and some patients may even say it is even too painful to pick up a cup of coffee. Although classically the symptoms start out mild and progress over time, some patients will complain of the acute onset of severe pain without noting a period of milder symptoms.
The initial treatment of tennis elbow is aimed at relieving the acute symptoms. This usually includes ``PRICE'': Protection, Rest, Ice, Compression and Elevation. Anti-inflammatory pain medications such as naproxen or ibuprofen are often recommended. Compression arm straps, and sometimes wrist braces (to minimize wrist motion to allow the injured tissues to rest), are often recommended. Phonophoresis (application of a steroid gel directly to the affected area) can also be helpful.
Acupuncture has also been shown to be beneficial for some patients, and can be utilized in addition to the conservative treatments outlined above.
Over 90 percent of people with tennis elbow will improve with these conservative measures, although it can take four to six weeks for this improvement to be significant. For those who do not improve with these treatments, the next step is often an injection of steroids to help decrease the inflammation. This treatment, in conjunction with continuing the above treatments, will help over 95 percent of patients. Some studies have shown that steroid injections are useful to help improve symptoms in the early period (first one to two months), but do not improve outcomes in the longer term (at one year).
For the minority of patients who do not benefit from any of the treatments discussed above, surgical intervention may be considered, although I could not find any controlled studies evaluating the benefit of surgical intervention. Before surgery, your health care provider may order an MRI to visualize the underlying structures to rule out subtle bone fractures, large muscle/tendon tears or other injuries.
Once the patient's acute symptoms have improved, the next phase of treatment is aimed at restoring normal function and preventing recurrence. Physical therapy may be recommended to help patients recover the strength they may have lost during the prolonged rest used to treat the tennis elbow flareup, as well as to help prevent recurrence. Exercises may include ball squeezing (to strengthen grip), and there are many other exercises your physical therapist may recommend. Recommendations will also include avoiding repetitive lifting or grasping, avoiding extremes of load (no heavy lifting when the elbow is almost straight or almost completely bent), using a two-handed backhand (for tennis players), using padded tools (to minimize gripping too tightly when using tools) as well as other strategies to minimize repetitive motions that may contribute to a recurrence of the condition.
If you have pain in your elbow, whether or not you play tennis, tennis elbow may be the cause. You should see your health care provider to be evaluated and to begin appropriate treatment since the chance of recovery is better when treatment is started within a couple of months.
Jeff Hersh, Ph.D., M.D., F.A.A.P., F.A.C.P., F.A.A.E.P., can be reached at DrHersh@juno.com.
