An orthopedic surgeon’s guide to tennis elbow

As a sports medicine orthopaedic surgeon, I often see patients with complaints at their elbow. One of the more common diagnoses is tennis elbow, otherwise known as lateral epicondylitis. Surprisingly, most of my patients with this condition don’t even play tennis! Many types of repetitive arm movement can lead to tennis elbow. It all has to do with the tendons in our arms.

Tendons are the structures that hold muscle to bone. The tendons in our bodies are very tough and stretchy, kind of like rubber bands. But like rubber bands, tendons can weaken over time. Wear and tear on these tendons as we go about our daily activities can eventually lead to micro tears, and instead of being one long, smooth bundle of stretchy fibers, the tendons become “tangled” by the process of tearing and re-healing, and are weakened. This leads to inflammation of the tendons. When this inflammation happens at the outside of the elbow, a part of the body called the epicondyle, it’s called epicondylitis, or tennis elbow. For the smarties in the room, the technical name of the tendon most often involved in an epicondylitis diagnosis is the extensor carpi radialis brevis, or ECRB tendon.

Tennis elbow can occur in men or women, and does so about equally. Anyone over the age of 40 is more at risk, with the likelihood rising as you age. As you may know, most people have not only a dominant hand, but a dominant arm (and sometimes, even a dominant leg!). Since we use our dominant arm for tasks more often, this is the arm most likely to fall prey to tennis elbow. Individuals who perform repetitive arm motions, especially repetitive wrist extension and rotating the arm forwards and backwards (much like when you swing a tennis racket), are much more likely to develop tennis elbow.

Developing tennis elbow is so common that some experts call it a rite of passage of middle age. Woo-hoo, right? Most typically, when I see a patient who is showing signs of developing tennis elbow. I will start with non-surgical treatment. The most important treatment advice for healing and preventing the recurrence of tennis elbow is slow, steady, and most importantly consistent healing. Repetitive re-injury of inflamed tendons leads to the kind of scarring that can make tennis elbow very hard to eliminate. Here are some examples of the types of exercises and non-invasive treatments that are often recommended:

  • If the inflammation and tenderness are mild, a course of rest and NSAIDs (non-steroidal anti-inflammatories such as ibuprofen) may be adequate. Preventing tennis elbow before it takes hold is always the best plan of action.
  • Physical therapy can also be a good way to deal with tennis elbow. Exercises which increase forearm strength and provide support for the tendons at the epicondyle will help reduce strain and inflammation. The “Tyler Twist” exercises are a great example of this, as they exercise muscles which don’t typically get a lot of use, providing better support for the elbow and its tendons.
  • Steroidal injections at the epicondyle can help reduce inflammation, and thus pain, and allow efficient blood flow to resume, promoting the body’s natural healing processes. However, some studies show that while there may be short term relief, there may be a negative effect beyond that. For that reason, some doctors avoid giving these altogether.
  • Platelet-rich plasma or PRP injections are injections of plasma spun down from the patient’s blood. The platelets and this the concentration of growth factors are thought to speed up the healing process.
  • A new type of treatment gaining traction is that of shock wave therapy, which uses sonic waves at the site of pain and inflammation. While studies are still being done about the effectiveness of this treatment, and how exactly it helps with tennis elbow, there is some evidence that it can be a good therapy, perhaps in concert with other more traditional treatments.

Ultimately, if there is no improvement with the treatments above, advanced imaging such as an MRI may be required to identify the extent of the injury to the tendon. At this point, surgery may be recommended. This surgery is sometimes called an open debridement. The surgeon makes a small incision on your arm just below the epicondyle and carefully dissects down until they can see the point where the ligaments attach to the bone and muscle. Broken down tissue and scarring can be seen as slightly greyish tissue, compared to the pure white of ligament, and the diseased tissue is cut away to allow the ligament to heal more cleanly, thus reducing future irritation, swelling, and pain at the epicondyle.

Recovery is an extremely important part of this surgery. Because the root condition treated by this surgery is one which results from poor healing over time, it is very important that if you do have tennis elbow and receive an open debridement surgery, you follow your surgeon’s instructions exactly to ensure your condition does not reoccur. Post-operative care usually involves NSAIDs and use of a splint or sling to immobilize the arm for up to 10 days following surgery. After this point, physical therapy can start, with careful supervision. Strengthening of the area, or sports involving twisting and bending the arm and wrist, are not recommended until at least six weeks after surgery.

Always consult your physician before undertaking or seeking any particular path of care. Your body is unique, and how you respond to various treatments will depend on a host of factors which your doctor can help you identify and interpret.

Nancy Yen Shipley is an orthopedic surgeon and can be reached at her self-titled site, NancyMD and on Twitter @_nancymd and Instagram @_nancymd.

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