Tennis elbow, which treatments work?

Tennis elbow is the common name for an overuse injury that results in pain on the outside (lateral aspect) of the elbow. The name comes from its association with playing tennis, although in most people tennis elbow develops for reasons other than a flawed backhand stroke.  Known in the medical literature as "lateral epicondylitis", tennis elbow occurs where the forearm muscles and tendons attach at the elbow.  Repetitive use of the forearm muscles, as when using a hammer or screwdriver, leads to "micro-trauma" at this attachment with ensuing inflammation.


How do you know if you have tennis elbow?  The signs and symptoms of tennis elbow may include: 1) pain at the bony prominence (lateral epicondyle) on the outside of the elbow, 2) pain that is worse when squeezing objects or shaking hands and, 3) the sensation of weakness when attempting to grip or lift because of discomfort.

How is tennis elbow diagnosed?  Doctors who have seen this condition often can often make the diagnosis from a description of the symptoms alone.  There are no diagnostic blood tests and x-rays are usually shown to be normal.  A few simple physical maneuvers performed by the doctor helps to confirm the diagnosis.  Rarely other tests, such as a nerve conduction study or MRI, may be recommended, but this is done to investigate for other conditions rather than to confirm the diagnosis of tennis elbow.

How is tennis elbow treated?  Conservative treatment involves rest, ice, stretching, strengthening, avoiding activity that hurts, and, as inflammation resolves, strengthening exercises.  Taking anti-inflammatory medications, such as ibuprofen, may help for the discomfort associated with tennis elbow, but there is little evidence that it helps to hasten its resolution. If self-care is ineffective, other treatment measures include:

• Corticosteroids.  For severe or persistent pain, a corticosteroid injection can often provide short-term benefits.  Steroids can also be delivered without injecting via a physical therapy modality called iontophoresis.
  
  
• Counterforce bracing.  The so-called tennis elbow strap is widely available in sporting goods stores.  They are worn around the forearm, just past the bony prominence (lateral epicondyle) of the elbow.  While the results of studies evaluating their usefulness are mixed, many people with tennis elbow find relief during activity while using this device.
  
  
• Physical therapy.  Initial physical therapy measures include application of ice, use of ultrasound, deep-tissue massage, and iontophoresis, with or without corticosteroids.  Once the initial pain and inflammation has calmed down, a gradual stretching and strengthening program can improve functional activities and promote a return to normal function.
  
  
• Extracorporeal shock wave therapy (ESWT) is a newer treatment used occasionally for tennis elbow.  Focused shock waves are delivered to the region of the bone-tendon connection at the lateral elbow.  Studies evaluating ESWT in tennis elbow have not shown consistent benefit in terms of improving pain and function.
  
  
• Surgery.  Ninety to ninety-five percent of people with tennis elbow will improve with conservative treatment.  Surgery should only be considered for persistent symptoms that have not responded to conservative care.  Most surgical procedures for tennis elbow involve removing diseased muscle and reattaching healthy muscle back to bone.

Can tennis elbow be avoided?  When lateral epicondylitis develops in tennis players, it is usually due to poor technique or improper equipment.  Equipment modification (lower string tension, increase grip size, reduce the size of the racket head, etc.) can help as can attention to proper racket swing technique.  Since tennis elbow may occur in the occupational setting also, attention to ergonomics and proper technique, particularly in those who perform repetitive activities is important.