Tennis elbow is a lay term for tendon pain on the outer side of the elbow. Itis a bit of a misnomer because it doesn’t just affect tennis players. In fact, it should be called manual workers elbow or something along those lines as it is caused by repetitive stress into the tendon at the elbow from gripping and pulling tasks such as vine pruning, DIY or even from doing certain exercises in the gym.
Tennis elbow affects the tendons of four forearm and wrist muscles that come off the elbow. One tendon is particularly affected – the extensor carpi radialis brevis tendon. This has a very short tendon and small tendon footprint at the elbow, we also know the tendon receives a limited blood supply at this point, thus overload of the tendon at this point is common. We know that it affects up to 3% of the population and is commonly equal between males and females between 35 and 55 years old.
Tennis elbow is quite easily diagnosed from a client’s story and also with some physical tests such as pain on resisted wrist extension, third digit extension and also local tenderness to touch over the lateral elbow. We can also look at the tendon on ultrasound to see if the tendon looks abnormal. Once we have come to a diagnosis of lateral epicondylitis a.k.a. tennis elbow there are various treatment options available.
The way to manage many tendon problems is to one reduce the offending load, and to do strengthening exercises on the tendon. Firstly, you will need to cut back on whatever has caused this injury and give it a little bit of rest. If the injury has only recently happened using ice, paracetamol or ibuprofen can be useful. So can using a tennis elbow strap to off load the painful tendon. Once the acute irritation has settled down and you have cut back on the amount of loading you must start a tendon strengthening program. This is key to tendon rehabilitation. Any other intervention without loading the tendon and making it stronger will provide inferior outcomes.
Other treatment options include shockwave therapy. This has been shown to be quite useful in managing many tendon problems including tennis elbow. A course of 3 to 6 shockwave treatments delivered to the tendon will create some micro-trauma from which the tendon will start to heal. Combining shockwave therapy with strength exercises is very effective. Similarly, you could have acupuncture/dry needling into the tendon, or you could even have needle fenestration of the tendon under ultrasound guidance. These treatments also create some micro-trauma within the tendon from which it will heal overtime.
There are some injections that can be given if load management, strengthening and other modalities such as shockwave and acupuncture are not helping. We now know that steroid injections provide short-term relief of tennis elbow pain at about three months post injection, but they lead to poor outcomes at 6 and 12 months compared to doing nothing or just having physiotherapy. In fact, we now believe that steroid injections can cause long-term damage to the tendon, making the tendon weaker and may also lead to tendon rupture. We do not recommend steroid injections for tennis elbow. There is emerging evidence now that PRP injections can be a useful adjunct to physiotherapy. PRP stands for platelet rich plasma, where some blood is taken from your arm, spun in a centrifuge to extract the platelet rich plasma which is then injected back into the tendon. PRP contains a host of your own natural growth and healing factors which stimulate tendon repair. However, having the injection without doing the suitable loading program will lead to inferior outcomes.