TENNIS ELBOW

What is tennis elbow?

The medical term for tennis elbow is lateral epicondylitis because it affects the outside of the elbow bone called the lateral epicondyle. The cause of the problem is damage to a tendon that joins the extensor muscles of the forearm to the upper arm bone (humerus). This tendon is called the common extensor tendon (see diagram).

Illustration showing the elbow joint and common extensor tendon

Tendon damage can occur after a single incident, such as lifting something very heavy, causing a tear in the tendon. But the most common cause is repeated overuse of the arm.

This overuse causes tiny tears (called microtears) in the tendon. You will make this worse if you continue doing the activity that triggered the pain and if you don't rest your arm. If you continue aggravating the injury you may get a more serious tear or even rupture your tendon.

Causes and risk factors

Playing tennis three times in a week when you haven't played for some time is the sort of overuse that could cause tennis elbow. But most people who develop tennis elbow have not been playing tennis. A range of different activities that involve repeated hand, wrist and forearm movements can be the cause. These include:

• using a computer mouse (especially if you have poor arm and neck posture)

• using a computer keyboard

• using vibrating equipment, such as strimmers

• using scissors or shears

• gardening

• manual occupations that involve repetitive twisting and lifting of the wrist - including plumbing, bricklaying and use of a screwdriver

• playing musical instruments such as the violin

Symptoms

The main symptom is pain and tenderness on the outside of the elbow and sometimes in the muscles on top of the forearm. Tennis elbow usually affects the arm of your dominant hand (right arm if you are right-handed) because this is the arm you use the most.

The symptoms usually develop gradually. The pain may go away after a day or so. But if you repeat the activity that triggered the pain, it may get worse as you will increase the damage to your tendon. The pain may become constant and even interrupt your sleep.

Other symptoms include:

• your affected arm feels stiff in the morning and painful when you turn door handles or shake hands

• your affected arm feels weak and heavy

• pain or stiffness in other parts of your affected arm, or your shoulder or neck, as your body tries to compensate for the weakness in your elbow

Treatment

To make a full recovery, you need to change the way you use your arm so that your tendon is rested and has time to heal. Exactly how you do this depends on how you came to have tennis elbow and how severe it is.

Treatment for tennis elbow includes the following.

• Reduce inflammation and pain. Your GP may prescribe medicines to reduce inflammation. Your physiotherapist may try various techniques to reduce the pain. These may include acupuncture, ultrasound, deep tissue massage and correcting posture. For tennis elbow that has failed to heal with normal treatment, a doctor may suggest a steroid injection, which can help relieve pain and inflammation.

• Activity modification. Your physiotherapist can advise you on how to improve your posture, or improve your technique at sports and other activities to help prevent further injuries. This may involve having a workstation assessment if your tennis elbow is due to your work.

• Rehabilitation. This involves strengthening exercises, such as a structured loading programme of the tendon as well as stretching. Your physiotherapist will be able to advise you on this.

• Arm brace or tape. This can alter where the tendon works from and allow the inflammation to settle.

Home treatment

You can treat your symptoms yourself if you have mild tennis elbow. The most important part of the treatment is to rest your injured tendon by stopping or changing the activity that is causing the problem. To relieve your symptoms, you can do the following.

• Apply an ice pack - to reduce the pain and swelling. Immerse your arm in ice for 10 minutes or use an ice pack (a bag of frozen peas will do) for 10 to 30 minutes. Don't apply the ice directly to your skin because it can cause cold injury - place a cloth between the ice your skin. Repeat every couple of hours as needed for the next 48 hours, allowing your arm to warm up between ice sessions.

• Take anti-inflammatory medicine - such as ibuprofen, according to the directions on the packet, up to the maximum daily dose. Ibuprofen is not suitable for people who have stomach ulcers, or for some people with asthma. If in doubt, ask your pharmacist or doctor for advice. Ibuprofen belongs to a group of drugs called non-steroidal anti-inflammatory drugs (NSAIDs). Always read the patient information leaflet that comes with your medicine. Other types of NSAIDs may be more appropriate for some people.

• Wear an arm brace - this is a form of strapping that you can wear around your forearm and elbow to help restrict the movement of your tendon. You can buy arm braces from some physiotherapists, larger pharmacies and sports shops. Your physiotherapist will be able to advise you on how to use it.

• Modify technique - when doing a manual task you can't avoid, use a tool with a smaller grip. If available, you should contact your employer's occupational health advisers. They can give advice on how to change your daily activity at work to allow your arm to heal.

 Rehab For Tennis Elbow: The Super 7

The "super 7” exercises are an important part of treatment for tennis elbow. They are designed to strengthen the muscles in the forearm and increase flexibility through stretching. In most cases te these exercises will help relieve elbow pain in about 4 to 6 week Each stretching exercise is held for 15 seconds and repeated 2 or 3 times. This pattern is repeated 5 times a day.

Exercise 1. Stretching the muscles that extend the wrist (extensor muscles): Straighten the arm out fully and push the palm of the hand down so you feel a stretch across the top of the forearm.

Exercise 2. Stretching the muscles that flex the wrist (flexor muscles): straighten the arm out fully (palm side up), and push the palm downward to stretch. Strengthening exercises are performed twice a day following the stretching exercises. To perform these exercises, the patient sits in a chair with the elbow supported on the edge of a table or on the arm of the chair the wrist hanging over the edge. Use a light weight such as a hammer or soup can when performing the strengthening exercises. Repeat the exercises 30 to 50 times, twice a day, but do not push yourself beyond the point of pain.

Exercise 3. Strengthening wrist extensor muscles: Hold the weight in the hand with the palm facing down. Extend the wrist upward so that it is pulled back. Hold this position for 2 seconds and then lower slowly.
Exercise 4. Strengthening wrist flexor muscles: Hold the weight in the hand with the palm up. Pull the wrist up, hold for 2 seconds and lower slowly.

Exercise 5. Strengthening the muscles that move the wrist from side to side (deviator muscles): Hold the weight in the hand with the thumb pointing up. Move the wrist up and down, much like hammering a nail. All motion should occur at the wrist.

Exercise 6. Strengthening the muscles that twist the wrist (pronator and supinator muscles): Hold the weight in the hand with the thumb pointing up. Turn the wrist inward as far as possible and then outward as far as possible. Hold for 2 seconds and repeat as much as pain allows, up to 50 repetitions.

Exercise 7. Massage is performed over the area of soreness. Apply firm pressure using 2 fingers on the area of pain and rub for 5 minutes.

If exercise aggravates any of your symptoms, contact a physician or physical therapist These exercises can be used to prevent or rehabilitate injuries in people who play sports or in those who do repetitive forearm work.