Tennis elbow

Tennis elbow, or “lateral epicondylitis”, is condition causing pain along the outside of the elbow.  The muscles that extend the wrist and open the fingers insert into a portion of the bone on the outside of the elbow called the “lateral epicondyle”.  Small tears of the muscle at its insertion site (the tendon) is a common cause of pain in the area that is experienced when lifting or grasping objects. 

Causes

Common causes include overuse, or trauma to the forearm muscles, especially the extensor carpi radialis brevis, an important muscle for extending the wrist (such as when hitting a backhand in tennis).  Tennis elbow is frequently seen in individuals between 30 and 60 years of age, and has been referred to as a “rite of passage of middle age”.

Diagnosis

Tennis elbow can be diagnosed by talking with your doctor and having them examine your elbow.  There is often pain when pushing on the “lateral epicondyle”, and when resisting wrist or finger extension. 

Non-surgical treatment

A counterforce strap decreases tension on the site of the tendon tear, which can decrease pain and facilitate healing

  • Activity modification – avoid aggravating activities, and focus on lifting objects with your palms facing up, which puts less tension on your extensor muscles

  • Anti-inflammatories (such as ibuprofen or naproxen – if medically safe)

  • Bracing - counterforce strap

  • Steroid injection into site of pain and inflammation

  • Therapy to stretch the forearm muscles

With your elbow straight and palm facing the floor, make a fist. Then, use your other hand to bend the wrist down. Hold the stretch for 30 seconds.

With your elbow straight and palm facing the floor, use your other hand to bend the wrist and fingers backward. Hold the stretch for 30 seconds.

MRI

  • If over 6 months have passed, and symptoms have not improved to an acceptable level with other treatments, an MRI is sometimes obtained to evaluate the extend of the injury.

  • In severe cases of tennis elbow, the tendon that extends the wrist and fingers can tear off of the bone along the outside of the elbow.

  • Inflammatory can develop at the injury site, which is painful and can block normal healing.

Left: MRI of a normal elbow - the typical appearance of the extensor tendon (white arrows) insertion is a black line attaching to the bone

Right: MRI of an elbow with lateral epicondylitis - the tendon has torn off of the bone. Fluid and scar tissue (white on MRI- white arrows) are interposed between the end of the tendon and the bone. An abnormal attachment results in pain along the outside of the elbow with use of the hand and arm.

Surgical treatment

  • Surgery is rarely required, as the condition tends to improve with time.

  • If over 6 months have passed, symptoms persist and an MRI shows a tear of the tendon, surgery may be considered to repair the torn muscle/tendon back to the bone.

  • Surgery involves removing the injured and inflamed portion of the tendon and suturing the remaining, healthy tendon back to the bone. 

  • This is an outpatient surgery, which is done through a 1-2 inch incision along the outside of the elbow, and typically takes about 30 minutes.

  • Healing of the repaired tendon takes ~6 weeks. During this period, motion of the elbow, wrist and hand is allowed without limits. However, lifting more than a few pounds with the injured side is avoided to allow healing

  • The forearm is usually temporarily weak and achy after recovery, and therapy is often helpful to restore strength and function.

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Dr. Schreiber is a board certified orthopedic surgeon specializing in hand, wrist, and elbow conditions. Dr. Schreiber practices at the Raleigh Orthopaedic Clinic in Raleigh, North Carolina.