The causes of tennis elbow, or lateral epicondylitis as it is known in the medical field, are not yet fully understood. However, the most popular explanation is that the extensor carpi radialis brevis (ECRB) becomes unable to properly repair itself, causing a growth of connective tissue in the tendons, or an increase of tendon damage. In both cases, this can lead to functional issues in the arm and elbow when exerting force through the tendon, resulting in pain when moving the arm, wrist and elbow.
Tennis elbow is most commonly diagnosed in cases where patients seek medical attention as a result of the following symptoms:
In most cases, the elbow’s range of movement is not affected by the condition. These symptoms can indicate a number of possible causes, including lateral epicondylitis, cartilage damage, synovial plica, calcific tendinitis and elbow instability. Accurate diagnosis relies on a thorough review of the patient’s medical history and a detailed health examination, carried out by a highly experienced physician. Important historical factors include the age and activity level of the patient—a 20-year-old patient suffering from elbow pain is unlikely to be diagnosed with tennis elbow.
A thorough health assessment and review of the patient’s medical history—both of which should be carried out by an expert physician—are usually sufficient to diagnose and plan treatment for tennis elbow.
When patients do not respond to treatment as expected, with either no change or a deterioration in their symptoms, medical staff will be required to make a new diagnosis. This may involve repeating the medical history review and physical assessment, and might include additional screening methods including x-rays, ultrasound scans, blood tests, MRI scans, and the screening of nearby joints, such as those within the neck and shoulders.
It is not necessary to x-ray every patient who undergoes diagnosis for tennis elbow. Unnecessary screening can be a waste of time and money.
Elbow pain can affect anyone at any age, but tennis elbow generally affects people during middle age (between 40-50 years old).
A typical patient would be a 45-year-old woman who has suffered elbow pain for 3-4 weeks. On some days the pain is so severe that she is unable to lift her arm, despite only undertaking light tasks such as sweeping the home and doing the laundry. However, on other days the pain may be present only in the morning, or may last for hours at a time before going away. A review of the woman’s medical history along with a physical examination should be sufficient to diagnose tennis elbow. Treatment in the form of rest, lifestyle adjustments, pain relief medication, and tailored exercises such as arm stretches and arm muscle training, are often adequate to resolve the issue within 2-3 months.
It is possible that tennis elbow can go away by itself without treatment. However, if the symptoms worsen or continue for a prolonged period, it could lead to other elbow injuries that are unrelated to tennis elbow, such as tendinitis. The fact that tennis elbow often goes away by itself means that persistent pain could be a result of a misdiagnosis or an underlying elbow issue. Fewer than 5% of tennis elbow cases are classified as recalcitrant tennis elbow, which can result from underlying health problems such as joint surface damage, cartilage damage or synovial plica. These conditions can lead to serious issues in the future, including chronic elbow injuries that often result in early onset osteoarthritis.
Patients with chronic elbow injuries that affect their daily lives should undergo thorough medical diagnoses to identify effective treatments.
Treatment of tennis elbow is focused on restoring function to the elbow, and relieving or reducing pain. The extent to which these objectives can be achieved depends on the patient’s individual situation and the expertise of the physician in charge of treatment. Some patients only require treatment to reduce pain so that they can use the elbow to some degree, while others hope for treatment that successfully eradicates all pain and restores full strength to the elbow. An appropriate course of treatment depends on a number of factors, including the state of the injured elbow, the patient’s age, and the length of time the injury has been present. Patients must communicate clearly with their physician to ensure the injury is fully understood prior to treatment.
Treatment of tennis elbow generally comes in two forms: surgical treatment and non-surgical treatment. Physicians generally begin with non-surgical treatment, such as pain relief medications, anti-inflammatories, physiotherapy, compression techniques, specially designed stretches to increase joint flexibility, and strength exercises focusing on muscle groups located in that area of the arm. Effective treatment of tennis elbow should consist of a combination of techniques.
Steroids are highly effective anti-inflammatory drugs, but tennis elbow is associated with tendon damage rather than inflammation, so the use of anti-inflammatories does not address the root cause of the problem. Studies into the long-term effects of treatment on tennis elbow patients has found that injection of steroids does not significantly affect results. However, steroid injections remain popular due to their ability to offer fast acting pain relief.
Steroid or cortisone injections carry with them the risk of additional complications, including the decay or tearing of tendons surrounding the elbow. Moreover, steroid injections make muscle and fatty tissue surrounding the joint susceptible to atrophy, and they can cause skin discoloration which may lead to paleness or localized vitiligo.
Extended steroid use can lead to decreased tendon function, which increases the risk of structural problems affecting the elbow tendons and joint instability, both of which are generally only treatable with surgery.
While localized steroidal injections offer rapid pain relief, they offer no clear long-term benefits. Each individual case must be carefully considered due to the potential side effects that come with the use of steroids, with steroid-related tendon damage a particular risk.
Prolonged use of steroid injections aimed at relieving pain can actually cause a number of dangerous side effects.
There is currently no information available to confirm just how many steroid injections are considered safe for tennis elbow patients. However, physicians usually provide them on no more than 2 occasions due to the high risk of side effects resulting from their use.
A study into the use of steroid injections found that in some cases they caused an atraumatic LCL rupture after just one injection. Factors that play a role in complications arising from steroid use include the number and frequency of injections, injection technique, depth of injection, concentration of steroids, and type of steroid being used.
Only 10-20% of cases of tennis elbow require medical assistance. Surgery is often not considered when treating the condition, except in the following circumstances:
Modern minimally invasive surgery techniques minimize the disruption to surrounding muscle tissue, allowing patients undergoing the procedure to quickly recover. We can clearly and fully explore associated lesions that are the possible cause of lateral pain in the elbow joint, and these lesions can be removed in the same procedure. Because of these benefits, I often recommend arthroscopic surgery to my patients for the treatment of chronic lateral elbow pain.
A 14 year old boy sought a second opinion at the hospital, complaining of pain in his elbow. Despite undergoing non-surgical treatment for tennis elbow for a number of months, his condition had not improved. In my position as his doctor, I diagnosed cartilage damage due to his reduced range of movement and his lack of improvement despite rest from activity and wearing a cast. An MRI scan showed that the cartilage had not yet fused, so arthroscopic surgery to repair the damaged cartilage was successful in returning him to the tennis court.
Another boy, this one aged 15 years, was a keen gymnast who was suffering from chronic elbow pain and an inability to fully extend the elbow joint. He had received pain relief medication aimed at treating his condition (tennis elbow), as well as physiotherapy and a period of rest and recovery, none of which were successful in improving his condition. It was therefore decided that he should be transferred to my care, where I was able to diagnose him with dislocated elbow cartilage. The patient underwent arthroscopic surgery and was able to once again fully extend his elbow within just 2 days of the procedure.
A 26-year-old woman was experiencing severe elbow pain and was unable to use her arm properly. After being diagnosed with tennis elbow, she had undergone unsuccessful treatment before being transferred to my care. By undertaking additional screening techniques—this woman had not yet undergone an x-ray—I was able to diagnose calcific tendinitis.
These images are from a 42-year-old male business owner who loves to exercise. After suffering elbow pain for around 6 months, he was diagnosed with tennis elbow and prescribed pain relief medication including injections, time off work, physiotherapy, shock wave therapy (SWT) and various anti-inflammatories, all with no success. The patient was then transferred to my care, where I utilized an arthroscopic technique to identify an impinge lateral plica during elbow flexion as the cause of his chronic pain. This patient had the plica successfully removed during arthroscopic surgery.
A 42-year-old nurse was unable to properly assume the press-up position (as pictured) or lift herself out of a chair due to the pain in her elbow. Pain relief medication, physiotherapy, and 3 separate steroid injections had all been unsuccessful in treating her condition, However, the steroids caused severe structural damage to her tendons, making the tendon reconstruction surgery we subsequently performed essential in her recovery from tennis elbow. Here is the example of severe complication from the steroid’s injection.
Another woman—aged between 39 years—had been diagnosed with tennis elbow and was treated with 3-5 steroid injections. However, her pain had actually increased and changed in nature, and was only relieved for short periods subsequent to the injections. Through arthroscopic surgery we were able to detect the presence of an impinge lateral plica in the elbow, which we removed. However, the many steroid injections had severely compromised her tendon structure, so we had to carry out additional lateral collateral ligament reconstruction surgery. Here is the example of severe complication from the steroids injection and demonstrated elbow arthroscopic surgery can do the reconstruction.
M.D., Faculty of Medicine, Srinakharinwirot University, 1998