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Tennis/Golfers elbow

Tennis and Golfers’ Elbow (also called lateral and medial epicondylitis)

 

What is it?

The outer and inner bony prominences (lateral and medial epicondyles) of your elbows are the tendinous points of origin for your forearm muscles. Repetitive microtrauma, or just ageing with increased use, can cause these tendon origins to become degenerate and painful. 

The particular tendon origin at fault in tennis elbow is almost always the Extensor Carpi (wrist) radialis brevis (ECRB).  This tendon originates just outside the capsule of your elbow from right on the tip of your outer elbow prominence (lateral epicondyle).  Its function is to extend (bend back) your wrist and its far end inserts into the base of your middle finger’s metacarpal bone. Grip becomes painful in tennis elbow as you need to extend your wrist in order to grip firmly.  

Elbow tendinopathy is very common, affecting 3% of us: typically people aged 35-55 years. Some patients will put their onset down to an intense period of activity or sport, but others will recall no cause.

What is Golfers’ Elbow?

Golfers’ elbow is caused by the same form of tendon degeneration as in tennis elbow, but golfers’ affects the inner, rather than outer prominence of your elbow. This is where the flexor muscles of your forearm, wrist and hand originate.  It is about four times less common than tennis elbow. 

Some patients will also experience symptoms of an irritable ulna nerve, which lies just behind the medial prominence of your elbow (symptoms include: pins and needles in the little finger, shooting pains when tapped over inner elbow, pain and weakness in the forearm and hand).  

The principles of treatment are the same as for tennis elbow: activity and technique modification, physiotherapy, PRP injection and surgery as a last resort

What are the symptoms of tennis elbow?

Most patients describe a gradual onset of pain felt over the outer prominence of their elbow (lateral epicondyle).  Pain typically comes on when gripping objects, or performing certain forearm movements.  As the condition becomes more chronic, the pain may deteriorate into a constant ache and most movements of the arm may exacerbate pain.

What else might it be?

Occasionally other conditions can mimic tennis elbow. Your surgeon will take a careful history and examine you to pinpoint your diagnosis.  In some cases you may be asked to have an ultrasound or MRI scan, or even a nerve test, to help confirm your diagnosis.  Conditions that also cause pain over the outer aspect of your elbow include:

  • Elbow joint problems
    • Arthritis (particularly of the radial head and capitellum)
    • Cartilage defect 
    • Capsule inflammation (synovitis)
    • Capsular fold (plica)
  • Elbow instability (posterolateral rotatory instability)
  • Posterior interosseous nerve entrapment (radial tunnel)
  • Nerve root compression in the neck 

What first-line treatments are there for tennis elbow?

Thankfully the natural history of tennis elbow is that it tends to resolve. Approximately 80% will achieve resolution of their pain by one year.  However, for some the problem will persist and your GP may refer you to a specialist.

The first thing to do is to identify whether a specific activity is causing your problem (e.g. tennis, weight training or a change in work role).  If this is the case, then modifying your technique, grip size, frequency of play or your work environment and duties can help achieve resolution.

The next step is to undergo physical therapy. Physiotherapists will teach you stretches and a specific form of strength training (eccentric training) for your muscles. There is good evidence that this exercise regime is successful at improving symptoms in the majority of patients (50-85%).  Of course, it is vital that you diligently perform these exercises to maximise your chance of success. The physiotherapy programme will take three to achieve its effect.

Other modalities sometimes employed by therapists, such as ultrasound, laser and shock wave have been tried in tennis elbow, but they are either only transiently effective, or useless. They are therefore not recommended. 

Some patients will derive benefit from wearing a brace, although the evidence for their use is less clear than for physiotherapy.  This may involve either a strap placed over the upper forearm, or a wrist splint. A comparative study showed the wrist splint to be superior. If you use a splint, it is important that you still undertake the eccentric physiotherapy programme.

What about injections for tennis elbow? (Second line treatment)

Cortisone (Steroid) Injection 

It used to be very common for doctors to treat tennis elbow with cortisone (steroid) injections.  While these injections provide good pain relief for 6weeks, they are worse than physiotherapy by 3 months.  More worryingly, steroid injections into the tendon substance have also been shown to be harmful to the tendon and they have also been shown to prolong the time to eventual recovery. Steroid injections are therefore no longer for elbow tendinopathy.

Platelet Rich Plasma or Autologous Blood Injections 

Our blood contains cells called platelets.  These cells secrete growth factors that stimulate tissue repair.  

Autologous blood injection aims to promote tissue healing and relieve your pain.  Autologous blood involves the injection of 1.5-3ml of your own blood into your affected tendon.  

Platelet rich plasma (PRP) is more sophisticated and aims to provide a higher concentration of the platelets that can promote healing.  For PRP, 15ml of your blood is taken and spun in a centrifuge to separate the platelet rich layer. This material is then injected. Both ABI and PRP are effective in improving patient symptoms by three months, but PRP is marginally superior in comparative studies. 

It is important that you avoid non-steroidal anti-inflammatory drugs (NSAIDS), such as: aspirin, naproxen, ibuprofen and diclofenac for at least a week before, and for the first three weeks after treatment, as these drugs stop the platelet cells from working.

A recent study into the use of PRP in a population of patients with troubling chronic elbow tendinopathy showed that 70% responded well enough to avoid the need for surgery.

When is surgery indicated?

Most patients improve without surgery, either through natural healing with time, or with the help of physiotherapy +/- PRP injection.  The minority who undergo surgery tend to do so only after these less-invasive strategies have failed. Before committing to surgery it is important that your diagnosis is confirmed, as other problems can sometimes mimic tennis elbow. Your surgeon may therefore order investigations such as ultrasound or MRI scans to confirm the diagnosis. 

Surgery for tennis elbow can be performed either by open or keyhole surgery.  See Procedures - Elbow - Tennis Elbow Release