What to do about tennis elbow

Tennis elbow is the common term for lateral epicondylitis, an inflammatory condition of the tendon that connects the extensor muscles of the lower arm to a bony prominence on the outside of the elbow called the lateral epicondyle. The condition causes pain at the point where the tendon attaches to the epicondyle. The pain may radiate to the forearm and wrist, and in severe cases, grip strength may lessen. It can become difficult to perform simple actions like lifting a cup, turning a key, or shaking hands.

As many as half of all people who play racket sports have the condition, but most people who have tennis elbow didn’t acquire it by playing tennis, squash, or racquetball. It can result from any activity that involves twisting or gripping motions in which the forearm muscles are repeatedly contracted against resistance, such as pruning bushes or pulling weeds, using a screwdriver, or playing a violin. Tennis elbow is an occupational hazard for professional gardeners, dentists, and carpenters.

There are many treatments for tennis elbow but not much high-quality evidence about their effectiveness.

What goes wrong in tennis elbow?

Chronic overuse stresses the extensor muscles, causing tiny tears in the tendons (see “Anatomy of tennis elbow”) that result in inflammation, tenderness, and pain.

Tendons are made up of parallel strands of collagen lined up in side-by-side bundles. When strains and tears disrupt this arrangement, the body responds by deploying fibroblasts and other substances to form scar tissue that helps shore up the area. Repetitive injury prevents the scar tissue from healing properly, so it remains weak and painful.

Treatments abound, but what works?

Studies haven’t come to any firm conclusions about the management of tennis elbow. Many treatments relieve the pain, but in most cases only temporarily.. Sometimes the best approach is to simply give the elbow a rest.

A trial published in the British Medical Journal (Nov. 4, 2006) randomly assigned 128 patients with tennis elbow to receive six weeks of physical therapy, two corticosteroid injections, or a “wait and see” approach in which participants were told to modify their daily activities and use heat, cold, pain-relieving drugs, and braces as needed. At the end of the one-year follow-up, improvements in pain-free grip strength and overall pain were roughly equivalent in the physical therapy and “wait and see” groups, while the corticosteroid group was worse off — possibly because the rapid early reduction of pain led to increased activity and overuse.

Australian researchers examined 28 randomized clinical trials involving various nonsurgical interventions, including physical therapy, bandaging, steroid injections, ultrasound, and acupuncture. They found that the studies were either too brief or too poorly designed to shed any light on long-term outcomes — or even to support the short-term use of most treatments. What to do?

Here are some strategies that may help you prevent further injury to the tendon, relieve pain and inflammation, and preserve or restore function.

Initial treatment. Cut back on movements and activities that cause pain in the affected elbow, forearm, and wrist. For additional pain relief, apply ice to the epicondyle for 15 to 20 minutes every four to six hours for the first day or so. Oral over-the-counter pain relievers (ibuprofen, naproxen, aspirin, and acetaminophen) may also help, but because of the risk of side effects, don’t take them for more than four weeks. Some people find that it helps to wear an orthotic (a brace, band, splint, or strap) around the forearm.

Intermediate steps. If symptoms persist, your clinician may recommend a corticosteroid injection. This often provides immediate relief, but don’t take that as a go-ahead to return to activities that aggravate tennis elbow. After the injection, you’ll be given a program to follow that includes rest, ice, and acetaminophen, followed by physical therapy. Repeated injections can cause tissue atrophy, so clinicians usually recommend no more than two to four, even in cases of chronic pain.

Other measures. Surgery is an option in rare cases when the symptoms have lasted more than a year despite rest and other efforts to relieve pain and restore function.

May 2007 update

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