Tennis Elbow Defined

By Joanna Marshall, DPT, CHT

Tennis Elbow Defined

Please watch this video on why tennis elbow pain can’t wait.

Tennis Elbow, Defined as Lateral epicondylitis, is the most common injury at the elbow. The name is somewhat of a misnomer as rarely is tennis the cause. It occurs most often between the ages of 30 and 50 and is found more frequently in the dominant arm. The causes of tennis elbow can vary.  The most common cause is a cumulative or degenerative overuse of the wrist extensor muscles, particularly the Extensor Carpi Radialis Brevis or ECRB.  This can be an acute repetitive activity, such as painting a room or a gradual onset after years of use. Although less common, tennis elbow can also be caused by acute trauma to the outside of the elbow (called the lateral epicondyle). This can damage the tendon and lead to symptoms of tennis elbow. Watch this VIDEO to learn more about tennis elbow.

illustration of anatomy of tennis elbow

Tennis elbow injury anatomy.

What are the Symptoms of Tennis Elbow?

The quick answer, symptoms of tennis elbow usually involve lateral or outside elbow pain that can radiate into the forearm and wrist. Pain is usually with gripping, lifting, and basic everyday activities. Symptoms usually have a gradual onset of pain, progressing with activity. At the beginning of the onset, the pain is minimal and usually just during activity. Patients often tend to “work thru” the pain instead of resting, leading to the progression of damage to the tendon until the pain can be severe enough to limit all activities.

This is one time where the pain is a useful guide. If it hurts, don’t do it. Rest and activity modification are the most effective treatments.  To understand how to treat tennis elbow effectively, you need to understand the anatomy and mechanics of the ECRB and how to modify your activities to decrease force on this muscle.

What is the Anatomy of the Tendons that are Affected with Tennis Elbow?

The quick answer, the ECRB muscle originates above the elbow and crosses the elbow joint, traveling down the forearm to attach at the index finger’s base. This muscle is responsible for extending and deviating the wrist but can be active with elbow motion. While this muscle creates wrist extension, the muscle is also active when flexing and gripping your wrist and hand. This is because the muscle co-contracts or stabilizes the wrist.  This allows you to have support from which to grip. The extensor muscles (ECRB) are often weaker than the flexor (grip strength) and can create a muscle imbalance and more stress on the ECRB muscle. This explains why most patients complain of pain with gripping activities such as shaking hands, lifting groceries, etc. Because this muscle crosses more than one joint (the elbow and wrist), the muscle forces vary based on the elbow and wrist position.

When your elbow is bent and  you extend the wrist, the muscle is in a very shortened position.  Very little stress is placed on its attachment sites when it contracts. However, when the elbow is extended while the wrist is flexed, the muscle is then being stretched, and a contraction at this position would put significantly more force at its attachment site. This stress causes small micro-tears of the tendon. These micro-tears cause small amounts of swelling and pain.  If microtrauma continues, the tears can become larger, causing the tendon quality to decrease and fray.

How Do You Treat Tennis Elbow?

Treatment for tennis elbow is largely activity modification. Avoiding stress to the ECRB by avoiding picking up objects with the palm down and elbow straight is key. Common things to avoid are reaching over a car seat to grab a bag, stretching around the desk to reach the phone, etc. Try to always lift with the wrist in neutral, and the elbows bent. A stretching program is also beneficial.

image of male performing wrist flexor stretch

Tennis Elbow Stretching

Painful muscles often tend to spasm or tighten up.  Many tennis athletes get relief of pain from over the counter creams such as Voltarin or Biofreeze.  If a muscle is tight, it will place more force on its attachment sites when trying to stretch the muscle. There are some stretches to help slowly stretch the ECRB. The key to remember is that the stretch should last at least 20-30 seconds to have a lasting effect and not be a very painful activity. Remember that these should be pain-free. Please perform stretches 2-3 times each, 3-4 times per day, and perform strengthening 1 time per day if pain-free for at least two days.

When in the acute stages, modalities that can help decrease the inflammation can be helpful. This can include anti-inflammatory medication, ice massage, and electrical stimulation. When more chronic, some will recommend moist heat or ultrasound (a deeper heat) to the muscle to help increase the muscle’s blood flow and extensibility. Some studies have also found that using electrical stimulation call High Volt Galvanic can increase tendon healing. Wrist braces can help keep you from extending the wrist as often and rest the muscle. Counter-force straps help tennis elbow, although actual results vary greatly. Place the brand over the muscle belly about 1.5 inches down from the elbow joint. It should be snug enough to act as a reminder not to contract the muscle but not compromise blood flow to the area.

Does Sports Equipment Matter with Tennis Elbow?

image of tennis racquet and ball on tennis court

The correct sized tennis racquet can help prevent tennis elbow

If you are active in racquet sports, such as tennis, you need to make sure your racquet is fitted properly to avoid extra stress on the ECRB, and you are often recommended to avoid sports for 4-6 weeks if symptoms are severe. Once you have been pain-free for at least two weeks, you can begin a very gentle progressive strengthening program for the wrist. The key is again to start slowly and avoid pain. The elbow should always be bent to allow less stress to the ECRB, and the focus is on endurance (lightweight and high reps) rather than heavy strengthening.

image of resisted wrist extension with a light weight dumbbell

Strengthening for Tennis Elbow

If the above treatments are not helpful, your doctor may recommend a steroid injection. While the injection itself is not comfortable, steroids help remove the swelling and decrease the tendon insertion’s pain. Steroid injections effectively relieve the pain, but the symptoms will often return if the activity is not modified. Most doctors will limit the number of injections to avoid further damage to the tendon. In very few cases, injections and conservative measures are not helpful, and surgical debridement is required. Please contact your JOI clinician or doctor for any questions.

To learn more about tennis elbow, please go to TENNIS ELBOW INFO

JOI Can Help With Tennis Elbow

The Jacksonville Orthopaedic Institute can help with your tennis elbow pain.  We offer comprehensive care from advanced medical intervention to Return to Tennis specific training programs.

JOI Physicians are currently offering ASAP Fracture and Injury Care as well. Make an appointment by calling (904)JOI-2000. This is a new option for patients who would like to avoid the emergency room if they have suffered a fracture or soft tissue injury. To learn more about this service, read this article about fracture and injury care.

By: Joanna Starkey, DPT, CHT

Book An Appointment with a JOI elbow Physician.

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