Tennis Elbow

The primary cause of tennis elbow is repetitive contraction of the forearm muscles used to straighten and raise the hand and wrist. Research published in the Journal of Hand Surgery (2023) suggests that the ECRB muscle is particularly vulnerable because it rubs against bony bumps during elbow movement, leading to gradual wear and tear. This is not always an inflammatory process; rather, it is a failure of the tendon to adapt to the mechanical load placed upon it.

Non-Modifiable Risk Factors

• Age: Most common in individuals aged 30 to 50.
• Anatomy: Variations in the shape of the lateral epicondyle can predispose certain individuals to higher tendon friction.
• Genetics: Some evidence suggests a genetic predisposition to tendon disorders (tendinopathies).

Modifiable Risk Factors

• Occupation: Jobs involving repetitive wrist extension (e.g., painters, plumbers, carpenters, auto mechanics, and professional cooks).
• Smoking: Tobacco use impairs blood flow to tendons, slowing the healing process and increasing the risk of chronic degeneration.
• Improper Technique: In sports, using a racquet that is too heavy or having a 'late' backhand stroke increases the load on the elbow.
• Physical Inactivity: Weakness in the shoulder and core muscles forces the elbow to compensate, leading to overuse.

According to the American Academy of Orthopaedic Surgeons (AAOS, 2024), individuals in manual labor trades are at the highest risk. Statistics show that nearly 40% of tennis players will experience this condition at some point, but they represent only 5% of the total patient population. Those who perform repetitive tasks for more than two hours per day are significantly more likely to develop chronic symptoms.

Prevention focuses on load management and ergonomics. Evidence-based strategies include:

• Strengthening: Regularly performing eccentric exercises (lengthening the muscle under tension) for the forearm extensors.
• Ergonomic Adjustments: Ensuring computer workstations are set up to keep wrists in a neutral position.
• Equipment Check: Using properly sized sports equipment and tools with vibration-dampening handles.
• Gradual Progression: Avoiding sudden increases in the intensity or duration of manual tasks.

Diagnosis is primarily clinical, meaning it is based on a thorough medical history and physical examination. Healthcare providers typically follow a diagnostic journey starting with an assessment of the patient's daily activities and the onset of pain.

During the exam, the provider will apply pressure to the lateral epicondyle to check for tenderness. Several provocative tests are used:

• Cozen’s Test: The patient resists wrist extension while the elbow is flexed; pain at the lateral epicondyle suggests tennis elbow.
• Mill’s Test: The provider passively stretches the forearm extensors; pain during this maneuver is a positive indicator.
• Maudsley’s Test: Resisted extension of the middle finger, which specifically stresses the ECRB muscle.

While often unnecessary for a straightforward diagnosis, tests may be ordered to rule out other issues:

• X-ray: Used to rule out arthritis of the elbow or bone fractures.
• MRI (Magnetic Resonance Imaging): Provides detailed images of the tendon. It can show the extent of tendon tearing or the presence of fluid around the tendon.
• Electromyography (EMG): If the patient has numbness, an EMG may be used to rule out nerve compression, such as radial tunnel syndrome.
• Ultrasound: A cost-effective way to visualize tendon thickening and micro-tears in real-time.

Clinical criteria for diagnosis usually include localized tenderness over the lateral epicondyle and pain elicited by resisted wrist extension or passive wrist flexion with the elbow extended.

Several conditions can mimic tennis elbow, including:

• Radial Tunnel Syndrome: Compression of the radial nerve.
• Cervical Radiculopathy: A pinched nerve in the neck (C6-C7) causing referred pain to the elbow.
• Osteoarthritis: Wear and tear of the elbow joint itself.
• Plica Syndrome: Irritation of the synovial lining within the joint.

The primary goals of treatment are to reduce pain, promote tendon healing, and restore full functional strength. Successful treatment is measured by the patient's ability to return to work or sports without discomfort and a measurable increase in grip strength.

According to the American Physical Therapy Association (APTA) guidelines, the standard initial approach involves the 'RICE' protocol (Rest, Ice, Compression, Elevation) combined with activity modification. This phase focuses on protecting the tendon from further micro-tearing.

Healthcare providers may consider several classes of medication to manage symptoms:

• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): These are used to reduce pain and minor swelling. They may be administered orally or topically (as a cream or gel). Common side effects include gastrointestinal upset or, with long-term use, kidney strain.
• Analgesics: Simple pain relievers like acetaminophen may be used for patients who cannot tolerate NSAIDs. They work by elevating the overall pain threshold.
• Corticosteroids: Injected directly into the area around the tendon, these provide potent, temporary pain relief. However, repeat injections are generally discouraged as they may weaken the tendon over time.

If first-line treatments fail after 6-12 weeks, providers may suggest:

• Platelet-Rich Plasma (PRP) Injections: Using the patient's own blood components to stimulate a healing response.
• Extracorporeal Shockwave Therapy (ESWT): Using sound waves to induce micro-trauma in the tendon, which triggers the body's natural repair mechanisms.
• Physical Therapy: Specifically focusing on eccentric strengthening exercises, which have the strongest evidence for long-term recovery.

• Bracing: A 'counterforce brace' (a strap worn around the forearm) can help redistribute pressure away from the injured tendon site.
• Surgery: Reserved for severe cases that do not respond to 6-12 months of conservative care. Procedures typically involve removing the damaged portion of the tendon (tenotomy).

Most patients (approximately 80-90%) recover within 6 to 12 months with conservative treatment. Monitoring involves regular assessments of grip strength and pain scales.

• Elderly: Focus on maintaining joint mobility and avoiding heavy NSAID use due to potential systemic side effects.
• Pregnancy: Treatment is usually limited to physical therapy and bracing to avoid fetal exposure to certain medications.

> Important: Talk to your healthcare provider about which approach is right for you.

While diet alone cannot cure tennis elbow, an anti-inflammatory diet may support tissue repair. Research in Nutrients (2023) suggests that Omega-3 fatty acids (found in fish oil) and Collagen peptides may assist in tendon health. Maintaining adequate Vitamin C and Zinc intake is also vital for collagen synthesis.

Rest is essential, but 'absolute rest' can lead to muscle atrophy. Patients should engage in 'relative rest,' avoiding the specific movements that cause pain while maintaining general fitness. Once the acute pain subsides, a progressive loading program—starting with isometric holds and moving to eccentric lowering—is the gold standard for recovery.

Pain often worsens at night. Using a pillow to support the arm in a neutral position can prevent the wrist from curling, which puts tension on the extensor tendons. Sleep hygiene is critical, as tissue repair primarily occurs during deep sleep stages.

Chronic pain is linked to central sensitization, where the nervous system becomes hyper-reactive. Techniques such as mindfulness-based stress reduction (MBSR) and diaphragmatic breathing can help lower systemic inflammation and improve pain tolerance.

• Acupuncture: Some studies suggest it may provide short-term pain relief by stimulating local blood flow.
• Yoga: Can improve overall flexibility and shoulder stability, reducing the load on the elbow, but certain poses (like 'downward dog') must be modified during recovery.

Caregivers should encourage compliance with physical therapy exercises and assist with heavy lifting tasks at home to prevent the patient from 'testing' the elbow prematurely, which can lead to setbacks.

The prognosis for tennis elbow is generally excellent. According to a study published in The Bone & Joint Journal (2023), over 90% of patients experience significant symptom resolution within one year using non-surgical methods. However, recovery is often slow and requires patient persistence with rehabilitation exercises.

If left untreated or if the patient returns to heavy activity too soon, complications may include:

• Chronic Pain: Permanent changes in the way the brain processes pain signals from the elbow.
• Tendon Rupture: A complete tear of the ECRB tendon, which usually requires surgical repair.
• Loss of Range of Motion: Stiffness in the elbow or wrist due to prolonged immobilization.

Long-term success depends on permanent activity modification. This may include using ergonomic keyboards, changing sports equipment, or continuing a maintenance strengthening program twice a week.

Patients can lead full, active lives by learning to 'listen' to their bodies. Using heat before activity to increase blood flow and ice after activity to manage soreness are effective long-term strategies.

Contact your healthcare provider if pain persists despite two months of consistent rest and bracing, or if you notice new symptoms like weakness in the hand or 'locking' of the elbow joint.