Tennis elbow is the most common elbow issue for which people seek orthopaedic care. What exactly is this problem and how can it be eliminated?
Tennis elbow, or lateral epicondylitis, is an overuse injury leading to lateral (outside)elbow pain and weakness. It is caused by degeneration in the origin of the extensor muscles of the forearm, primarily the extensor carpi radialis brevis (ECRB). These are the muscles on the top of your forearm which extend your wrist and hand when they contract. Activities which require repetitive wrist extension and gripping, such as tennis, can overload the attachment of these muscles on the outside of the elbow, leading to pain and dysfunction. On a microscopic level the tendinous attachment of these muscles shows degeneration and inadequate healing response more than inflammation. Most people who seek treatment for this are not tennis players, but simply active individuals with painful elbows. It usually affects people age 30 and older, causing pain with and without activity which impairs sports participation and activities of daily living. In general, tennis elbow is not a dangerous injury in that it does not lead to elbow arthritis or permanent dysfunction, but it is painful and the recovery can be prolonged.
Standard treatment for lateral epicondylitis is non-surgical and most people eventually have resolution of their symptoms. While inflammation is not the predominant finding on a cellular level, anti inflammatory medicines such as ibuprofen or naproxen (Motrin/Advil or Alleve) are helpful in controlling symptoms. Exercises aimed at stretching and strengthening the affected musculature, either on your own or with a physical therapist, enhance recovery. Use of a counter force brace (tennis elbow strap) may decrease the force generated at the injured tendinous origin with wrist extension/gripping and improve pain. Local measures such as ice massage and topical anesthetics like Biofreeze decrease pain, and a wrist extension brace to help rest the wrist extensors may be useful. Activity modification to protect the injured musculature, either by altering activity level according to symptoms or changing the manner in which these muscles are loaded (changing raquet grip/size/string strength) is of paramount importance for speedy recovery. When these measures fail to improve symptoms, a cortisone injection in the extensor origin can be helpful.
For patients who fail extensive conservative treatment and have symptoms lasting 6 months or more, surgical intervention is warranted. Multiple procedures have been described, all of which involve excision of the degenerative tendon at the origin of the ECRB, often with drilling 2-3 small holes in the bone of the of the lateral epicondyle to allow bone marrow cells to heal new tendon. This procedure was first described by Dr Nirschl, who reported a 75% success rate in terms of functional improvement and resolution of pain. Other options include arthroscopic or ultrasonic debridement of the tissues, but the underlying principle of treatment remains the same regardless of the surgical technique used to accomplish this. Risks and benefits of surgery should be discussed with your orthopaedic surgeon, and patients should understand that conservative treatment remains standard of care because no procedure has been shown to consistently achieve a 95% success rate in unbiased large population studies.
Alternative treatment options, primarily stem cell/PRP injections, have produced conflicting results in multiple studies. A recently published literature review concluded that these interventions lack published results which would support widespread use. Consequently, insurance plans do not pay for these procedures, and the charges from those who recommend them are often in the range of a couple thousand dollars or more. I would not recommend this option until the cost becomes reasonable and the data becomes more convincing.
I hope this information helps you to overcome your tennis elbow and get back in the game!