Do all the tennis players have tennis elbow? Let us find out!

If you want to know and understand about tennis elbow, you are in the right place! This article will discuss its causes, symptoms, and diagnosis, followed by pathophysiology and treatment. 

Definition

The disease, tennis elbow (TE), is medically known as lateral epicondylitis. It is defined as a repetitive strain injury due to the extensive burden on the extensor carpi radialis brevis (ECRB) tendon (bands of tissue connecting the muscles and bone) at the lateral epicondyle (bony bumps on the outer side of the elbow).¹ That was too many fancy scientific words, so put simply, it is a painful condition of the elbow resulting from overuse of muscles. Excessive use of tendons causes inflammation and damage, resulting in pain in the elbow, forearm, and wrist. 

TE is common in athletes playing tennis, badminton, or squash, and among professionals such as painters, carpenters, plumbers, and butchers involved in repeated forearm and wrist movement. Despite the name, only 10% of the affected population are tennis players.¹ TE generally occurs between 30-50 years of age and affects both men and women equally. For proper management of TE, it is important to understand the cause and physical and functional changes happening during the process.

Causes of TE

TE is caused by the repeated contraction of the forearm muscles, leading to injury. Constant and repetitive use of muscles leads to the tear and rupture of the ECRB tendon on the outer side of the elbow. This leads to discomfort, pain, and difficulty in the normal functioning of the affected hand over time. 

TE can develop due to a sudden forceful physical trauma to the elbow or due to small amounts of force over a longer time. This is why people involved in manual labour, such as auto workers, cooks, musicians, and even computer professionals, are prone to TE. In severe cases, it can hinder routine activities, affecting the quality of life in patients. Apart from age and professions involving the repeated motion of arms, smoking, and obesity are also risk factors that can cause TE.

Symptoms and diagnosis

The symptoms of TE vary from person to person and can result in mild to severe pain, which may be intermittent or persistent. They can be as follows:

1. Pain on the outside of the elbow
2. Burning sensation
3. Tenderness or swelling 
4. Weak grip 
5. Trouble in lifting things
6. Stiffness in the wrist

TE usually affects the dominant hand, but in some cases, it can affect both hands. Symptoms can develop gradually over time or suddenly after starting a new type of work. 

TE is typically diagnosed by medical history and physical examination. The healthcare provider assesses the number of recurrences and duration of symptoms to determine TE. Other physical tests to diagnose TE include the Chair test, Cozen’s test, Miller’s test, and Maudsley’s test. There is a questionnaire, Patient-Rated Tennis Elbow Evaluation (PRTEE), designed specifically for TE patients to measure pain and disability at a single time-point and detect changes over time.² Further tests, such as an X-ray, ultrasound, MRI, or EMG, may be required to check for injury or rule out other causes of pain.³

Pathophysiology

Pathophysiology combines pathology and physiology, which deals with physical and functional changes that occur during the progression of a disease. 

Anatomy

To understand the pathophysiology of TE, let us first learn the anatomy of the elbow. The elbow joint is made of three bones: the humerus (upper arm), radius, and ulna (forearm), and is held together by muscles, ligaments, and tendons. The bony bumps at the bottom of the humerus are called epicondyles. The one on the outside of the elbow is the lateral epicondyle. When the ECRB tendon is extensively used over time, it leads to microscopic tears near the lateral epicondyle, causing injury and pain in the elbow.

Physiological changes

TE was earlier thought to be an inflammatory process, but with research, it was later termed tendinosis/tendinopathy, indicating an absence of chemical inflammation. A tendon is a rope-like structure that connects the muscles to the bones and aids movement. It primarily consists of well-structured collagen, with cells called tenocytes and tenoblasts. In TE, the collagen is disrupted and disorganised because of cell death, and healing does not occur as it is continuously under strain.⁴ Another change often seen is angiofibroblastic tendinosis, which is degeneration of the extensor tendon. Here, healing does not occur due to reduced blood flow and the generation of abnormal tissue.⁴

Thus, the physiological changes associated with TE, in a nutshell, are:

1. Collagen disruption
2. Abundant fibroblasts
3. Lack of inflammatory cells
4. Vascular hyperplasia

The mechanical overload, together with limited blood supply and neurogenic involvement, contributes to the progression of TE. A research article indicated the involvement of neuropeptides in TE, which can be a possible cause of pain.⁵  

Treatment

The management of TE does not have a single clear-cut remedy; instead, it can be a combination of various methods. Non-operative methods resolve the TE symptoms significantly in almost 90% of the cases. They can be divided into:

1. Activity modification- Avoiding strenuous activities or work can help relieve the symptoms. Rest, ice, compression, and elevation (RICE) can help with pain in the initial stages
2. Physiotherapy- Various exercises in physiotherapy, specifically eccentric exercise (EE), have been helpful in TE 
3. Non-steroidal anti-inflammatory medicines (NSAIDs)- They are generally used to relieve pain, but can have adverse effects after a long period
4. Acupuncture- Helps alleviate pain associated with TE by increasing the blood flow and circulation to the affected area
5. Shock-wave therapy (ESWT)- Uses high-energy sound waves to promote healing and reduce pain in tendons, ligaments, muscles, and bones
6. Counterforce brace- Helps to reduce pain in short-term cases by restricting the full extension of muscles and tendons.
7. Autologous blood injection (ABI)
8. Platelet-rich plasma injection (PRP)- Both ABI and PRP injections contribute to tendon healing and are used in multiple treatments apart from TE

Operative methods are employed when the conventional non-operative methods fail to work in TE management. About 4-11% typically require surgical intervention, which is rare. The surgeries may be open, percutaneous, or arthroscopic surgery.⁶

FAQs

Can TE be cured? How long does it take?

Yes, it is curable, and most people recover from TE in less than a year. If symptoms persist even after a year, surgery may be considered. 

What are the other names of TE?

The medical term for TE is lateral epicondylitis, but it is also known by names such as lateral elbow tendinopathy and pickleball elbow.

To whom should I reach out for TE treatment?

You should consult with orthopaedic experts, such as elbow specialists and sports physicians, as they can guide you better in managing the symptoms.

Can steroids be used for pain in TE?

Steroids are anti-inflammatory drugs that provide instant relief from pain. However, TE is not associated with inflammation. But they are popular because they are fast-acting.

How long does TE surgery and recovery take?

Surgery is generally done in less than an hour. Recovery depends on the type and extent of surgery done. The patient is mobile and functional in a few months, but returning to sports or other physical activities may take longer.

Can someone who is not an athlete acquire TE?

Yes. Sometimes, TE occurs without any known cause of repetitive stress or injury. It is called idiopathic or of an unknown cause in such cases. 

Summary

Though TE is not a serious or chronic condition, it does affect a considerable number of people across the globe. Repetitive strain over a period can lead to tendon injury, causing discomfort and pain. Awareness and patient education are key factors that can help manage the disease better. Timely help from healthcare providers and following the instructions can lead to a seamless recovery. TE can also be prevented by taking precautionary measures such as avoiding strenuous repetitive tasks, warming up before intense physical activity, and regular exercise to keep the muscles fit.