Introduction

Tennis elbow, also called lateral epicondylitis, is a condition that causes pain and inflammation on the outside of the elbow, commonly seen in athletes and labourers. 50% of tennis players develop elbow pain at some point in their lifetime, and 75% of these cases are tennis elbow. It is associated with activities that involve repetitive strain on the wrists and elbows, which is caused by gripping and extension movements.¹ The pain usually improves with rest and conservative treatment.² People with persistent pain may require surgery, but it doesn’t always provide increased benefits compared to conservative treatment.

Symptoms

• Pain, tenderness and weakness in the forearm and back of the elbow, which worsens with bending/lifting the arm, gripping and extending the wrist^1,2
• Difficulty straightening the arms

Causes 

• Improper form in the backhand stroke while playing tennis
• Weak muscles in the wrist and shoulder
• Other racket sports, like racketball or squash
• Extensive painting with a brush or roller
• Working with a chainsaw
• In butchers, musicians, dentists, autoworkers, and carpenters who use their hands a lot⁴

What can you do?

The NHS recommends:⁵ 

1. Reducing activities that increase pain
2. Using paracetamol or anti-inflammatory gel on the affected area
3. Applying a hot or cold pack for up to 20 minutes every 2 to 3 hours
4. Doing simple exercises, such as bending and straightening the forearm
5. Wearing an elbow counterforce/wrist brace
6. It is important to visit a doctor if pain continues after 2 weeks of at-home treatment.

Diagnosis

The doctor may need to do the following: 

• Physical examination of the forearm, wrist and elbow joints by performing special movement tests⁶
• X-rays to rule out arthritis, electromyography (EMG) to check for nerve compression, and ultrasound to assess tendon damage^1,6
• Pain assessment:
  • With either a visual assessment scale, where the pain is rated using pictures provided, or a numeric assessment scale, where it is rated from 0 to 10, 0 being no pain and 10 being the worst pain. The scale is used as a guide for assessing pain before, during and after a rehabilitation exercise by a person doing it at home.
    • 0 to 3 – minimal pain 
    • 4 to 5 – acceptable pain
    • 6 to 10 – excessive painIf the pain increases beyond 5, it is recommended to reduce the number of repetitions, slow the speed and take resting intervals
  • Self-assessment questionnaires where a person rates pain and disability from 0 to 10 (0- no pain, 10- worst pain) by answering questions

Conservative treatment options

• Rest, ice application, anti-inflammatory medications, and, occasionally, steroids
• Using high-voltage galvanic stimulation to improve healing⁷
• Exercises to improve strength and flexibility.^5,6,7 The NHS provides information on the duration and frequency of exercises to be repeated.⁸ There are videos on different exercises for elbow pain given by the Chartered Society of Physiotherapists
• Lifestyle modifications such as avoiding heavy weight lifting, reducing activities which involve excessive wrist movement, wearing a forearm brace to reduce strain on the arm muscles and incorporating resting periods in between activities are recommended

How can you avoid surgery?

Ice and heat application

Alternating between hot and cold applications using ice packs, hot water bottles, frozen peas, etc, for at least 15-20 minutes, 3-4 times a day helps in reducing swelling and healing the muscles.⁹

Medications

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) such as paracetamol, ibuprofen in the form of tablets, creams or gels are often prescribed to reduce inflammation and swelling.¹⁰ Local corticosteroid injections can be beneficial when given early, followed by a 1-2 week rest and then repeated 2 times in 3 months. Steroid injections can be unpleasant, and a person taking them may develop unwanted side effects.

Physiotherapy sessions

Physiotherapy involves stretching, endurance, and strengthening exercises for forearm muscles and tendons, with massages to reduce muscle tightness. This is done under supervision of a physiotherapist.

Stretching exercises 

• Fully extending (straightening) the elbow while flexing (bending) the wrist to maximum limit without pain, 15-25 seconds and 3 to 4 times a day
• Fully extending (straightening) the elbow, turning the forearm palm down, bending the wrist downwards for 30-45 seconds, 3 times before and after eccentric exercises

Eccentric exercises

Eccentric exercises strengthen the muscles of the opposing movement to the movement causing repetitive strain, to balance and stabilise your elbow joint. They are done using dumbbells (2-pound weights) and repeated 15-20 times, for 2 sets.

Steps

• Hold the weight (dumbbell) in your hand of the affected side, with your palm facing down
• Sit at a table with your forearm resting on the table
• Use your other hand to hold the wrist of the affected elbow from below
• Remove your good hand and slowly lower your affected wrist while holding the weight

Fist-clenching exercises can help strengthen your forearm muscles too - they focus on grip strength using a towel.

Steps

• Sit with your forearm resting on a table 
• Hold a rolled-up towel or a small ball with the injured hand
• Squeeze it and hold for 10 seconds, then release
• Repeat 10 times, and repeat on the other side

Resistance band and resistance bar exercises

Exercises with small weights are done every day for 4 weeks, for 3 sets of 10 repetitions. Resistance devices are also used for at-home self-guided practice.

Steps

• Place the band under the feet and hold the other end with the hand of your injured side
• Stand up straight, keeping your elbows close to your sides with the back of your hand facing the floor
• Lift the forearm of your affected side up using your free hand, bending the affected elbow
• Let the resistance band move the affected wrist down slowly

Ultrasound therapy for healing

Ultrasound therapy involves a hand-held device (shown below) that transports sound waves through the forearm, deeply heating the skin, tendons and muscles, which helps them heal.^6,7 

Advanced conservative treatments

In people who do not respond to conventional conservative treatments, like resting, applying ice, medications and physiotherapy, there are some alternative options:

1. Shock waves are sometimes used on the forearm (3 to 5 sessions) to help the repair process and for pain relief¹¹ 
2. TENS therapy is a simple, safe and inexpensive treatment used to reduce pain using electrical impulses on the skin.¹² Over-the-counter kits are available, which you can use at home by following the instruction manual given in the kit
3. Plasma (a blood component) taken from your own blood that is rich in platelets, called platelet-rich plasma (PRP), is injected into the elbow to help in chronic pain¹³
4. Fine needles are inserted into special muscle points in a process called acupuncture treatment. This increases the blood flow around the injured arm and promotes faster healing. It is often used in chronic tendon and deep tissue pain
5. Manual therapy is when the therapist uses massaging hand movements around the forearm to provide relaxation, control pain and swelling, and enable movement. It is one of the oldest methods and includes massages of deep tissues and passive movements of the forearm¹⁴
6. Customised splints, orthotic braces and compression bandages are used to reduce movement and stress while allowing healing in the elbow region
7. Occupational changes involve modifying work activities that increase stress and pain around wrist and forearm, assessing activities and progress with time, and incorporating resting intervals and wearing braces and straps to support the arm and wrist

FAQs

What can I do if I have elbow pain?

Reduce or stop activities that increase pain, take over-the-counter pain reliever medicines, and use ice and heat packs.

What medicines should I take for elbow pain?

Locally available paracetamol or ibuprofen can be taken.

When do I see a doctor?

If the pain continues after 2 weeks of at-home measures.

How do I do exercises at home?

Instructions are available on the NHS website, and videos are on the Chartered Association of Physiotherapists’ webpage.

When do I visit the physiotherapist?

Your GP or doctor will advise you on whether you need a physiotherapist after around 6 weeks of rest and symptom control.

Summary

Tennis elbow, also called lateral epicondylitis, is a condition that causes pain and inflammation on the outside of the elbow, commonly seen in athletes and labourers. So, in simple terms, tennis elbow is an elbow injury due to overuse. Conservative treatments have shown successful results in treating it when followed over time. So, conservative treatment like ice pack/heating pad treatment, physiotherapy, weight-workout (especially with dumbbells), resistance band exercise, etc, are useful. Surgical treatments are invasive, but most people with tennis elbow recover over 6-18 months without surgery and instead by doing physical therapy, along with medications and lifestyle changes.