About Elbow Pain, Elbow Pain Treatment, Elbow Surgery, Tennis Elbow Pain

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What is Tennis Elbow or Lateral Humeral Epicondylitis?

Lateral epicondylitis, commonly known as tennis elbow, is not limited to tennis players. The backhand swing in tenis can strain the muscles and tendons of the elbow in a way that leads of repetitive activities can also lead to tennis elbow. But many other types of repetitive activities can also lead to tennis elbow: painting with a brush or roller, running a chain saw and using many types of hand tools. Any activities that repeatedly stress the same forearm muscles can cause symptoms of tennis elbow.

Anatomy:

What parts of the elbow are affected?

Tennis elbow causes pain that starts on the outside bump of the elbow, the lateral epicondyle. The forearm muscles that bend the wrist back (the extensors) attach on the lateral epicondyle and are connected by a single tendon. Tendons connect muscles to bone.

Tendons are made up of strands of a material called collagen. The collagen strands are lined up in bundles next to each other.

Because the collagen strands in tendons are lined up, tendons have high tensile strength. This means they can withstand high forces that pull on both ends of the tendon. When muscles work, they pull on one end of the tendon. The other end of the tendon pulls on the bone, causing the bone to move.

When you bend your wrist back or grip with your hand, the wrist extensor muscles contract. The contracting muscles pull on the extensor tendon. The forces that pull on these tendons can build when you grip things, hit a tennis ball in a backhand swing in tennis, or do other similar actions.

What are the causes of Tennis Elbow or Lateral Humeral Epicondylitis?

Overuse of the muscles and tendons of the forearm and elbow are the most common reason people develop tennis elbow. Repeating some types of activities over and over again can put too much strain on the elbow tendons. These activities are not necessarily high level sports competition. Hammering nails, picking up heavy buckets, or pruning shrubs can all cause the pain of tennis elbow.

In an acute injury, the body undergoes an inflammatory response. Special inflammatory cells make their way to the injured tissue to help them heal. Conditions that involve inflammation are indicated by -itis on the end of the word. For example, inflammation in a tendon is called tendonitis. Inflammation around the lateral epicondyle is called lateral epicondylitis.

However, tennis elbow often does not involve inflammation. Rather, the problem is within the cells of the tendon. Doctors call this condition tendinosis. In tendinosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers.

Instead of inflammatory cells, the body produces a type of cells called fibroblasts. When this happens, the collagen loses its strength. It becomes fragile and can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue.

No one really knows exactly what causes tendinosis. Some orthopaedics think that the forearm tendon develops small tears with too much activity. The tears try to heal, but constant strain and overuse keep re-injuring the tendon. After a while, the tendons stop trying to heal. The scar tissue never has a chance to fully heal, leaving the injured areas weakened and painful.

What does Tennis Elbow feel like?

The main symptom of tennis elbow is tenderness and pain that starts at the lateral epicondyle of the elbow. The pain may spread down the forearm. It may go as far as the back of the middle and ring fingers. The forearm muscles may also feel tight and sore.

The pain usually gets worse when you bend your wrist backward, turn your palm upward, or hold something with a stiff wrist or straightened elbow. Just reaching into the refrigerator to get a carton of milk can cause pain. Sometimes the elbow feels stiff and won’t straighten out completely.

How is Tennis Elbow or Lateral Humeral Epicondylitis diagnosed?

Our specialist will first take a detailed medical history. You will need to answer questions about your pain, how your pain affects you, your regular activities, and past injuries to your elbow.

The physical exam is often most helpful in diagnosing tennis elbow. Our specialist may position your wrist and arm so you feel a stretch on the forearm muscles and tendons. This is usually painful with tennis elbow. There are also other tests for wrist and forearm strength that can be used to detect tennis elbow.

You may need to get X-rays of your elbow. The X-rays mostly help our specialist rule out other problems with the elbow joint. The X-ray may show if there are calcium deposits on the lateral epicondyle at the connection of the extensor tendon.

Tennis elbow symptoms are very similar to a condition called radial tunnel syndrome. This condition is caused by pressure on the radial nerve as it crosses the elbow. If your pain does not respond to treatments for tennis elbow, our specialist may suggest tests to rule out problems with the radial nerve.

When the diagnosis is not clear, our specialist may order other special tests. A magnetic resonance imaging (MRI) scan is a special imaging test that uses magnetic waves to create pictures of the elbow in slices. The MRI scan shows tendons as well as bones.

Ultrasound tests use high frequency sound waves to generate an image of the tissues below the skin. As the small ultrasound device is rubbed over the sore area, an image appears on a screen. This type of test can sometimes show problems with collagen degeneration.

What are the treatments of Tennis Elbow or Lateral Humeral Epicondylitis?

Nonsurgical Treatment:

The key to nonsurgical treatment is to keep the collagen from breaking down further. The goal is to help the tendon heal.

If the problem is caused by acute inflammation, anti-inflammatory medications  may give you some relief. If inflammation doesn’t go away, our specialist may inject the elbow with anti-inflammatory medication.

Shock wave therapy is a newer form of nonsurgical treatment. It uses a machine to generate shock wave pulses to the sore area. This is to help generate the healing process of the tendon.

Surgical Treatment:

Sometimes nonsurgical treatment fails to stop the pain or help patients regain use of the elbow. In these cases, surgery may be necessary.

Tendon Debridement

When problems are caused by tendinosis, surgeons may choose to take out (debride) only the affected tissues within the tendon. In these cases, the surgeon cleans up the tendon, removing only the damaged tissue.

Tendon Release

A commonly used surgery for tennis elbow is called a lateral epicondyle release. This surgery takes tension off the extensor tendon. The surgeon begins by making an incision along the arm over the lateral epicondyle. Soft tissues are gently moved aside so the surgeon can see the point where the extensor tendon attached on the lateral epicondyle.

The extensor tendon is then cut where it connects to the lateral epicondyle. The surgeon splits the tendon and takes out any extra scar tissue. Any bone spurs found on the lateral epicondyle are removed. (Bone spurs are pointed bumps that can grow on the surface of the bones). Some surgeons suture the loose end of the tendon to the nearby fascia tissue. (Fascia tissue covers the muscles and organs throughout your body). The skin is then stitched together.

Rehabilitation

Nonsurgical Rehabilitation:

In cases where the tendon is inflamed, nonsurgical treatment is usually only needed for four to six weeks. When symptoms are from tendinosis, you can expect healing to take longer, usually up to three months. If your tendinitis is severe, it may take at least six months for complete healing.

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