Tennis Elbow (Lateral Epicondylitis)
Tennis Elbow (Lateral Epicondylitis) | Denver, Colorado
Lateral epicondylitis, oftentimes referred to as Tennis Elbow, is an extremely common and very painful condition I see frequently in my hand surgery practice in the Denver metropolitan area.
The good news is tennis elbow rarely needs any sort of surgical intervention. The bad news is it can linger for a significant period of time. The root of the problem lies at the interface between the muscles that extend your hand and wrist and where they attach to the bone at the outside of your elbow. Repetitive injury at this interface can lead to degeneration and a cycle of pain known as lateral epicondylitis.
In general, I think the term tennis elbow is a disservice. It downplays how painful and debilitating this condition can be.
Tennis Elbow Diagnosis & Treatment
Figure 1 - If you have pain at this location on the outside of your elbow, chances are high that you have lateral epicondylitis, or “Tennis Elbow.”
The diagnosis of tennis elbow is straightforward and largely a clinical diagnosis. This means we can usually detect it based on a detailed conversation and physical examination. Additional imaging or testing is not generally helpful or necessary.
Classic symptoms of tennis elbow include pain at the outside of the elbow that may radiate down the back of the forearm (see Figure 1). This pain can be made worse with the slightest of arm movements. The most common complaint I hear is severe pain with typing or something as simple as grabbing a cup of coffee.
You may first notice these symptoms after a prolonged period of inactivity followed by a burst of upper extremity use. I commonly see this following a big house project (spring cleaning) or shoveling a big snow.
As I said before, very few patients go on to need surgery for tennis elbow. The mainstay of treatment is rest, activity modification, over-the-counter medications, and therapy. Steroid injections to the elbow used to play a large role in treating this condition. But over time, we have learned that while they may make you feel better in the short term, they can actually prolong the condition in the long term.
Interventions such as PRP or shockwave therapy have not yet produced reliable enough results to justify using these expensive treatments.
Tennis Elbow Surgery
If your symptoms have lasted nine months to a year and continue to be resistant to nonoperative treatment measures, some patients benefit surgery.
In this procedure, a 4-5 cm incision is made over the outside of the elbow. The degenerative muscle fibers are excised, and the remainder of the tendon is repaired back down to the bone to facilitate healing.
Patients will then progress through a splinting and therapy protocol to initially limit their wrist activities to allow the repair to heal. Most patients are back to full activities without restrictions by 3-4 months after surgery.
Additional Information
If you’d like more information on lateral epicondylitis, please continue reading through the frequently asked questions below. You can also access my ‘deep dive’ section to the right of the FAQs where I have links to the longer-form articles I have written about various topics related to lateral epicondylitis and its treatment.
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The Basics
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Tennis Elbow, or Lateral Epicondylitis is a painful tendinitis that occurs on the outside of the elbow. It affects movements of the elbow, forearm, wrist, and fingers.
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Tennis elbow is typically thought of as an overuse injury. There are many muscles involved in extending the wrist and fingers. These muscles attach as a large bundle to the humerus bone at the outside of the elbow. This is where they are anchored and from where they generate all of their force.
The inner core of this interface receives relatively poor blood supply and overuse injury to the area can lead to a cycle of painful degeneration that causes significant pain and dysfunction. While this may feel inflammatory in nature, it is technically not an inflammatory condition when examined in the laboratory under the microscope.
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Tennis elbow is extremely common. It is estimated that 2-3% of all adults will develop this condition each year. It is most common between the ages of 30 and 50 years old.
While it is common in tennis players, it is also common in people who engage in heavy labor or repetitive hand/wrist activities.
Tennis Elbow Symptoms & Diagnosis
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Tennis elbow symptoms include pain on the outside of the elbow that radiates down into the back of the forearm. Many patients feel it all the way down to their wrist. It is common for this pain to worsen with movements of the elbow, wrist, and even fingers.
Remember that the disease lies at the interface between the wrist and finger extensor muscles with the bony attachment at the outside of your elbow. So any activities that involve repetitive wrist or finger extension will exacerbate symptoms.
Oftentimes symptoms are out of control by the time I see patients in my clinic. Most patients note severe pain with motions as simple as grabbing a coffee cup. If you think about it, this motion involves extension of your wrist to allow your fingers to grab the cup, resulting in classic tennis elbow pain.
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Tennis elbow diagnosis is usually pretty straightforward with a simple discussion of the details of your symptoms and an examination. Patients are typically very tender to the touch directly on the outside of the elbow where the muscles attach. Pain with resisted wrist extension or finger extension that recreates their symptoms is also diagnostic.
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Imaging is not a necessary component of tennis elbow diagnosis. In cases where the diagnosis is unclear or overlapping pathologies are present, X-rays, ultrasound, and in rare cases, MRI can be beneficial.
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This is the inherent “danger” of getting an MRI. It is common for patients to come to me with an MRI that was ordered elsewhere. This MRI will inevitably show a ‘tear’ of the muscular origin at the lateral epicondyle.
It is natural human instinct to associate ‘tear’ with a need for surgical fixation. This simply is not the case. In this entity, as I've mentioned before, more than 90% of patients will heal from this on their own without the need for surgical treatment.
Tennis Elbow Treatment
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The bulk of lateral epicondylitis treatment is nonoperative. We have several very good natural history studies that tell us what occurs naturally with this condition if we do nothing at all to intervene. Essentially all cases of tennis elbow will resolve after one to two years.
Now I understand that most patients don't want to deal with the pain from this condition for one to two years. So everything we do nonoperatively is to speed up that timeline as much as possible. The majority of patients will find a combination of treatments that resolves their symptoms. This may include rest, modifying their activities, using a wrist brace (more on that below), or working with therapy. A combination of these tactics and a little bit of patience is very effective.
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Historically, injections played a large role in the treatment of lateral epicondylitis. Unfortunately, as more data has been gathered over the years, we have realized that while injections make patients feel quite good in the short term, they actually slow down the healing process and prolong their symptoms long term. With this understanding, very few patients opt for injections. I typically don’t recommend it, but I will consider injections in special circumstances.
Additional interventions such as PRP or shockwave therapy have not yet shown enough promise to justify their high cost of use in the treatment of this condition. While I would love to offer a faster solution to the resolution of symptoms, that magic bullet just doesn't yet exist for this condition.
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Notice that I mentioned a wrist brace above. Again, refer back to the anatomy and remember that the cause of this issue comes from stress between the muscles that extend your wrist and fingers at the bone where they attach. A wrist brace will prevent repetitive use of these muscles and will allow that interface to rest and heal itself.
I realize it is counterintuitive to use a wrist brace for elbow pain. But this is exactly the most effective thing you can do.
Tennis Elbow Surgery
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Surgical treatment for tennis elbow becomes an option after nine months to a year of resistance symptoms. If the above nonoperative measures have failed over a long course of time, we may consider surgery. However, even surgery isn't a guarantee if your symptoms have lasted this long.
In this surgery, a 4-5 cm incision is made over the outside of the elbow. The muscle layers are carefully split to reveal the inner core of poorly healing tissue. This tissue is excised and the remaining healthy tendinous tissue is repaired back down to bone with a device called a suture anchor.
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Following tennis elbow surgery, you will be placed into a post-operative splint. All my patients have a visit with a Certified Hand Therapist within a week or so of surgery. At this visit, the splint is removed and some gentle exercises are begun.
I will then meet with you approximately 2 weeks after surgery to evaluate your healing process. The sutures I use are absorbable, so they will not need to be removed in the office.
The next stage of healing is a period of intermittent bracing, limitation of use of the hand/wrist, and progressive strengthening. This whole process will play out over 2-3 months after surgery. The majority of patients feel 90% recovered by 3 months.
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All surgeries have risks, many of which are generic to surgery itself. I go over these in detail with you before surgery as part of the informed consent process. Examples include bleeding, infection, damage to surrounding tendons/nerves/vessels, anesthesia risks, or failure of the procedure.
The most common risk of tennis elbow surgery is incomplete resolution of pain. While 80-90% of patients resolve their pain with surgery, that means 10-20% still have lingering symptoms. These typically do not require any further intervention, but these are numbers to be aware of before electing for surgery.
