Prof. Dr. Belma Füsun Köseoğlu

Department of Physical Medicine and Rehabilitation, Faculty of Medicine

TOBB University of Economics and Technology

COMMON CAUSE OF ELBOW PAIN: TENNIS ELBOW (LATERAL EPICONDYLITIS)

Lateral epicondylitis or tennis elbow is one of the most common painful conditions of the elbow, characterized by pain on the outer surface of the elbow, tenderness to touch, and sometimes weakness in the forearm. Patients typically complain of pain radiating from the outer side of the elbow to the forearm, and sometimes even to the hand, especially during gripping, writing, rotating the forearm, and lifting activities with the palm facing down. Symptoms can be so severe that activities like handshaking, holding a coffee cup, opening a jar lid, blow-drying hair, or lifting a pot can cause intense pain.

How does it occur?

Tendons are strong tissue bands connecting muscles to bones. Lateral epicondylitis is a condition related to the tendons around the elbow, known as the common extensor tendon. Tennis elbow is often considered an overuse injury resulting from repetitive and forceful wrist-forearm activities, responsible for lifting the wrist upward while the palm faces down. Overuse of the tendon leads to injury, inflammation, degeneration, tears (microtears, partial, or complete tears), and even calcification over time. Tennis elbow can also occur less commonly as an acute (sudden) injury after trauma to the outer surface of the elbow. Inflammation and pain occur at the bony prominence on the outer side of the elbow where muscles and tendons attach.

Who is most commonly affected?

While this condition can occur at any age, it is most commonly seen between the ages of 35-55. There is no gender difference observed. It is one of the most common causes of elbow pain, affecting 1-3% of the population. Risk factors for this condition include engaging in repetitive (for at least two hours a day) or strenuous wrist-forearm activities (lifting loads over 20 kg), exposure to repetitive vibration, rapid and forceful repetitive performances in certain sports activities like tennis, computer use, gripping, heavy lifting, squeezing, and other occupational, sports, or daily life activities. Lateral epicondylitis resistant to treatment is more common in individuals engaged in heavy manual labor compared to those in lighter jobs.

What are the symptoms of the disease?

1. Pain around the elbow joint

Patients typically complain of pain radiating from the outer side of the elbow to the forearm. This pain can spread downwards to the hand and upwards to the shoulder. The pain increases with strong gripping and squeezing, and sometimes the squeezing force may be reduced. The onset of pain is generally slow. The type and intensity of pain can vary from mild tenderness felt when touched on the outer surface of the elbow to severe, continuous pain.

2. Muscle weakness

Weakness in the forearm muscles can be felt during gripping and squeezing.

3. Swelling

Some patients may feel swelling around the elbow.

How is the diagnosis made?

The diagnosis of this condition is usually made through the patient’s history and the physician’s examination. However, radiological evaluation (X-ray, ultrasound, or MRI) may be required to rule out other diseases.

What is the prognosis of the disease?

Although in most cases, it is a self-limiting condition within 8-12 months, some cases can become chronic. Simply immobilizing the arm without any treatment is not sufficient, and the recovery period can last from 6 to 24 months.

How is the disease treated?

There is no universally accepted optimum treatment regimen for tennis elbow, and many commonly used treatments have been identified. The goal of treatment is to eliminate pain and tenderness and improve functions. No treatment has been proven to be superior to others. Initially, treatment options such as activity modification, lateral epicondylitis strap, medication use, physical therapy applications, and steroid injections can be performed to relieve pain and other symptoms. Other treatment options may be considered in persistent cases and in later stages. The following are discussed below.

NON-DRUG TREATMENTS:

1. Patient education and activity modification: Providing information to the patient about what the disease is, how it occurs, its symptoms, treatment options, activities to avoid, and the prognosis of the disease. It is recommended to reduce or avoid activities that cause overuse and exacerbate pain.
2. Orthoses

Lateral epicondylitis strap: Such support for six weeks following injury can alleviate pain and improve functions by reducing tension in the extensor tendons at the beginning of the forearm. These orthoses are placed on the forearm just below the most sensitive point (below the lateral epicondyle). Wrist-hand rest splint: It can be used to completely eliminate wrist movements in case of severe symptoms.

3. Physical therapy applications and exercises

Cold and hot applications, iontophoresis, phonophoresis, therapeutic ultrasound, laser, electrotherapy applications, massage, manipulation-mobilization, taping, and various exercise applications such as strengthening and stretching have been shown to reduce pain and correct functions to varying degrees.

4. Extracorporeal shockwave therapy (ESWT), acupuncture, and radiofrequency applications

These treatments have been shown to provide symptomatic improvement in various studies.

DRUG TREATMENTS:

Non-steroidal anti-inflammatory drugs (NSAIDs): These drugs reduce pain and improve functions for a short period (an average of six weeks).

Topically applied drugs to the joint: Topical NSAID drugs (creams, gels, etc.) can be used on the painful skin. Short-term benefits have been demonstrated. Topical nitroglycerin has also shown short-term clinical improvement in pain and functions.

Injections

A single steroid injection mixed with a local anesthetic has been shown to reduce pain for a short period (an average of six weeks). However, multiple steroid injections are not recommended.

PRP, autologous blood, prolotherapy, botulinum toxin injections, and dry needling are other treatments shown in various studies to provide symptomatic improvements.

SURGICAL TREATMENT

Surgical treatment (surgery) is rarely necessary for this condition. More than 90% of patients can be treated non-surgically. Surgical treatment may be considered in cases where symptoms last longer than 6-12 months despite all applied treatments.

FOR MORE INFORMATION:

1. Akın Ceyda, Öken Öznur, Köseoğlu Füsun. Short-term effectiveness of ultrasound treatment in patients with lateral epicondylitis: randomized, single-blind, placebo-controlled, prospective study. Turk J Rheumatol, 2010, volume 25, pages 50-55.
2. Masatoshi Amako, Takeshi Arai, Kousuke Iba et al. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus – Secondary publication. Journal of Orthopaedic Science, 2022-05-01, Volume 27, Issue 3, Pages 514-532.
3. S Cutts, Shafat Gangoo, Nitin Modi et al. Tennis elbow: A clinical review article. Journal of Orthopaedics Volume 17, January–February 2020, Pages 203-207.
4. Neeru Jay