Tennis Elbow

Although playing tennis can result in tennis elbow, most cases of tennis elbow, also known as lateral epicondylitis, are actually due to overuse when working with the hands. A tendon is the tissue that attaches muscle to bone. The suffix "itis" means inflammation, and while acute overuse injury can cause inflammation, the typical case of tennis elbow is more chronic, due to repeated overuse, and results in degeneration of the tissue. This situation is more appropriately called "tendinosis."

The pointy bone that sticks out on the outside of the elbow is called the lateral epicondyle. This is the common origin of the wrist extensor muscles which cross the elbow and then cross the wrist. It is this tendon that is injured with tennis elbow. 

Tighter grip with wrist extended

When gripping something with your fingers, more power is developed by slightly extending the wrist. This occurs naturally.

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Weaker grip with wrist flexed

Test this by trying to make a tight fist with your wrist flexed (palm moved closer to the forearm) and then repeat the fist with your wrist extended (back of hand moved closer to the forearm). It is much harder to make a tight fist when the wrist is flexed. 

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So, when attempting to grip something firmly, the wrist extensor muscles (that attach to the outside of the elbow called the lateral epicondyle) contract firmly. This is fine. Now when elbow range of motion is added simultaneously, the wrist extensor muscles experience shearing, or variation in the force they experience, while the elbow moves. Additional irritation like a short rapid wrist flexion force can sometimes occur. This combination of forces can create trauma to the extensor muscle group at its insertion point on the lateral elbow (lateral epicondyle).  

A perfect example of the above scenario is when the tennis ball makes contact with the racket during a backhand swing, hence the name tennis elbow. 

A more common situation in my practice would be swinging a hammer all day, scraping paint, or pulling weeds. Basically power grip with the hand superimposed on simultaneous wrist and elbow range of motion.

Acutely, micro-tears can occur in the muscle origin on the outside of the elbow (lateral epicondyle). This can create pain and inflammation. When allowed to rest and recover, the issue resolves. However when the overuse occurs repeatedly, and the micro-tears are not allowed to fully resolve prior to additional trauma, the condition can become chronic. The normal tendon tissue (a tendon is the tissue that attaches muscle to bone) breaks down, and the tissue becomes disorganized and weak (tendinosis). 

Lets talk about treatment. It is important to know that proper non-operative treatment will cure 90% of people. Unfortunately, especially in chronic cases, it can take months to resolve. 

1. Stop the offending activity.
2. Use rest, ice, massage, and anti-inflammatory medication (if ok'd by your physician).
3. When attempting to resume activities consider using a brace. A classic tennis elbow strap should be positioned so the pillow is just down the forearm from the painful spot. A wrist brace will reduce the excursion of the muscles by reducing wrist motion.  Remember how the wrist moves to create power grip? This prevents that from happening. 
4. If symptoms persist- physical therapists can help by using a variety of modalities including phonophoresis, iontophoresis, stretching, strengthening and massage. Most states require a prescription from a physician.
5. Cortisone (steroid) injection can be considered.....sparingly. Although an injection can provide dramatic, immediate relief, it is important to understand that a steroid injection doesn't magically make the tissue healthy again. There is some evidence that this type of injection can actually be counterproductive in the long-term. Especially when used to mask the pain and continue the offending activity. This is a mis-use of cortisone for this condition. I use this sparingly, and as a last resort prior to recommending surgery. 
6. Ultrasound guided microtenotomy with/without platelet rich plasma injection. This procedure involves making a series of poke holes in the degenerative tendon with a needle to induce a more aggressive healing response. Platelet rich plasma is really a topic for another post, but basically it consists of concentrating a portion of the patient's blood that is rich in platelets. This fluid contains a high concentration of growth factors and there is some evidence that it can help induce a healing response. 
7. Surgical debridement and repair. This 15-20 minute outpatient procedure involves a 1.5 inch incision over the affected tissues. The tendon is longitudinally opened, the abnormal tissues are removed (excised) and the underlying bone is irritated (scraped), then the tendon is sutured back together and the skin is closed. The arm is splinted and gradually rehabilitated. This generally cures 90% of patients that have not improved with prior treatment options.