Tennis Elbow: Overview

Tennis elbow is caused by overusing the forearm extensor muscles. These muscles extend the wrist and are active when you grip something, such as a tennis racquet. Overusing these muscles can cause deterioration or tearing of the tendons attached to the lateral epicondyle.

Causes include:

• improper technique for hitting a tennis ball
• improper size of tennis racquet or tension of racquet strings
• doing certain arm motions too much, such as:
  • tennis strokes
  • golf swings
  • painting
  • raking
  • pitching
  • rowing
  • using a hammer or screwdriver
  • improper golf swing technique or grip of golf clubs
  • wrong model of golf clubs

Risk Factors

Risk factors that increase your chance of getting a tennis elbow include:

• playing tennis or golf
• work that requires repetitive wrist extension and gripping with a closed fist
• muscle imbalance
• decreased flexibility
• advancing age

Diagnosis

Symptoms include pain and tenderness on the outside of the elbow.

Pain increases when:

• shaking hands
• turning doorknobs
• picking up objects with your palm down
• hitting a backhand in tennis
• swinging a golf club
• pressing on the outside of the elbow
• possibly pain extending down the forearm
• tightness of forearm muscles
• stiffness or trouble moving the elbow or wrist
• lack of full elbow extension

The doctor will ask about your symptoms and medical history, your recent physical activity, and how the injury occurred. You may not remember the event that caused the injury because tennis elbow pain develops over time. The doctor will examine your elbow for pain on the outside of the elbow when:

• doing certain arm motions
• pressing on the lateral epicondyle
• stiffness of elbow and wrist movement

X-rays are not usually necessary. However, the doctor may x-ray your elbow to make sure the bones of the elbow are normal, and that there is no calcium deposit in the tendon attachments.

Treatment Options

Treatment of tennis elbow includes:

• rest
  Do not do activities that cause pain. Do not play sports, especially tennis, until the pain is gone.
• ice
  Apply ice or a cold pack to the outside of the elbow for 15 to 20 minutes, four times a day for several days. Wrap the ice or cold pack in a towel. Do not apply the ice directly to your skin.
• medication

  Take one of the following drugs to help reduce inflammation and pain:

  • aspirin
  • Ibuprofen (Motrin, Advil)
  • naproxen (Aleve, Naprosyn)
  • acetaminophen (Tylenol)

  If you still have tenderness in the elbow while taking these drugs, do not return to physical activity. Check with your doctor.

• compression
  Wear a counter-force brace on your forearm if recommended by your health care professional. This brace limits the force generated by your forearm muscles when you use them.
• heat
  Apply heat to the elbow only when you are returning to physical activity. Then use it before stretching or getting ready to play sports.
• stretching
  When the acute pain is gone, start gentle stretching of the wrist and elbow as recommended by a health care professional. Stay within pain limits. Hold each stretch for about 10 seconds and repeat six times.
• strengthening
  Begin strengthening exercises for your wrist extensor muscles as recommended by a health care professional.
• gradual return to your sport
  Begin arm motions of your sport or activity as recommended by a health care professional. (For example: tennis strokes, golf swings, painting)
• cortisone injection
  The doctor may inject cortisone into the tendon attachment at the lateral epicondyle to reduce pain and inflammation.

Prevention

To reduce your risk of getting tennis elbow:

• Keep yur arm muscles strong so they can absorb the energy of sudden physical stress.
• After a short warm-up period, stretch out your arm muscles.
• Learn the proper technique for activities that require forearm motion.
• If you play tennis, ask a tennis specialist to check your:
  • Technique for hitting the ball, especially your backhand
  • Racket size, tension of racket strings, and composition of the racquet frame

How can I prevent tennis elbow?

• Keep your arm muscles strong so they can absorb the energy of sudden physical stress.
• After a short warm-up period, stretch out your arm muscles.
• Learn the proper technique for activities that require forearm motion.
• If you play tennis, ask a tennis specialist to check your technique for hitting the ball, especially your backhand as well as your racket. Pay special attention to the racket size, tension of racket strings, and composition of the racquet frame.

Improving sports performance

The key to improving sports performance after recovering from tennis elbow is proper a rehabilitation program, and adhering to some of those same principles after the injury is gone.

The single most important aspect of improving performance is stretching before and after you step onto the court or golf course.

Benefits derived from stretching include:

• increased physical efficiency and performance
• decreased risk of injury
• increased blood supply and nutrients to joint structures
• increased coordination
• improved muscular balance and postural awareness
• decreased risk of lower-back pain
• reduced stress
• enhanced enjoyment

Tennis elbow rehabilitation

As an athlete, your number one concern is getting back to full strength as soon as possible so that you can return to training and competition. That is why appropriate rehabilitation is extremely important. Rehabilitation for tennis elbow often includes the following:

• Rest
  Do not do activities that cause pain. Do not play sports, especially tennis, until the pain is gone.
• Ice
  Apply ice or a cold pack to the outside of the elbow for 15 to 20 minutes, 4 times a day for several days. Wrap the ice or cold pack in a towel. Do not apply the ice directly to your skin.
• Medication
  Take ibuprofen to help reduce inflammation and pain.
• Compression
  Wear a counter-force brace on your forearm if recommended by your health care professional. This brace limits the force generated by your forearm muscles when you use them.
• Heat
  Apply heat to the elbow only when you are returning to physical activity. Then use it before stretching or getting ready to play sports.
• Stretching
  When the acute pain is gone, start gentle stretching of the wrist and elbow as recommended by your doctor. Stay within pain limits. Hold each stretch for about 10 seconds and repeat 6 times.
• Strengthening
  Begin strengthening exercises for your wrist extensor muscles as recommended by your doctor.
• Gradual return to your sport
  Begin arm motions of your sport or activity as recommended by your doctor. (For example: tennis strokes, golf swings)
• Cortisone Injection
  The doctor may inject cortisone into the tendon attachment at the lateral epicondyle to reduce pain and inflammation.

Rehabilitation exercises

The major objectives of rehabilitation from tennis elbow are to improve the elasticity of the elbow joint and to gradually increase pain-free range of motion. The exercises below stretch the muscles of the forearm and upper arm. These exercises should be performed once or twice daily.

• Wrist flexor stretch
  Extend affected arm forward with palm up and elbow straight. Place fingers and palm of opposite hand across palm and fingers of the extended hand and draw back with it until stretch is felt in the forearm. Hold this position for 3 to 5 seconds, then relax for 3 to 5 seconds. Perform this exercise 10 times.
• Wrist extensor stretch
  Extend affected arm forward with palm down, elbow straight, and fingers slightly curled. Grasp the affected side hand with other hand and draw affected side hand down until stretch is felt in the forearm. Hold this position from 3 to 5 seconds then relax for 3 to 5 seconds. Perform this exercise 10 times.
• Pronation/suppination stretch
  Extend affected arm forward in a hand-shaking position with palm facing up. Slowly rotate the hand from a palm-up position to a palm-down position. Hold for 3 to 5 seconds and then rotate back. Perform this exercise 10 times. When you work your way up to strength training, you may use a small weight while rotating the hand and wrist.
• Tricep stretch
  Stand erect with feet at about shoulder width. Raise injured arm at the shoulder with elbow bent and place the forearm behind the head. Grasp the injured elbow with opposite hand and draw it toward the center of the body until stretch is felt. Hold this position for 3 to 5 seconds then relax for 3 to 5 seconds. Perform this exercise 10 times.
• Bicep stretch
  Stand erect with arms raised to shoulder height and palms up. Press arms backward until stretch is felt. Hold this position for 3 to 5 seconds then relax for 3 to 5 seconds. Perform this exercise 10 times. The bicep is stretched by this exercise as well as the muscles of the shoulder and upper chest.

Strengthening exercises

The following exercises develop strength of the muscles of the forearm and upper arm. To maintain symmetry of the arms in terms of strength and appearance, perform these strength exercises with the uninjured arm as well as the injured arm.

• Wrist extension
  Sit in a chair with forearm resting on the end of a table, palm down. Grasp a light weight dumbbell and raise the weight up as high as possible while maintaining contact with the table top. Hold this position for 3 to 5 seconds. Relax for 3 to 5 seconds. Repeat this exercise 5 to 10 times. Substitute a heavier dumbbell as strength increases.
• Arm curls
  Either standing or sitting, grasp a 2- to 4-pound dumbbell in one hand. With palm up, flex elbow and draw the dumbbell up to the same side shoulder while maintaining erect posture. Do not bend at the waist or swing the dumbbell. Lower dumbbell slowly and with control to the starting position. Repeat this exercise 10 times. Use a heavier dumbbell as strength increases

Alternative exercises

During the period when normal training should be avoided, alternative exercises may be used. These activities should not require any actions that create or intensify pain at the site of injury. They include:

• swimming (if pain allows)
• jogging
• stationary bicycle

How long will the effects of my injury last?

Duration of effects varies significantly. Unless surgery is required, symptoms may diminish within 7 to 10 days and disappear in 2 or 3 weeks. Grip strength can return to normal in about the same time period.

However, some stubborn cases requiring injection or surgical intervention may show symptoms that persist for months.

Finally, recurrence of tennis elbow is common. It may take months for a recovery in which all symptoms vanish forever and there is a return to full activity.

When can I return to my sport or activity?

Some may be ready for full participation in two wees, others not for two months or more. Of course, time for return to activity is much longer if surgery is necessary.

Remember: The goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon you may worsen your injury, which could lead to permanent damage. Everyone recovers from injury at a different rate. Return to your activity is determined by how soon your tennis elbow recovers, not by how many days or weeks it has been since your injury occurred.

A good rule is to allow pain to dictate when you're ready to return to activity. You should return in moderation, and back off if you feel any pain.

If you require surgery for your tennis elbow, your doctor will prescribe you with physical therapy, and returning to your sport may take longer.