Tennis Elbow: Symptoms, Treatment And Management

Mr Butt covers the onset of tennis elbow, highlighting that its development is typically gradual, with sufferers rarely able to pinpoint a precise cause. He covers the spectrum of tennis elbow symptoms, diagnosis, and the multifaceted approach to management and treatment. From activity modification and physiotherapy to the potential of surgery, Mr Butt offers a comprehensive overview as well as dispelling common myths surrounding the condition.

If you’re suffering from elbow pain, think you may have tennis elbow or want to book an appointment, get in touch today. You can find out more about our Orthopaedic Surgery here.

What causes tennis elbow?

Tennis elbow, a common ailment often dismissed until it becomes severe, typically begins with subtle signs that many don’t immediately connect to their actions. “Most people have an insidious or slow onset that they don’t necessarily relate to a particular activity,” explains Mr Butt during the interview. However, for some, the pain is distinctly linked to recent activities: “Some people say ‘I’ve started playing tennis’ or ‘I did some intense gardening’”, tracing the onset of discomfort back to specific exertions.

The condition, medically termed ‘epicondylitis’, is characterised by inflammation of the epicondyle—a prominent bone on the side of the elbow. This inflammation is a result of “repetitive overuse tendinopathy,” a scenario where the tendons are damaged repeatedly over time. The anatomy of the elbow, coupled with poor local blood supply, hinders proper healing, leading to “cumulative microscopic damage,” which can escalate to significant tears in the tendons.

Mr Butt explains that “we sustain damage to the tendons throughout our bodies whenever we use them, but in certain areas, they don’t heal well and your elbow is one of them.” He adds that this is because of the local blood supply and the anatomy in the region which doesn’t allow the damage to heal. This results in cumulative microscopic damage, which can lead to proper tears within the tendon. In other cases, it can be an accumulation of failing reparative tissue.

Our bodies try to repair this damage. “You get new blood vessels, which don’t actually work very well as blood vessels, and you get other inflammatory tissue which is not healing the tear and which gets worse and worse with continual use. People might say, ‘It started off mildly. It was only after I played tennis or did X activity, but now it is painful all the time. Now it hurts if I lift a coffee cup or carry a bag down by my side. It wakes me at night occasionally’, it becomes increasingly intrusive.” And, as Mr Butt explains, “that’s when they tend to seek medical help.”

Tennis elbow symptoms

“Elbow pain is the main complaint,” notes Mr Butt, explaining the common yet often ambiguous symptom that plagues patients, who often struggle to be more specific. “Patients rarely articulate their pain using terms like lateral, medial, posterior, or anterior” but the location is important to differentiate various conditions.

Tennis elbow is the most common cause of elbow pain in the working-age population, ages 30 to 60 and affects around 3% of the population at some point in their lifetime.

Describing the type of discomfort experienced can be tricky. “It’s difficult to be more specific about the type of pain because everyone describes things slightly differently,” he adds. What is consistent, however, is the nature of the pain: “It’s a localised deep-seated ache. It’s not usually a sharp pain, and it’s not usually something that takes your breath away. It creeps up on you.” The true challenge with this condition isn’t just the intensity of pain at any given moment but the fact that it can go on for long periods, making it a persistent and troubling issue for many.

Tennis elbow can be aggravated by any activity where you grip because the muscle that’s particularly affected is always used in all gripping activities. This can become pervasive and intrusive throughout all activity because symptoms appear whenever we use our arm or whenever we grip. “It’s persistent, deep elbow pain that is aggravated by activity.

“By the time I see patients, they often have an idea that it might be tennis elbow or they’ve had some treatment elsewhere.”

Symptoms of tennis elbow include:

• Persistent elbow pain
• Pain that worsens with gripping or holding activities
• A localised deep-seated ache in the elbow
• Difficulty performing tasks that involve arm or wrist movement
• Pain that gradually develops and becomes more intrusive over time
• Discomfort or pain when lifting objects
• Tenderness on the outside of the elbow
• Stiffness in the elbow, especially in the morning
• Weakness in the forearm or grip.

Tennis elbow diagnosis

“Diagnosis is usually straightforward,” says Mr Butt. “We do it clinically. I’ll take a history, ask how it’s come on and perform an examination.”

Clinicians will often confirm the initial diagnosis by using an MRI scan or ultrasound. Both can show changes in the soft tissue. “If there’s a concern that it might be something else, we might recommend an X-ray, ultrasound, or an MRI.”

The first step after a diagnosis is to educate the patient about the condition and discuss an appropriate course of conservative management.

How can I manage my tennis elbow?

Activity modification

Patients should try to limit or alter the activities which are leading to the problem.

In tennis, that might mean:

• Altering your grip
• Changing the racquet
• Restringing your racquet to reduce rigidity
• Reducing how hard you hit the ball
• Reducing aggressive backhand
• Using two hands.

There are various techniques, and a tennis coach or a physio could help with those things.

“Activity modification can be a challenge,” explains Mr Butt adding that this is especially true for those in physical jobs or with intense fitness regimes. Many people find it difficult to reduce activities that exacerbate symptoms, for example, professional athletes, “who can’t simply stop their activities.” He adds that surgery often means an enforced rest period, which is essential to its success.

A key difficulty is modifying activity for a reasonable amount of time – often a minimum of six weeks. In many cases, patients might need a permanent change to activity or a careful alteration for at least three months. Within that time, physiotherapy can be helpful to reinforce the techniques and maintain the appropriate loading of the damaged area.

Counterforce strap

A counterforce strap is a band that goes around the muscle. While it doesn’t address the underlying problem, it reduces the stress on the portion of damaged tendon. This helps symptoms at the time of activity. It can sometimes reduce the overall symptoms, but, as Mr Butt explains, “it’s management not a cure.”

Painkillers

People can take non-steroidal anti-inflammatories, such as ibuprofen. These simple medications help with the pain.

Physiotherapy

Physiotherapists use various techniques, including self-directed exercises that the patient does themselves and/or massage.

Physiotherapists might use other techniques for pain relief, including ultrasound and acupuncture. While these methods aren’t backed by strong evidence, they’re relatively low risk and they can provide some relief.

Tennis elbow surgery

“Only 5% of people with tennis elbow end up having an operation,” he says. “The majority manage it through self-limitation and the problem is usually better by 12 months.”

“For those who’ve undergone six months of conservative treatment without improvement and show abnormalities on ultrasound or MRI, surgery might be considered. The procedure involves removing the diseased area and repairing the tendon back onto the bone. This is one of many techniques available, but it is my preferred approach.

“Importantly, surgery has a high success rate for those who reach this stage.”

Tennis elbow myths

1. You don’t have to play tennis to get tennis elbow
2. Steroid injections are not a quick fix. They might provide temporary relief but can ultimately delay healing
3. If you have tennis elbow, it can only be fixed by surgery
4. Surgery is not a quick fix – it involves weeks of rest
5. People often don’t consider that what they’re doing could be influencing their symptoms – for example increased outdoor activity in summer or the adoption of a new physical hobby

The final word…

“The key is making the right diagnosis,” says Mr Butt. “It’s crucial to see a specialist because other conditions can cause similar pain but are treated differently.

“My role is to ensure that the diagnosis is correct, whether it’s tennis elbow, arthritis, radial tunnel syndrome, a ligament injury, or other potential issues in the same area.”

Accurate diagnosis is essential, as is educating patients on prevention and appropriate treatment, including physiotherapy.

“It’s important not to ignore the pain, hoping it will simply get better. Early presentation can lead to a more accurate diagnosis and effective treatment plan.”

Find out more about our Orthopaedic Surgery here.