Tell me where it hurts

Tennis elbow is a fairly straightforward diagnosis: a pain on the lateral – or outside – elbow. It gets worse with lifting or forceful gripping and can radiate down the forearm. It’s not usually associated with any particular injury. Most commonly, it comes on gradually over time and the pain can increase and subside, depending upon activity. Not necessarily an athlete’s affliction Despite its name, tennis elbow doesn’t typically afflict tennis players. “Most commonly, I see tennis elbow in men who do manual labor – factory workers, mechanics – people with repetitive activity associated with their occupation,” says Scott D. Burgess, MD, specialist at the Orthopaedic Associates of Michigan Hand & Upper Extremity Center. “Some women who do repetitive work with their arms get it, as well. But, usually it’s men – and most often those who are in their 40s and 50s.” Why? Repetitive, forceful gripping and repetitive lifting are thought to be the main causes of tennis elbow, which is actually microscopic tears in the tendon in the lateral – or outside – region of the elbow. These microscopic tears accumulate over time and cause a painful tendon. The pain can range from very mild to severe.

The first line of defense

People whose work or daily activities require repetitive forceful gripping and lifting can take steps to prevent tennis elbow. “Stretching and good ergonomic practices can be very helpful,” says Dr. Burgess. “Beyond that, overall body conditioning is extremely important. If you’re in good condition, this type of injury is less likely to happen. If it does happen, it will heal better if you’re in good condition.” Dr. Burgess points out that it’s important to be aware of any onset of pain, and catch it early. “If pain starts, look for the cause and for things that make it worse,” he says. “Try to alter the way you do those activities. Sometimes just a slight modification can make a big difference.”

Home remedies vs. professional care

The majority of people who develop tennis elbow are able to adjust their activities, and the condition goes away on its own. “This is one of those conditions like low back pain,” says Dr. Burgess. “Almost everyone has it at some point in their life, but it doesn’t become chronic for most people. Most can adjust what they’re doing, and it gets better.” But for some people, the pain doesn’t subside, or it becomes so intense that the person can’t perform normal daily activities. “That’s the time to see a doctor,” advises Dr. Burgess. “If the person has tried to rest their elbow, modify activities, and has taken anti-inflammatories, but these remedies haven’t helped over the course of four weeks, they should consult a physician – sooner if the pain is so severe that it’s disrupting normal daily activities or their sleep.” The first stop would be a primary care physician. The doctor would typically talk with the patient about modifying daily activities and may recommend other conservative treatment including physical therapy or some type of brace, such as a forearm strap. Both can help treat tennis elbow and prevent a worsening condition. If the patient doesn’t experience noticeable improvement this these measures, it may be time to see a specialist. That’s where Dr. Burgess and his colleagues at the OAM Hand & Upper Extremity Center come in.

Round 2

“By the time we see patients, they have usually gone through a round of therapy and other conservative treatment,” says Dr. Burgess. “I assess their condition and typically begin with another round of therapy. But second round is directed at activity coaching. We work with the patient to change the way they do activities at home and at work to decrease the stress on that area.” The key here is modification. Patients aren’t told to give up their normal daily or work activities; rather, they’re shown how to alter them. “The therapist acts more like a coach to help them adapt to the pain and make it feel better,” he explains. “They also do some manual techniques to help decrease the pain during the period of rest, change and healing.” At this stage, physical therapy may be used on its own, or in combination with injection therapy.

The right injection, and a little patience

Patients commonly ask Dr. Burgess about cortisone, or steroid, injections – are they effective in treating tennis elbow? The simple answer is, no. “Tennis elbow isn’t tendonitis; it’s tendonosis,” says Dr. Burgess. “It’s a disease of the tendon, not an inflamed tendon. Cortisone is used to treat inflammation and may improve symptoms for a short time, but it can actually weaken the tendon and sometimes even the ligament on that side of the elbow. Repeated cortisone injections in the elbow can lead to elbow instability and worsening pain over time.” But that doesn’t mean injections aren’t a treatment option. “If a patient fails to respond to other conservative treatment, the next thing I offer is an autologous – or whole blood – injection,” says Dr. Burgess. “That’s where we draw some of the patient’s blood, mix it with a local anesthetic, and inject it into the diseased tendon. “This causes an intense inflammatory response and actually attracts cells to the area that work to clean it up and heal the injured tissue,” explains Dr. Burgess. “The injection works slowly, over the course of a few months, allowing that area to heal.” Some patients feel complete relief a few months after a single injection, while others notice improvement but require one or two additional treatments.

Is surgery an option for tennis elbow?

Surgery is an option for treating tennis elbow, but the number of people who need it is very low and it should only be considered after trying other treatment options. “I see two to four patients daily with tennis elbow,” says Dr. Burgess. “By the time they come to me, they’ve already seen their primary care physician, so these are the more severe cases. Despite that, I’d say only 10-15 percent of them need surgery.” In recent years, there has been more of trend toward non-operative treatment of tennis elbow. In fact, some orthopaedic surgeons don’t offer a surgical option for this condition, but Dr. Burgess hasn’t taken it off the table. “I think some patients can be helped by surgery, but we exhaust other options first,” he says. If surgery is recommended, it’s an outpatient procedure. Recovery includes six weeks in a splint and a couple months of physical therapy. Following recovery, most patients’ pain is significantly improved, but not all have complete relief. “I tell patients we’re trying to hit a triple,” says Dr. Burgess. “We’ll see improvement, but we might not hit a homerun.” He says some patients with residual pain are helped with another round of post-surgical injections. “The good news is, there are several very good treatment options for tennis elbow, most of which are conservative and don’t require surgery,” says Dr. Burgess. “Most people get well simply by changing the way they do an activity that caused the condition.”