Tennis elbow, or lateral epicondylitis, is the most common injury in patients seeking medical attention with the complaint of elbow pain. Exactly what causes tennis elbow is unknown, but it is thought to be due to small tears of the tendons that attach the muscles of the forearm to the arm bone at the elbow joint.

The muscle group involved, the wrist extensors, function to cock the wrist back. Specifically, the extensor carpi radialis brevis, has been implicated in causing the symptoms of tennis elbow

Causes and risk factors

Playing tennis three times in a week when you haven't played for some time is the sort of overuse that could cause tennis elbow. It is especially likely if you have a poor backhand technique or use a racquet with a grip that is too large

But most people who develop tennis elbow have not been playing tennis. A range of different activities that involve repeated hand, wrist or forearm movements can be to blame. These might include:

• using scissors or shears
  
  
• gardening
  
  
• sports that involve lots of throwing
  
  
• swimming
  
  
• golf (golfers also get golfers' elbow, which affects the inside of the arm)
  
  
• manual occupations that involve repetitive turning or lifting the wrist, such as plumbing or bricklaying
  
  

Weakness and inflexibility in the forearm muscles makes tennis elbow more likely.

Some people seem to be at increased risk of tendon injury. They may also have trouble with the tendons in the shoulder and the wrist (carpal tunnel syndrome).

Symptoms Of Tennis Elbow

• Recurring pain on the outside of the upper forearm just below the bend of the elbow; occasionally, pain radiates down the arm toward the wrist.
  
  
• Pain caused by lifting or bending the arm or grasping even light objects such as a coffee cup.
  
  
• Difficulty extending the forearm fully (because of inflamed muscles, tendons and ligaments).
  
  
• Pain that typically lasts for 6 to 12 weeks; the discomfort can continue for as little as 3 weeks or as long as several years.
  
  

The damage that tennis elbow incurs consists of tiny tears in a part of the tendon and in muscle coverings. After the initial injury heals, these areas often tear again, which leads to hemorrhaging and the formation of rough, granulated tissue and calcium deposits within the surrounding tissues. Collagen, a protein, leaks out from around the injured areas, causing inflammation. The resulting pressure can cut off the blood flow and pinch the radial nerve, one of the major nerves controlling muscles in the arm and hand.

Tendons, which attach muscles to bones, do not receive the same amount of oxygen and blood that muscles do, so they heal more slowly. In fact, some cases of tennis elbow can last for years, though the inflammation usually subsides in 6 to 12 weeks.

Many medical textbooks treat tennis elbow as a form of tendonitis, which is often the case, but if the muscles and bones of the elbow joint are also involved, then the condition is called epicondylitis. However, if you feel pain directly on the back of your elbow joint, rather than down the outside of your arm, you may have bursitis, which is caused when lubricating sacs in the joint become inflamed. If you see swelling, which is almost never a symptom of tennis elbow, you may want to investigate other possible conditions, such as arthritis, infection, gout or a tumor.

Treatment

Initial treatment of tennis elbow usually involves self-care steps including rest, icing the area and use of acetaminophen (Tylenol, others) or over-the-counter (OTC) anti-inflammatory medications, such as ibuprofen (Advil, Motrin, others) or naproxen (Aleve, others). If those steps don't help and you still have pain and limited motion after a week or so, your doctor may suggest other steps. These may include:

• Analyzing the way you use your arm at work or at play. Your doctor may suggest that experts evaluate your tennis technique or job tasks to determine the best steps to reduce stress on your injured tissue. This may mean going to a two-handed backhand in tennis or taking ergonomic steps at work to ensure that the way you use your wrist and forearm doesn't continue to contribute to your symptoms.
  
  
• Exercises. Your doctor — or physical therapist to whom you've been referred by your doctor — may suggest exercises to gradually stretch and strengthen your muscles, especially the muscles of your forearm. Once you've learned these exercises, you can do them at home or at work. Your doctor may also suggest you wear straps or braces to reduce stress on the injured tissue.
  
  
• Corticosteroids. If your pain is severe and persistent, your doctor may suggest an injection of a corticosteroid medication. Corticosteroids are drugs that help to reduce pain, swelling and inflammation. Injectable corticosteroids rarely cause serious side effects, although they may temporarily raise blood sugar levels in people with diabetes. However, these medications don't provide a clear long-term benefit over physical therapy exercises or taking a wait and see approach and simply resting your arm. Your doctor may also suggest use of topical corticosteroids for pain relief. These corticosteroids are absorbed through your skin during a treatment called iontophoresis, which involves drawing the medication into the tissue through electrical charges.
  
  
• Surgery. If other approaches haven't relieved your pain, if you've been faithful with your rehabilitation program and given it enough time, and if the activity of your arm is still restricted, your doctor may suggest surgery. Only about one in 10 people with tennis elbow need surgery. You'll be able to have the surgery done on an outpatient basis, meaning you can go home the same day. Surgery involves either trimming the inflamed tendon, or surgically releasing and then reattaching the tendon to relieve pain.
  
  Other treatments for tennis elbow are being investigated. Some treatments being studied include low-energy shock wave treatment and treatment with topical nitric oxide.
  
  

Relief of Tennis Elbow

The best way to relieve tennis elbow is to stop doing anything that irritates your arm — a simple step for the weekend tennis player, but not as easy for the manual laborer, office worker, or professional athlete.
The most effective conventional and alternative treatments for tennis elbow have the same basic premise: Rest the arm until the pain disappears, then massage to relieve stress and tension in the muscles, and exercise to strengthen the area and prevent re-injury. If you must go back to whatever caused the problem in the first place, be sure to warm up your arm for at least 5 to 10 minutes with gentle stretching and movement before starting any activity. Take frequent breaks.

Conventional medicine offers an assortment of treatments for tennis elbow, from drug injections to surgery, but the pain will never go away completely unless you stop stressing the joint. Re-injury is inevitable without adequate rest.

For most mild to moderate cases of tennis elbow, aspirin or ibuprofen will help address the inflammation and the pain while you are resting the injury, and then you can follow up with exercise and massage to speed healing.
For stubborn cases of tennis elbow your doctor may advise corticosteroid injections, which dramatically reduce inflammation, but they cannot be used long-term because of potentially damaging side effects.

Another attractive option for many sufferers, especially those who prefer to not ingest medication orally, is the application of an appropriate and effective topical anti-inflammatory. CT Cream with A.C.P. was specifically designed to reduce inflammation and does so by taking advantage of well known elements Arnica, Choline, Pyridoxine and Vitamin B6. Researched, formulated and introduced recently by Dr. Ying Lee, CT Cream has proven to be extremely successful in treating inflammation related ailments such as epicondylitis, tendonitis, bursitis & carpal tunnel syndrome.

If rest, anti-inflammatory medications, and a stretching routine fail to cure your tennis elbow, you may have to consider surgery, though this form of treatment is rare (fewer than 3 percent of patients). One procedure is for the tendon to be cut loose from the epicondyle, the rounded bump at the end of the bone, which eliminates stress on the tendon but renders the muscle useless. Another surgical technique involves removing so-called granulated tissue in the tendon and repairing tears.

Even after you feel you have overcome a case of tennis elbow, be sure to continue babying your arm. Always warm up your arm for 5 to 10 minutes before starting any activity involving your elbow. And if you develop severe pain after use anyway, pack your arm in ice for 15 to 20 minutes and call your doctor.

Home treatment

Mild cases of tennis elbow can be treated at home. The priority is to rest the injured tendon by stopping or changing the activity causing the problem. To relieve symptoms you can:

Apply an ice pack - for a maximum of 20 minutes. A bag of frozen peas wrapped in a damp cloth works well because it moulds to the shape of the arm. Ensure that the skin does not change colour (the sign of an ice burn). If the skin has turned bright pink or red after a few minutes, stop using the ice. Applying a film of oil (cooking oil will do) to the skin before applying the pack helps to avoid burning the skin.

Take ibuprofen - according to the directions on the packet, up to the maximum daily dose. It is not suitable for people who have a history of stomach ulcers, or for some people with asthma. If in doubt, ask your pharmacist for advice. Ibuprofen belongs to a group of drugs called non-steroidal anti-inflammatory drugs (NSAIDs). Other types of NSAIDs may be more appropriate for some people.

Wear an arm brace - this is a form of strapping made of silicone or other plastic material that can be worn around the forearm and elbow to help restrict movement of the tendon. Braces are available from larger pharmacies and sports shops.

When doing a manual task you really cannot avoid, use a tool with a smaller grip. If available, contact your employer's occupational health advisers. They should be able to provide advice about modifying your daily activity to allow your arm to heal and minimise the risk of further harm.

Prevention

To prevent tennis elbow:

• Lift objects with your palm facing your body.
  
  
• Try strengthening exercises with hand weights. With your elbow cocked and your palm down, repeatedly bend your wrist. Stop if you feel any pain.
  
  
• Stretch relevant muscles before beginning a possibly stressful activity by grasping the top part of your fingers and gently but firmly pulling them back toward your body. Keep your arm fully extended and your palm facing outward.
  
  

Caution!

To prevent a relapse:

• Discontinue or modify the action that is causing the strain on your elbow joint. If you must continue, be sure to warm up for 10 minutes or more before any activity involving your arm, and apply ice to it afterward. Take more frequent breaks.
  
  
• Try strapping a band around your forearm just below your elbow. If the support seems to help you lift objects such as heavy books, then continue with it. Be aware that such bands can cut off circulation and impede healing, so they are best used once tennis elbow has disappeared.
  
  

Call Your Doctor If....

• The pain persists for more than a few days; chronic inflammation of the tendons can lead to permanent disability.
• The elbow joint begins to swell; tennis elbow rarely causes swelling, so you may have another condition such as arthritis, gout, infection or even a tumor.