TENNIS ELBOW - Full extract 

Emilio is a 30-year-old computer programmer who loves getting into his overalls. At weekends and nights he has been busy renovating an old house near our surgery.

One Monday morning he came in with a sore right elbow. He said it had gradually become worse over the weekend. "I spent all Saturday cleaning windows," he said. "Then yesterday I fitted on a few doors. My elbow was so sore this morning I could hardly hold a cup of coffee."

When I helped him lift off his shirt he pointed to the outer side of his elbow. As I touched the area he grimaced in pain. The elbow joint itself seemed normal and there was nothing else to find. The diagnosis was fairly obvious. "You've got tennis elbow," I said. "And it's going to take quite a while to settle down."

Emilio and I talked about how tennis elbow occurs and the various options for treatment. We decided on a course of physiotherapy and some anti-inflammatory medication. He will be reviewed in a couple of weeks but I suspect he will require further treatment.

The bone of the upper arm is called the humerus. At the elbow, it splays out slightly to form a bony projection on each side. Several forearm muscles attach to the outer projection. Their action is to extend the wrist and fingers backwards, and rotate the forearm and palm to a facing upwards position. This is a similar movement to what happens when playing a backhand in tennis.

Tennis elbow symptoms occur when the area where these muscles and tendons attach to bone somehow becomes damaged. Why this happens is not fully understood. It is quite a common condition in adults and usually occurs with overuse or repetitive movements.

Sometimes it is caused by direct trauma to the elbow.

The main problem with the tendon attachment is that, unlike muscle, it has a relatively poor blood supply. When it becomes injured it takes a long time to heal.

Interestingly, an almost identical condition can occur when the attachment point joining the forearm muscles to the projection on the inner side of the elbow becomes inflamed. The golf swing can put great strain on this tendon attachment and the condition is often referred to as "golfer's elbow". The principles of managing both conditions are the same.

Another similar condition, called plantar fasciitis, occurs when the main tendon attachment on the bottom of the heel becomes inflamed. It can result in persistent heel pain and often takes a long time to resolve.

Tennis elbow may appear as an acute condition, after a sudden burst of heavy physical activity, or it may be a chronic condition that drags on for many months. The main complaint is pain in the outer elbow, frequently radiating into the forearm. Other conditions, such as fractures and other injuries to the elbow, can cause similar symptoms. However, in these instances, there is usually a history of some direct trauma. Pressure on nerves at the wrist or in the neck can also produce pain around the elbow and forearm. However, the telltale sign of tennis elbow is the marked local tenderness where the tendons join on to the bone. Reproducing pain by causing these tendons to stretch will confirm the diagnosis.

The treatment of tennis elbow has altered little over the years. It remains one of those frustrating conditions that can take a long time to settle. The many types of treatment available indicate how difficult it can be to treat.

In acute cases, rest and cool packs can help. Physiotherapy with local ultrasound treatment can also be useful. Anti-inflammatory medication may give relief but these medications need to be used with caution. Any history of indigestion or ulcers needs to be mentioned to the doctor in case anti-inflammatory medication cannot be used, or some additional medication has to be taken at the same time.

In more chronic cases, gentle stretching and hand exercises can help. Some people find a strap support over the upper forearm useful. When tennis elbow is slow to settle, a combined cortisone and local anaesthetic injection into the area can give lasting relief. The injection has to be precisely administered into the area of maximum tenderness. Repeat injections may be required. Sometimes alternative treatment approaches, like acupuncture, can bring about a significant improvement. In very persistent cases, an operation may also be considered.

Health Tip:
* With tennis elbow, it is important to look carefully at the mechanics of how the injury occurred in order to prevent the condition recurring.

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: August 18, 2001