Tennis Elbow

Dr M K Mam
Tennis elbow also called lateral epicondylitis is a common cause of pain on the outside of the elbow. Tennis was the first sport to bring attention to this type of problem as earlier it was found mostly in tennis players. Tennis players may be more susceptible; however it does occur in lot many people who have never used racquet. It is also found in other sports and professions that involve repetitive motions of the wrist and arm like plumbers, painters, carpenters, bricklayers, gardeners, butchers etc. e Computers are certainly an essential part of our life these days and most of us use whether we are in office or at home. There are reports that Tennis elbow (TE) is one of the problems that are associated with use of computer- mouse and /or key board for longer hours that is why it is also called mouse or computer elbow.
Causes: Exact cause of TE is not known. It is an overuse injury and usually follows repetitive stress at the tendinous attachment of the common extensor muscle of wrist at the outside bony prominence of elbow i.e. lateral epicondyle. Repetitive wrist extension and forearm rotation movements and the stresses due to sports and professional activities may result in a series of tiny tears in the tendinous attachment at lateral epicondyle of the muscles that are responsible for these movements
Clinical Picture:  The patient is usually an active adult complaining of pain on outside of the elbow. Pain often comes gradually and then gradually increases.  The pain may  radiate down into forearm and wrist. The patient feels pain and weakness on lifting even small things, using computer mouse, shaking the hands, turning a door knob, turning a tap or holding a cup of tea. The patients also complain of weakened hand grip strength.  Dominant extremity is more often affected. There is pain with passive wrist flexion and wrist extension against resistance. The elbow usually looks normal. There is a localized tenderness i.e. pain on pressure over front of the lateral epicondyle i.e.  bone projection on the outside of elbow.   The movements of the elbow and the forearm are normal.
Risk factors:  Various factors that may increase the risk of TE include–  i)- Profession- People having jobs that involve repetitive motions of the wrist and arm like plumbers, painters, carpenters, butchers, gardeners etc. are more likely to develop TE . Again the people involved in handling heavy loads are also at a higher risk of getting TE.  Spending  long hours at your computer whether you are typing or playing games does increases the chances of getting TE or computer elbow. There are reports that TE is associated with computer use of more than 20 hours per week and the risk increases in line with years of use. ii) Sports- People involved in racket sports especially where overhead movements are used, are more likely to be affected with TE. Poor technique of the sport certainly   increases the chances of TE.    iii) Age -It can affect people of any age, however it is more common in people of 30 to 60 years of age. iv) Sex- It somehow affects women more often than men.
Prevention:  It is very important that an individual learns proper technique for all aspects of their sport or the profession especially when it involves weight lifting as poor technique increases the chance for injury including TE. It is also essential that one remains in overall good physical shape. It is good to avoid or modify activities involving any repetitive lifting or pulling of heavy objects. We must strengthen the muscles of the forearm by proper strengthening exercises so as to increase the stability of the elbow joint. We must ensure that any equipment that is used has to be appropriate to the ability, body size, and muscular strength of the individual.  Individuals working on computers for long hours just need to relax the shoulder, forearm and wrist. They should get up, stretch, and walk around periodically for five minutes or so at least once an hour. It is suggested that forearms and upper arms are at a ninety-degree angle by adjusting your chair up, down, backward, and forward. The fingers have to be in line with forearm.
Treatment:  Despite all the advances, there is no true consensus on the most effective treatment of TE especially for effective long-term outcomes. Good thing is that majority of cases resolve spontaneously within a year or so and the main aim of treatment is to speed up the recovery. Rest to the elbow joint is important. TE braces do help by giving some rest and reducing strain to the forearm muscles.  Elbow strap helps as it applies a binding force over the origin of the wrist extensors.  Analgesics and anti-inflammatory drugs help the patient to cope with the pain on short term basis. Topical non-steroidal anti-inflammatory drugs (NSAIDs) gels may improve pain in the short term. Physical therapy – stretching and strengthening exercises of forearm muscle, and local ultrasonic therapy is useful in many of the patients. It is also important that we avoid or modify the activities which aggravate the pain like lifting, especially heavy weights. Workload modifications have to be considered, especially in patients involved in manually strenuous jobs.
Majority of patients respond to an injection of a local anaesthetic and corticosteroids. It certainly provides a good pain relief, but it is for a short term and the recurrences are usual.  We may also have local skin problems such as hypo-pigmentation and fat atrophy leading to indentation of the skin around the injection site especially after repeated steroid injections.
Surgery is considered in a very small percentage of cases that are not responding to a sustained period of conservative treatment for at least for a year or so. Tendinous attachment of the common extensor is released surgically and this can be done percutaneously with or without use of an arthroscope (pin hole surgery) or by an open method.