13 March 2019
Jeremy Granville-Chapman, our Consultant Orthopaedic Surgeon specialising in shoulder, elbow and trauma, tells us about tennis elbow:
As the days become longer, tennis players will inevitably look forward to the up-coming season. Some will have played indoors over the winter and a few will have done sport-specific conditioning in the off-season. For most however (if you’re anything like me), I suspect pre-season preparation is limited to trying to find your racket in the garage and buying some new balls in advance of your first game!
Nobody wants to dwell on injuries, but elbow tendinopathy is very common and it can often reduce enjoyment or even prevent people from playing altogether. The good news is that there are simple things you can do now to reduce your chance of getting tennis elbow this season.
What is tennis elbow? (also called lateral epicondylitis)
The outer bony prominence of your elbow (lateral epicondyle) provides the tendon origin for your forearm extensor muscles (muscles that lift your fingers and wrist).
Repetitive microtrauma, ageing, or increased use can cause one of these tendon origins (a wrist extensor called ECRB) to become degenerate and painful. Grip is painful in tennis elbow because you need to extend your wrist to grip firmly.
Why might I get it?
Elbow tendinopathy is very common, affecting 3% of us all and 40% of tennis players at some stage. It typically affects people aged 35-55 years. Some patients put their onset down to an intense period of activity or sport, or a change in equipment or technique, but many will identify no particular reason.
What can I do to avoid it?
- Strengthening exercises
These improve muscle strength, tendon quality and pain in tennis elbow and should reduce the chance of you getting it in the first place. The aim is to work your extensor muscles as they are being stretched (eccentric work). This maximizes adaptation in the tendon and evens out the tension in the fibres.
Please follow this link to see the exercise demonstration. https://youtu.be/xUiAAwzwXsE
Use a water bottle (filled with 500ml-1L of fluid). Do 10-15 repetitions three-times a day and, at the end of each set, stretch the muscle for 20 seconds. If you do this for 8 weeks it should significantly improve your muscle strength and tendon quality.
Strengthening your muscles and tendons through these exercises probably offers the best way to avoid getting tennis elbow. You can however address the issues below if you feel at particular risk, or have had problems in the past.
- Tennis technique
The backhand stroke is thought to be a particular trigger. Many of us have imperfect technique and this is something that we can improve. If you play a single-handed backhand, it may be worth having a coaching session to help you optimize your grip and technique.
- Grip size, racket balance and string tension
I often recommend double-wrapping the racket handle for patients with tennis elbow. This allows them to grip the racket more gently but it also moves the balance of the racket nearer the hand and so offloads the tendon. String tension is also something that can affect the forces that pass across the elbow. A high-tension offers more control, but passes more forces through the elbow. You may want to try lowering your string tension a little.
What to do if you already have tennis elbow?
The first thing to say is that most patients (approx. 80%) will get better on their own over a year. There are things you can do to help speed-up your recovery.
First step - exercises. These have good evidence supporting their efficacy. Please understand that it will take 2-3 months for these exercises to make a difference, so do persevere!
Next, consider points 2 (technique) and 3 (equipment) above and see if you can address likely causes for your problem.
You may also want to wear a forearm clasp brace when playing tennis. Many are available online. I’d recommend one that has a compression pad that focuses the pressure over the muscle-wad on the outer aspect of your forearm about 3-4 cm below the elbow joint. The idea is that, by compressing the muscle just beyond the tendon’s origin, you offload the origin itself. The evidence supporting these braces is mixed, but some have shown benefit and they will cause no harm.
If these steps fail to help and you’ve had your pain for 3 months or more, you should seek referral to an upper limb surgeon. Your surgeon will exclude other less common causes of lateral elbow pain. Assuming it is tennis elbow he/she may recommend platelet-rich plasma injections. These are done with you awake and allow concentrated cells from your blood to be injected into the tendon to provide a biological ‘kick-start’ to help your degenerate tendon to heal. They work in approximately 70% of patients and make it less likely you will need surgery for your elbow.
I recommend you avoid steroid (cortisone) injections. This is because, despite good short-term relief, these have been shown in high-quality studies to prolong the condition of tennis elbow and prevent physiotherapy exercises from working. You are more likely to have pain at one year if you’ve had a steroid injection than if you’ve had no treatment.
Mr Jeremy Granville-Chapman is a Consultant Orthopaedic Surgeon here at Spire Thames Valley Hospital. If you would like to learn more about any procedures or have any questions, please call us on 01753 665 404 or email us.