Tennis elbow

Definition

As written on the previous page, "tennis elbow" is often used as a synonym for repetitive strain injury, mouse arm or for general pain in the forearm. In contrast to these diffuse diseases, tennis elbow is a diagnosis for a clearer pattern of pain. Tennis elbow refers to local irritation or inflammation of the outer elbow area (where the forearm tendons connect to the bone).

Synonyms

The corresponding technical term is called epicondylitis. It exists in the following two forms:

1. Lateral epicondylitis (tennis elbow): pain in the outer elbow area
2. Medial epicondylitis (golfer's elbow): pain in the inner elbow area

Tennis elbow is more widespread.

Symptoms / pain

Pain in the elbow area (outside or inside) initially only occurs while playing tennis or golf or while working by hand. After a few hours or by the next day, the pain is usually gone. If the workload is not temporarily scaled back or if you don't perform stretching exercises, the pain may becomes persistent. In some cases people can't even clench into a fist without severe pain and they have trouble holding objects of all kinds. The usually local pain in the elbow might radiate to the hand.

Causes

The cause is an overload of the affected tissue. However, many sufferers do not play too often but "only" have a poor technique. They grab the racket too forcefully, cramp in the game or play without warming up before.
A repetitive strain injury is not a classic tennis elbow! A tennis elbow usually arises from activities in which you hold something with a closed fist and you yourself are in motion. Repetitive strain injuries are caused by thousands of small finger/hand movements in a mostly non-ergonomic working posture. Although computer work can also cause tennis elbow, the tendinosis of the lateral epicondyle of the elbow then is usually just only one of several pain triggers. If you work at the computer several hours a day, the measures discussed on this page are very useful, but you can do much more! Please have a look at the main page about repetitive strain injuries.

Am I affected?

All those affected complain of a very painful spot at the elbow (tennis elbow: outside area, golfer's elbow: inside area, see pictures). The easiest way you can provoke the pain is by pulling your clenched hand in the direction of the arrow. The red circle depicts the area where you should feel pain now. You can amplify the pain by either putting pressure on the circled area with your other hand or by pushing the other hand against the arrow.

This kind of pain mostly affects people over the age of 40, but as always, there are exceptions to that rule.

If you can see a (strong) swelling in the circled area, you might have bursitis. It might be the consequence of a hard impact or of reading with both elbows lying on a hard surface for several hours a day (and is then called "student's elbow"). In this case, the exercises on this page are not useful!

Therapy

Before you start with any exercise, you should wait until any existing swelling has subsided. You can support this process by cooling and with anti-inflammatory drugs (tablets and/or gels). Initially minimize the workload. Cortisone injections are not recommended because the risk of long term damage is high (especially when applied repeatedly) and an effect is often only short-lived. If your arms are swollen, you have to visit a doctor in any case!

Treatment      /     Time >					Prevention
Treat swelling	x
Minimize workload	x	x
Stretching		x	x	x	x
Deep friction massage		x
Myofascial release		x	x	x	x
Reduce workload			x	x
Epicondylitis brace			x	x
Work on sports technique			x	x	x
Warm up before exercise			x	x	x
Hanging				x	x

• Stretching exercises are among the most effective treatments for tennis and golfer's elbow. The first exercise is primarily against a tennis elbow, the second and third are against a golfer's elbow. I recommend that you perform all three exercises no matter where your pain is located, because those three are the most important exercises against the repetitive strain injury. And with today's widespread use of computers, more and more people are diagnosed with this disease. In acute cases, you should perform all exercises 2-3 times a day. As prevention it is sufficient when you perform all exercises before and after stressful activities or at least once a day.

  

  Left image: With straight arms, hold both hands in front of your hip area and bend the wrists to the right (palms facing up). Now you embrace the four fingers of your right hand with your left hand and pull it up (figure 1). After ten seconds, you rotate the right hand by almost 180° and stop again for ten seconds (figure 2). Finally, turn it forward as far as possible (figure 3). Repeat this exercise with the other hand. Make sure not to pull up your shoulders during the exercise. Video tutorial (I'll create an own video soon which fits my three images better.)

  Right image: Press your palms against each other and slide both arms in one direction (right or left). Hold this position for at least 20 seconds and slide your arms in the other direction then.

  

  Lean against a wall with your arms straight. Rotate the hands inwards as far as possible, hold for ten seconds (figure 1). Then turn them upwards, without lifting them from the wall. Hold for another ten seconds (figure 2). Finally rotate your hands outwards as far as possible (figure 3).

• Deep friction massage is a technique that forcefully massages the area where the forearm muscles are connected with tendons to the bone in the elbow area (humerus). The pressure causes additional micro injuries, which forces the body to immediately begin with repairing the tissue. Once the initial swelling has subsided, you can start with the deep friction massage. You can perform this massage yourself, but I recommend that you visit a physical therapist at least once so that he/she can show you how to do it correctly.
  After a maximum of six massages you should feel an improvement, otherwise the treatment should be discontinued. A total of twelve treatments should not be exceeded. The deep friction massage can be applied two to three times a week for five minutes each. Rub your thumb back and forth over the painful tendon (in all directions). You have to find out the exact spot yourself, but it is usually near the areas of the red circles on the photos. Although it is called a "massage", it doesn't feel like one. If you have tennis or golfer's elbow, the deep friction massage will hurt! If it doesn't, you don't have a tennis/golfer's elbow or you haven't found the correct spot yet.
  In the subsequent repair phase, it is extremely important that you don't put your arm in plaster or permanently wear a wrist brace. The tissue has to be used lightly, in order to be able to regenerate properly. Light stretches are useful as well.
• The forearm muscles and their surrounding fascia (connective tissue) tend to stick together over time. Unlike the deep friction massage this myofascial release doesn't cause micro injuries. Thus it is much more pleasant to perform and should also be continued as means of prevention. Using a foam roller you can comfortably massage your forearms yourself (video). There are several brands available, I recommend The Grid Foam Roller (price: ).
• When the deep friction massage and myofascial release bring about an effect, you can slowly resume your activity (usually a sport). An epicondylitis brace (price: ) helps to reduce the stress on the tendon while playing. Do not forget to warm up before playing. Ideally you also work on your playing technique with a sports coach.
• Hanging: When the pain has already subsided a bit, you can start hanging several times a day. Hanging means that you rest in a pull-up position for at least 30 seconds. If you don't have a stair for your hanging, you can use a doorway pull-up bar (price: ). You can start by hanging with your feet still on the ground to support your body weight. You don't have to do any pull-up, just hang with straight arms. With this exercise you also prevent back pain.

Healing period

Most sufferers will feel a significant improvement after four weeks of stretching exercises. However, mild pain can still occur several months later. A complete recovery usually occurs within six months.

Other treatment options

• As prevention, you can strengthen your forearms with light strengthening exercises. This can be helped by a gyroscopic exerciser (price: ), a tennis-ball sized gyroscope which is powered by circular wrist motions. More strengthening exercises can be found on the main page about RSI.
• If all conventional treatments fail to improve your condition after several months, then there is the possibility of surgery (with all its risks).