By James K. Rotchford, MD, MPH

May 19, 1997

INTENDED AUDIENCE:

This handout is for established patients of Dr. Rotchford. After the diagnosis of "tennis elbow" has been made this handout will serve either as an introduction to concepts concerning tennis elbow or a review thereof. Because many of my patients have often already seen providers for their condition, I'm hoping that this more comprehensive discussion will be helpful.

WHAT IS TENNIS ELBOW?

Anatomically speaking, "tennis elbow"is an inflammation/pulling away of tendons of the forearm at the l elbow where they insert into the bone. The part of the arm bone where these tendons insert is called the lateral epicondyle, hence the official name of this condition is "lateral epicondylitis," which means inflammation of the lateral epicondyle.

The muscles which attach to the tendons involved are the muscles of your forearm which allows you to lift your wrist up. Almost every time you grip something you hold your wrist upwards. Because people who play tennis are often extending their wrists and gripping their racket firmly, they are susceptible to injuring the tendons and their insertion on the arm bone. Hence the name "tennis elbow."

WHAT CAUSES TENNIS ELBOW?

Traditionally, we think of this condition as simply resulting from the overuse of the arm and the tendons involved. Granted, if a person's activity doesn't include any repetitive use of his/her arms, he/she is unlikely to develop tennis elbow. Nonetheless, there are a lot of people who vigorously use their forearms; carpenters, tennis players, etc., who never get "tennis elbow." Thus there must be explanations other than overuse which can help to explain the "disease" of "tennis elbow."

It is Dr. Rotchford's opinion that many active people experience tennis elbow to some degree. In the average person, however, the area is able to heal just fine with some rest, and then the individual continues on free of any problem. For some reason, in people with persistent tennis elbow, their "healing rate" can't keep ahead of their "injury rate."

Perhaps knowingly or unknowingly, the person struck the elbow hard, and because of continued activity the elbow has been unable to heal. Because the injury often involves bone (where the tendons insert into the bone) in addition to the tendons themselves, it could be expected even under the most ideal of circumstances for the arm to take 4-6 weeks to heal. Or perhaps, like an athlete who exerts himself too quickly without warming up and/or stretching, an individual has "torn" the tendons and just can't heal because of continued activity.

I believe the explanations behind why some people don't readily heal from their tennis elbow can be quite complicated, and often the reasons don't have anything to do with their arms per se. Neck problems and posture problems can clearly be contributory. I'm going to discuss more of these issues when we get into treatment options. For the time being, let's just accept that the "cause" of your tennis elbow is probably not just one factor but several factors which acting together contribute to the "cause."

TREATMENT OF TENNIS ELBOW

Basically, treatment consists of three things: 1. Stimulating blood flow to the area. (With blood comes healing). 2. Keeping the muscles involved nice and loose so they don't pull on their insertion on the lateral epicondyle. 3. Avoiding any unnecessary injury or stress to the elbow. Sounds simple? Not quite so. Let's start with ways to stimulate blood flow to the area.

INCREASING BLOOD FLOW TO YOUR ELBOW:

a. Applying heat to the area is the most common way of increasing blood supply. Warm moist heat is perhaps the best. We recommend heat application of no more than twenty minutes or so at a time.

b. Human physiology dictates that blood flow is to a large measure under the control of the autonomic nervous system. Your nerves determine how much your blood vessels open and consequently the amount of blood flow in them. Acupuncture is perhaps the most common therapeutic intervention to help improve blood flow through the regulation of the autonomic nervous system. Any intervention that is directed toward relaxing muscles at the base of one's neck is also probably helpful in this regard. The source of the nerves controlling your arm's autonomic nerve function is at the base of your neck just lateral to your back bone. Ways to help muscles relax will be discussed below.

Regular vigorous aerobic exercise helps optimize autonomic nervous system function, as does learning and practicing an effective relaxation response.

c. When you irritate the skin or body tissue in general it turns red. This is because of increased blood flow to the area. We know that there are chemicals released when skin or tissue is irritated or damaged. These chemicals directly and probably indirectly cause blood vessels to dilate causing increased blood flow to the injured area. As a result of this, minor irritation to the skin and the tissue adjacent to the injured area in tennis elbow can help. Frequently we'll recommend that a patient wear "herbal" patches that irritate the skin in this area. Acupuncture clearly acts as a minor irritant and there is some very recent evidence that acupuncture releases local chemicals that promote healing in ways additional to increasing blood flow and relaxing muscles.

KEEPING MUSCLES OF YOUR FOREARM RELAXED:

a. Physical therapists and massage therapists are generally trained to teach people how to keep their muscles relaxed. It's not easy with your forearm muscles, because every time you grip something you tighten these muscles. Be very aware of how tightly you're gripping the telephone, the steering wheel, your pen, or your tennis racket!! You might be surprised how much unnecessary activity there is in using these muscles.

Typing and other repetitive type functions at work or at home can clearly contribute to this problem. Occupational interventions can clearly be of help. We'll discuss this further below. Just "shaking out" your arms, massaging, and stretching the muscles involved can make a big difference.

b. Any professional who has had experience with biofeedback knows that a lot of people hold tension in their forearms. Helping people to learn how to relax deeply, encouraging them to get vigorous aerobic exercise, providing support and a listening ear to emotional concerns can all be of help in the care of tennis elbow. Biofeedback itself can be a useful tool in teaching one how to keep the muscles of the forearm relaxed. Unfortunately, qualified biofeedback technicians are not always readily available and some insurances won't pay for their services.

c. During sleep, specifically when we are dreaming, there are mechanisms which normally cause muscles to be paralyzed. These periods of muscle paralysis can only be good for someone suffering from tennis elbow. Possibly for this reason amongst others, sleep abnormalities can and do effect one's recovery from tennis elbow. Let Dr. Rotchford know if you are having sleep abnormalities so this can be formally addressed.

AVOIDING FURTHER INJURY:

a. Avoid gripping anything too suddenly or too tightly. Occasionally, depending upon one's activities, certain activities need to be curtailed or limited during the period of recovery. A good physical therapist as well as your physician can help guide you with regard to current activities.

b. For those of you whose activities might result in repetitive stress reactions, certain occupational strategies need to be entertained. There are books and other material on this subject which may be reviewed. See references below.

c. Only in the most recalcitrant cases do we recommend casting the arm. Firstly, because it severely limits activity and is a significant "disability" on its own, and secondly because when the arm isn't used, muscles atrophy and tendons can shorten. This is not good news for someone susceptible to tennis elbow.

d. A good physical/massage therapist can go a long ways in helping someone rehabilitate the muscles of their forearm and teach them how to keep the muscles loose and as a result avoid further injury.

e. A trial of a well fitting forearm band can help protect the arm from further injury. Dr. Rotchford recommends an armband manufactured by Aircast, but several helpful ones are on the market. A wrist brace is often used as well in order to minimize extension by the wrist.

OTHER TREATMENT OPTIONS:

a. Local cortisone injections. This technique is often used in an attempt to reduce inflammation and as a result facilitate healing. In acute cases it could have a role but in my experience it's useful in less than a third of the cases and because cortisone can negatively effect bone and tendons it might make things worse in the long run. Also for some patients cortisone injections are quite uncomfortable.

b. Surgical interventions: This is a drastic intervention and my surgical colleagues advise me that a large number of patients aren't helped by the procedures currently used, and a good number actually get worse.

c. Local bee venom injections. I have only recently been made aware of this option. I have limited experience with it, but in talking with colleagues who use it I feel that it is a worthwhile adjunctive therapy to consider.

d. Some clinicians interpret tennis elbow as a localized form of fibromyalgia, and as a consequence initiate similar therapeutic options used in fibromyalgia.

e. In oriental medicine, a problem with the tendons can be interpreted as resulting from a deficiency of blood, not an anemia per se, but a deficiency that results in tendons being less resilient than they should be. Herbs and acupuncture can help this "state." Also, according to acupuncture theories, tennis elbow can simply reflect a blockage in "Qi" or energy fields. Effective mobilization of the "Qi" will result in significant improvement. There are also many western theories to explain how acupuncture might work. Some patients clearly respond to acupuncture and some do so in a dramatic fashion requiring only a couple of treatments for prolonged relief.

f. One could look at tennis elbow pain that lasts for more than three to six months as another form of Chronic Pain Syndrome. Techniques and interventions helpful in treating patients with chronic pain can be used here.

g. Nutritional issues with regard to tennis elbow and other forms of repetitive stress disorder have come up. I've heard that a manganese deficiency may contribute to the condition, and apparently some patients have responded to a product called Remedium, which is a special formulation of niacin and the amino acid alanine.

h. Whenever the specific "cause" of a condition is unknown or standard treatments fail, a variety of treatment options often appear. My list of therapeutic options is therefore not exhaustive but nonetheless represents relatively cheap and possibly effective options for you.

WHAT TO EXPECT:

Although immediate response to treatment may be fairly dramatic in terms of relief, in general, patients who have had tennis elbow for more than a month or so generally require a month or two at least for recovery to occur. Recovery depends on re-injury rate, the frequency and quality of care, individual factors, etc.. The important thing is to not expect rapid recovery and to be content with progress however gradual it might be. It is hard to define cure when it comes to tennis elbow. Once one has suffered from tennis elbow, there is always an increased chance of reoccurrence.

HOW MUCH WORK CAN I DO?:

This is a good but tough question to answer categorically. Each patient is different and clearly our working together can help determine the answer. In general, I don't think putting the arm entirely to rest or in a cast is good. Likewise, I think it is unwise to continue to do what one was doing and just ignore the pain. Both of these approaches might work in very mild cases but generally by the time someone comes to see me these approaches will just make matters worse. In general, I recommend activity that is at about 60% of normal activity with no activities requiring sudden or severe gripping. If the activity makes one worse the following day it was definitely too much. I've had patients with tennis elbow who, for example, went snow skiing and at the beginning of the day their elbow was stiff and sore but by the end of the day, after loosening and warming up, their arms felt great. Other patients I've seen continue to have problems because they can't say no to jobs or tasks. Either they're concerned about losing their job, or their self worth or sense of well being is all tied up in their activities. Sometimes these issues have to be formally addressed in order for the patient to start to recover.

REFERENCES:

1. Repetitive Strain Injury, A Computer User's Guide, Emil Pascarelli, MD, Published by John Wiley & Sons, Inc, 1994 This is a paperback in the $15 range which has a lot of helpful suggestions for patients with tennis elbow related to the office setting. It also would be helpful for the athlete or construction worker.

2. http://info.med.yale.edu/ortho/ysmc/injuries/telbow.htm This is a web site amongst others that gives a picture of the area involved and discussion of the problem. The web in general is a good source of information about tennis elbow. Discussion, however, is generally limited to standard western approaches.

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