Tennis Elbow: symptoms, causes and treatments

Photo by Julian Schiemann on Unsplash

Tennis elbow, or Lateral Epicondylalgia, which is the correct medical term, refers to an overuse and repetitive loading of the tendons and forearm extensor muscles on the outside of the elbow. This in turn causes pain, mostly at the elbow and down into the forearm. It can be a very debilitating injury if left untreated for too long, causing disability, debilitating pain and loss of function. 

In this blog I will review the symptoms, who get's it, the causes and my treatment advice to get you back on the court as fast as possible.

What are the symptoms?

As it is an overuse injury typically the symptoms of tennis elbow progress from tightness and mild pain at the elbow when completing the aggravating task, to marked pain at the elbow and down the forearm. As the condition progresses you will begin to notice the symptoms creep into your normal activities of daily living. Aside from pain when making ball contact in tennis, common aggravating actions I often hear are lifting and pouring from a kettle or jug, lifting heavy objects especially with an outstretched arm in front of you, completing a gym work out and gripping weights, or even shaking hands when it’s at its worst. 

Are tennis players the only one’s affected?

Research has shown that tennis elbow will affect 40% of people in their life time. It is most prevalent among men and women in the 35 – 54 age group. In my experience with tennis players it is more common amongst tennis players at the social level rather than professional level. However, despite the name, it is not limited to tennis players alone. Manual labourers, office workers, anyone doing repetitive arm and hand movements, older women (hormonal influence), people with current shoulder injuries and adolescents as they are growing (due to evolving changes in their scapular stability, rapid growth, and high training loads) are all at a higher risk.

What are some common factors that can cause tennis elbow?

Tennis elbow is a multifactorial overuse injury. In tennis this can be due to an increase in your training or playing load, change in equipment or old equipment, poor technique, playing tennis at a higher level than normal, coming back to tennis after taking a break, or rapid growth when it comes to teenagers. Interestingly, research has shown that females are less susceptible to tendon injuries before reaching menopause than their male counterparts. After menopause due to the rapid decrease in oestrogen, females become more susceptible to tendon injury than before. However this is at about the same incidence rate as their male counterparts.

If my elbow hurts does that mean I have tennis elbow?

In short the answer is no. There are many other causes of elbow pain which may sound similar when you are discussing your ailments with your friends! The elbow consists of 3 joints as well as the many ligaments, muscles and tendons that support and move the joint. It has of course a rich nerve and blood supply. Any of these structures could be contributing to your pain, not just the extensor muscles and tendons. It is therefore imperative that you seek the correct professional help. A thorough examination by a sports physiotherapist who understands thoroughly the anatomy and functionality of the elbow and upper quadrant (neck, shoulder girdle and arm) is essential as well as a therapist who understands the biomechanics and technical aspect of tennis, along with an understanding of tennis equipment relating to your injury. 

What do I do if I have elbow pain?

If you are noticing the onset of elbow pain during your normal daily activities or when playing tennis it is best to seek help from a tennis specific sports physiotherapist sooner rather than later. I used have a rule with the elite tennis players I worked with – If they had more than a 3-4/10 pain for more than 3 days in a row when hitting they had to check in with me! Your tennis specific sports physiotherapist will examine your elbow, shoulder and neck and diagnose your condition. They should then set out a treatment plan with you including a comprehensive rehab program. 

What exactly will physiotherapy consist of?

During your initial examination your physio will identify the cause of your pain. In the case of tennis elbow there will be overloading of the common extensor tendon, with or without a tear - depending on the severity, and tightness through the forearm musculature. There may also be involvement of the radiocapitellar joint – one of the three joints that make up the elbow joint, and most likely involvement of the radial nerve. Your physio will assess any areas of instability or weakness and create a targeted exercise program specific to you and your sport. Hands on treatment is imperative for a good outcome. This will consist of neck and elbow joint mobilisations, soft tissue treatment of the tight structures identified and perhaps dry needling.

As your treatment plan progresses your physiotherapist will decide if you need further investigations or onward referral if your symptoms are not progressing as well as they would like. Further investigations are likely to include ultrasound of the elbow extensor tendon and musculature. Other treatment options for more advanced or non-responding cases can include non-steroidal anti-inflammatories, triple therapy (green tea, anti-inflammatories and antibiotic), PRP or steroid injections. 

If I see a physio will they tell me to stop playing tennis?

Getting started on treatment early is crucial for any tendon injury. If you leave it until you have severe pain when hitting or have pain using your arm you may have to stop for a while. However, if you get started early you may not have to stop at all or you may just have to modify your shots. There are a wide variety of elbow braces on the market to assist with pain symptoms.

It is best to discuss the type of brace you need with your physio as there are many out there that don’t actually provide enough support. Some of your causative factors may actually be to do with your technique or your equipment. A tennis physio will be able to look at footage of you hitting and discuss potential technical errors with your coach. There are many tricks you can try in regards to string tension, string type and type of racket you are using that may also assist in reducing your pain and allowing you to stay on court.

The best advice is to get an experienced physio, preferably one with tennis experience, to assist with your diagnosis and treatment.

In future blogs I will be reviewing other tennis conditions and providing case studies and examples or treatment options so follow me to get the latest information.

Regards Anne-Marie