A TENNIS ELBOW

A tennis elbow, also known as a lateral epicondylitis, is a common condition affecting mostly middle aged, active people, males and females alike. Patients usually present sometime after becoming aware of an annoying pain, located over the outer aspect of the elbow, over the prominent bony protrusion. Most of them can accurately localise the most tender spot on the elbow.

What starts off as an intermittent, dull ache, gradually develop into pain that is worse during repetitive or strenuous activities involving use of the hand. As time goes on, the pain is eventually elicited by the simplest of actions, such as just holding a cup of tea. Although the pain is mostly localised over the bone prominence, it may also radiate down into the muscles of the forearm.

In most patients, the cause of the pain is a tendinosis (an aging process affecting the tendons (sinews)) at the site where some forearm muscles originate; seldom would an inflammation of the tendons (tendinitis) be the cause of the pain. The muscles in question are responsible to "cock-up" (extend) your wrist. They come into play whenever you use your hand; explaining why you experience pain during use of the hand, even with a simple action, such as holding the tea cup.

In most cases no clear precipitating cause can be found, but the condition may be considered an overuse syndrome. It therefor follows that repetitive actions involving the use of the arm may contribute to the development of the pain. Keep in mind that as we age, our tissue may not be able to keep up with the same degree of activity as it did when we were younger; the same level of activity may cause an "overuse" response at the site of origin of the muscles in question.

How is a tennis elbow diagnosed?

A proper history and thorough clinical examination are in most cases enough to diagnose the condition. Tenderness over the bony prominence of the elbow and pain when attempting to "cock-up" the wrist against resistance, are reliable signs your doctor may find during the examination.

X-rays are hardly ever useful but may be considered if the patient has a history of a previous injury to the elbow. If additional same-side neck pain or shoulder and upper arm pain is also present, an x-ray of the neck may be indicated.

An MRI is not considered appropriate for the diagnosis of a tennis elbow.
An ultrasound imaging of the tendons on the outer aspect of the elbow may be requested in some cases but is not deemed necessary for all patients.

Certain blood tests may be requested if conditions such as gout or any other arthritis are suspected; there is no blood test that can confirm the diagnosis of a tennis elbow.

Treatment Options

Non-surgical Treatment

No treatment – by the time patients present, most of them have such uncomfortable pain that few will accept no treatment. There is however no proof that early treatment has any bearing on the outcome. In the rare cases where an activity can be identified as contributing to or possibly causing the condition, avoidance of such an activity and resting the elbow may allow for the inflammatory response to heal.

Rest and splinting of the wrist – the application of a removable splint to the wrist, is a possibility to consider when the condition develops directly after strenuous or repetitive activity involving the use of the hand and wrist. The application of ice early on, just after onset of the pain, may also help.

Oral non-steroidal anti-inflammatory drugs, non-steroidal anti-inflammatory ointments and oral painkillers - may afford temporary relief but are mostly found to be of little use.

Infiltrating the elbow with a mixture of a local anaesthetic and cortisone - infiltration of the most tender spot with a mixture of local anaesthetic and cortisone is our preferred method of conservative treatment: 3 infiltrations, administered 2 weeks apart, at the site of maximum pain, is seen as a "course" and another 3 injections may be given if the pain returns after a period of relief. After a maximum of 6 infiltrations, surgery should be considered; more cortisone may cause permanent harm and will probably also not help.

Infiltrating the tender spot with platelet rich plasma (PRP) – injecting the tender site with a concentrated solution of platelets, harvested from the patients own blood, is thought to promote "healing". Proof of this assumption is inconclusive. When conservative treatment fails, and if the symptoms interfere with quality of life and activities of daily living of the patient, surgery may be considered.

Surgical Treatment

The Procedure

Surgery to release a tennis elbow is done as a day procedure, i.e. you will be admitted and discharged on the same day. It should never be attempted in a consulting room.

The procedure is done using a form of local anaesthetic, called regional anaesthetic, which aims to numb either the whole arm or at least a part of the arm. In addition to the regional anaesthetic, you will also be given a sedative. A general anaesthetic may be used in patients that cannot tolerate local anaesthetic.

A short skin incision (some 3 to 4cm) is made over the tender bone prominence on the outside of the elbow, exposing the attachment of the muscles in question. A release is then performed by cutting through the fibres. "Cutting time" (from the first incision, to complete wound closure), is normally about 10-20 minutes.

The skin wound is normally closed with self-dissolvable stitches. A soft dressing is placed on the wound and kept in position with a crêpe bandage, leaving the hand and fingers free, allowing you to do almost all essential everyday activities. No plasters or splints are required that may limit movement of the elbow or the wrist.

Instructions after the Procedure

General Instructions

You will be allowed to leave the hospital when:

  • All the paperwork is done
  • When you are completely awake
  • When your wound is not bleeding
  • When your pain is under control
  • When you have received your take-home medication
  • When you have received your follow-up appointment card

The do's & the don'ts until your 1st follow-up visit

The bandage:

  • Keep the bandage dry and clean and don't remove it. If for some unforeseen reason it needs replacement, contact us or your general practitioner or visit you nearest clinic.
  • Do not stick anything in underneath the bandage, not even your finger(s).

Your hand:

  • Keep the hand of your operated arm elevated by placing your elbow on a sturdy surface, with your fingers pointing upwards. Do not allow the hand to hang or point downwards for long periods; this promotes swelling, which can slow down wound healing, cause pain and even bleeding from the wound

The do's:

  • Frequently open and close your fingers, lightly making a fist; this promotes circulation, reduces swelling and prevent stiffness of the fingers.
  • Use your fingers to do light, every day activities, such as putting on clothing and buttoning up a shirt, holding a knife and fork, brushing your teeth, and holding a book or a phone, etc
  • Typing on a keyboard is also encouraged.
  • Gently curl up and straighten the elbow a few times per day.
  • Prevent stiffening of the shoulder joint by putting your hand first behind your head and then behind your back; do this a few times per day.

The don't:

  • Do not forcefully make a fist or grip something tightly; this may cause pain.
  • Do not drive for the first 18 to 24 hours after surgery; you are under the influence of medication that may impair your ability to handle the vehicle. Apart from being sound medical advice, it is also a legal and an insurance issue.

Medication use following the Procedure

Painkillers

  • Unless you indicate otherwise, a mild painkiller will be prescribed and issued from the hospital pharmacy at the time of your discharge. This medication should help you manage your pain.
  • If the medication does not adequately control you pain, please contact our office or your general practitioner.
  • If the medication causes undesirable side effects or complications, please contact our office or your general practitioner, or if an emergency, go to your nearest emergency unit
  • Only take the prescribed painkillers when necessary and do not exceed the prescribed daily dosage. Also, do not add other painkillers without consulting with us or your general practitioner.

Antibiotics

  • All patients will receive one dose of an appropriate antibiotic in theatre to prevent the onset of an infection.
  • Unless there is a sound medical reason, a full course of an antibiotic will not be prescribed.

Chronic medication

  • Do not stop taking you chronic medication, not even on the day of your surgery. Although you are instructed to take nothing by mouth for the 6 hours before your surgery, do take your necessary chronic medication with the least amount of clear water.
  • If we feel that any of your chronic medication may negatively affect the outcome of your surgery or may increase your risk for complications, you will be instructed to timeously stop taking such chronic medication, or we will replace it with something that’s more controllable.
  • If you are uncertain about taking your chronic medication, please contact us or your general practitioner.

Follow-up Appointments

1st Follow-up visit (10 to 12 days after surgery)

  • The purpose of this appointment is to check if the wound is healing.
  • The stitches are self-dissolving; they need not be removed.
  • You will receive instructions regarding:
    • Further wound care
    • Activities to initially avoid
    • When we anticipate you may resume your normal activities.
  • We will also deal with any questions you may have at this stage.
  • If applicable, how soon you may return to work.

2nd Follow-up visit (6 weeks after surgery)

  • The purpose of this appointment is to confirm wound healing.
  • Confirm that you have full use of the elbow, wrist and hand

FAQ

Should I first have the injections, or can I immediately opt for surgery?

  • A substantial number of patients find long term or even permanent relief with the injections; so, it is worth having the injections first.

I was told that the cortisone injections are quite painful. Is that true?

Yes, it is painful, but almost all patients tolerate it well and if it helps you avoid an operation, most will endure the pain rather than go for surgery. We also mix the cortisone with some local anaesthetic, which lessens the pain of the injection

What can I expect in the 1st day or 2 after the injection?

As the local anaesthetic works within minutes, you may report some relief of you pain even whilst still in the consulting room. The numbing effect of the local anaesthetic will wear off after some 3 to 4 hours, leaving you with a bruised feeling at the site of the injection. Most patients report minimal or zero pain for the next few days, after which the pain may return, but to a lesser degree. The initial relief may be short-lived but the relief after the second injection is better and even better after the 3rd injection.

Will all my pain be gone after the first course of injections?

Although this is possible, and what we aim for, patients frequently still have some discomfort or even pain at the site of injection. If you can tolerate this residual pain, there is a chance that it may eventually subside. If possible, allow some 6 weeks for natural healing to occur before requesting another course of injections or submitting to surgery.

Are there any negative effects associated with the cortisone injections?

3 cortisone injections are unlikely to cause any permanent harm. The temporary side-effects you may experience include: hot flushes (sometimes even in males), insomnia and very seldom would patients experience worse pain the first night after the injection. Diabetic patients will notice that their blood glucose levels fluctuate in the first day or 2, but it will then stabilise.

Repeated injections on the same spot may lead to local loss of skin pigmentation, local loss of hair and the underlaying soft tissue may collapse, causing a local sunken appearance of the skin.

Cortisone also suppresses the adrenal glands, and long-term use may permanently shutdown these glands. If unrecognised, this may have serious consequences and may even cause the death of the patient.

What are the possible risks and potential complications when releasing a tennis elbow?

Serious Complications – there are no serious complications. Releasing a tennis elbow is a safe and effective method of dealing with a troublesome pain condition.

Common Complications

  • Theoretically sepsis should be the most common complication, but is in fact very rare, especially if you are healthy. Some patients, such as diabetics and other patients with suppression of their immune systems, have a higher risk but this is still manageable.
  • Some patients still experience some discomfort, even after the wound and soft tissue has healed, especially down into the muscles of the forearm. This pain will eventually clear up, usually after some 2 to 3 months.
  • Some patients are prone to developing thickened scars (keloid), but these seldom interfere with use of the elbow.

How effective is surgery?

If conservative treatment fails, surgery is an effective solution to a harmless but troublesome chronic pain problem.

Can a tennis elbow recur after surgery?

Theoretically it is possible, but seldom seen.

How long is the recovery time after surgery?

Your wound should take about 10-12 days to heal to such an extent that further wound dressings are unnecessary. After that, you should be able to gradually take on more of your everyday activities, and at six weeks you should be able to perform all your normal activities.

How soon after surgery can I drive?

Do not attempt to drive for the first 18 - 24 hours after surgery, as you are under the influence of an anaesthesia and painkillers; this is a medical, but also an insurance issue. After a few days, depending on your ability to effectively handle a vehicle in normal and emergency situations, you should be able to drive without causing harm to the operated arm.

What will happen if I do not have surgery?

Nothing will happen. Apart from experiencing pain with use of the hand and potentially dropping objects from your hand, you will not come to any harm. Surgery to release the muscle fibres can always be performed later.

Can the development of a tennis elbow be prevented?

If you could identify and avoid a specific action that may cause or contribute to the development of a tennis elbow, you should theoretically be able to prevent the onset of the condition; otherwise, the answer is, no.

Is physical therapy routinely indicated after surgery?

No. If, in our opinion your progress towards healing is slow or you are unable to regain normal use of the hand and mobility of your elbow, you may be referred to a physical therapist.

I have been diagnosed with tennis elbow; will I also develop it on the other side?

It is possible, but unlikely

I previously had surgery for my tennis elbow and have now developed the same condition on the other side.
Will I also require surgery for the second tennis elbow?

No. It is still worth having conservative treatment first, and if unsuccessful, then submitting for surgery

Dr Pierre de Villiers

Dr Pierre de Villiers is one of a growing, world-wide group of physicians, specifically trained to manage difficult painful conditions. A multitude of painful conditions that exist, are known to be non-responsive to conventional treatment options, but new approaches and equipment make therapies safer and more effective.

Contact

Suite 4, Mediclinic Hermanus, Hospital Road, Hermanus

+27 28 313 0528