How to treat Tennis Elbow

You may have come across people who suffer from elbow pain. Some have symptoms without any trigger, where the elbow becomes swollen and painful spontaneously. In others it happens after strenuous activity or sports. Tennis Elbow and Golfer’s Elbow are terms given to categorize activity related to elbow pain. And these two conditions do not necessarily mean that you need to play tennis or golf before  symptoms are noted. You might not know that Tennis Elbow was earlier described as Writer’s Cramp in 19th century. Later on as the Washer Women’s Elbow! Finally, Henry Morris a British surgeon termed this condition as “Lawn Tennis Arm” in 1883.  

Structure of the elbow
The elbow is a complicated joint. There are basically two different types of movement possible within this joint. You can bend and straighten the elbow. Then you can rotate the forearm (this happens from within the elbow) so that the palm of hand is either up or down. The latter movement is called pronation and supination. All this complexity is the gift from evolution to aid us in using the most advanced tool of all – our hand. So actually the elbow is a large joint which holds the human hand steady and aids it in various maneuvers.  

A classification of pain
Elbow pain can be simply classified in to two different types. Pain generating from within the joint, which is sometimes associated with a bit of swelling and redness of skin. And pain arising from the structures that surround the joint.  

And when the time of occurrence is considered, we classify pain again into three different types. The early morning pain and stiffness of the elbow, which could be inflammatory arthritis related. The “At the end of the day” elbow pain which is probably osteoarthritis related. And the third category is the “Aftermath of injury/ playing sports” pain. The latter is how usually golfer’s or tennis elbow happens.  

Pain arising from structures that surround the elbow
There are two groups of muscles which commence at the elbow level and end up at the hand. These two muscle groups move the forearm, wrist and fingers. The muscle bundle at the outer aspect of the forearm mainly helps the fingers and wrist to straighten out. The muscles at the inner aspect of forearm help the wrist and fingers to bend. These muscles are attached to bony hills named epicondyles.  When there is pain over the outer epicondyle, the term tennis elbow is given. When the pain is felt over the inner aspect epicondyle, its called golfer’s elbow.  

Carpenters
Tennis elbow isn’t confined to tennis players. It is seen in people who use heavy tools like the hammer. Swinging movements of the forearm done by carpenters or other professionals can injure the area surrounding the outer (lateral) epicondyle. This is an area where a bundle of forearm muscles unite and tightly fit in to the bone.  

Movements which involve fist clenching and straightening out the wrist can worsen the Tennis Elbow. This condition is also given the complex term lateral epicondylitis.  

Baseball players
Golfers elbow is also named pitcher’s elbow. This condition is seen in baseball pitchers who throw the ball. Pain is felt at the inner aspect of the elbow where muscles unite at a bony prominence called the medial epicondyle. Rotating/twisting the forearm or bending the wrist can worsen the symptoms.  

Pain coming from within the elbow joint
The elbow is a place where three arm bones unite. There is a joint cavity which has a bit of fluid in it. And several structures like ligaments, muscles and tendons to keep the joint steady. Certain blood vessels and nerves surround the joint as well.  

 The joint swells up in a process called inflammatory arthritis. Inflammatory arthritis in turn can develop in conditions like rheumatoid arthritis and spondyloarthritis. The symptoms are worse in the morning. Pain and stiffness cause severe agony. As the day progresses the symptoms might subside. In very severe inflammatory arthritis the movements in the elbow joint are restricted; patient complains of inability to completely bend or straighten out the elbow. If this continues there will be visible deformities of the elbow.  

In osteoarthritis pain and stiffness can develop at any time of the day. But this is worse after prolonged periods of rest. And also at the end of the day. Osteoarthritis isn’t just a disease of the elderly. Unlike what we earlier thought osteoarthritis isn’t purely a wear and tear process of the joint.  
Both inflammatory and osteoarthritis can cause clicking or creaky elbow. 

Treatment 
A proper evaluation by a consultant is needed before commencing any treatment. As there are a variety of conditions that could mimic these symptoms.  

A period of rest from strenuous activity involving the elbow is advised. Patients should be taught elbow protection strategies. Advice on how to carry weights is provided. A tennis elbow band is helpful. This is an orthotic device which is worn over the forearm to prevent muscle tension acting over the injury area. And also a wrist brace which holds the wrist in slightly straightened out posture is helpful as well. The wrist brace again reduces the strain over lateral epicondyle.  

Physiotherapy methods like ultrasound therapy and heat therapy might help. We also prescribe drugs such as NSAIDS and steroids. In resistant cases steroid injections are administered.  

How pain is evaluated
As mentioned earlier features of inflammatory(swollen) arthritis should be differentiated from osteoarthritis. 

The patient is usually evaluated for all the difficulties faced when moving about the joint. If you imagine, even the simple process of eating involves picking up food from the plate, then bending the elbow while rotating the hand/forearm to eat. After obtaining details investigations such as X rays and blood tests are done.  

Treatment for inflammatory arthritis is a combination of disease modifying drugs, proper physiotherapy and in certain instances injections. 

In osteoarthritis disease modifying drugs have no place. Pain relief, physio and joint injections are helpful.