Patient Information Guide
Lateral Epicondylitis or
“Tennis Elbow”
237 Route 108, Suite 205
Somersworth, NH 03878
Ph: (603) 742-2007
Fx: (603) 749-4605
www.sosmed.org
Summary:
Lateral epicondylitis is an overuse condition that
results in pain and loss of function of the affected arm. It occurs in people who use their
hands for activities that require repetitive gripping and squeezing. Pain on the outside of
the elbow with grip and wrist extension may be severe and prevent even simple tasks.
This pain may radiate into the forearm. Lateral epicondylitis results from tendon
degeneration of the extensor carpi radialis brevis tendon (a wrist extender muscle).
Treatments are aimed at allowing this tendon to heal while preventing further damage.
This condition tends to be self-limited in the majority of cases and fewer than 10% of
patients require surgery. The sections below will discuss the diagnosis and treatment
options in greater detail.
Tendon Anatomy:
Tendons are composed of collagen which is the
building block of our connective tissues. In tendons,
this collagen is arranged into fibers and fibers are
arranged into bundles much like a rope. This highly
organized arrangement allows tendons to transmit
the force generated by a muscle to the adjacent
bone. Collagen is manufactured by cells within the
tendon called tenocytes. These cells are responsible
for maintaining tendon health and for tissue repair
and remodeling. Most tendons have relatively little
blood supply. Consequently, tendon healing can be very slow. When tendons heal, new
collagen must be formed through a repair process. This collagen must then mature from
early scar tissue into organized tendon tissue. Not until this reorganization process is
complete and the tissue reconditioned are tendons capable of withstanding the demands
of everyday activities.
Definitions of Tendon Injury
Tendinosis refers to internal tendon degeneration. This occurs because on an imbalance
between tendon breakdown and tendon repair. Thus, tendinosis can result either from an
increase in breakdown such as from overuse or injury, or from a decrease in the healing
response.
Tendonitis refers to tendon inflammation. While this term is commonly used to describe
activity related pains in various joints of the body, recent studies have shown that there
is very little inflammation present in the majority of cases of tendon-related pain. This
conditions like lateral epicondylitis and rotator cuff tendonitis are actually not
inflammatory but degenerative in nature and should be referred to and treated as
tendinosis.
When tendons are exposed to repetitive stress and overuse, their capacity for internal
repair may be exceeded and injury occurs at a microscopic level within the tendon
substance. This is similar to individual strands tearing within the substance of a piece of
rope. As individual collagen fibers separate and tear, the ability of the tendon to transmit
force from the muscle is compromised and pain
results. The highly arranged organization of the
tendon substance becomes disorganized as shown in
the picture to the right. Notice how there are no
longer well defined bundles of collagen.
In response to repeated insult and injury, the tendon
undergoes a healing response. Blood vessels invade
the damaged area to bring in new building blocks. In
the face of continued use, however, this healing
response leads to the formation of fibrous scar tissue
rather than an organized tendon. Thus, areas of intact tendon fibrils are separated by
areas of disorganized scar. Several studies have verified that process occurs with little or
no inflammatory response.
Anatomy of Lateral Epicondylitis
The lateral epicondyle is the projection of bone on the outside of the elbow. This point
serves as an attachment for several muscles which extend the wrist and fingers. The
extensor carpi radialis brevis (ECRB) tendon is the one most commonly involved. This
tendon aids in wrist extension. The extensor digitorum communis (a extendor of the
fingers) may also be involved.
The picture of the left
Be
shows a front view of the
ca
bones of the elbow joint.
us
LE
The lateral epicondyle is
e
the projection labeled LE.
the
The picture to the right
inv
shows the insertion of the
olv
extensor muscles at the
ed
lateral epicondyle. The
ten
ECRB inserts directly onto
do
the lateral epicondyle
ns
lie
directly against the outside of the elbow joint itself, many patients will develop irritation
of the lining of the joint, called synovitis.
Causes/Risk Factors:
Lateral epicondylitis has many possible causes that may act alone or in combination to
result in tendon degeneration. The causes are listed as follows:

Overuse: Repetitive use is the main cause of lateral epicondylitis. Activities that
involve forceful grip and those that involve prolonged wrist extension place people
at risk for this problem. If the rate of tissue breakdown exceeds the rate of tissue
healing, tendon degeneration may occur. This may be know as Repetitive Strain
Injury (RSI). Giving the damaged tissue sufficient time to heal is essential to
recovery. Continued pain during activity is an indicator of internal tissue damage
and should not be ignored. Efforts to “work through” the pain will likely only result
in further injury. A significant problem in today’s busy world is the inability to
avoid the activity that causes lateral epicondylitis especially if it is work-related.

Age: as we age, our tendons and ligaments lose strength and their internal
capacity for tissue repair and healing decreases. Thus, they are equally more
prone to injury and less likely to recover quickly. Age greater than 35 is considered
a risk factor for tennis elbow.

Weakness/Inadequate Fitness: many people who engage in repetitive motion
activities, whether through work, sport or recreation, develop fatigue in the lateral
elbow muscles. Muscle fatigue results in weakness that can predispose to injury.
With continued use, fatigue can lead internal damage to the muscle and tendon.

Improper Technique: for some work and sport related causes, faulty technique
may result in excessive stress to the wrist extensors. In tennis, improper grip size,
a single-handed back predispose both recreational and competitive players to
“tennis elbow.”

Tendon Healing: Tendons have a poor blood supply and thus do not heal as
readily as other tissues such as skin. Thus, when tendinosis ensues, internal
tendon repair and remodeling can take many months

Smoking: as with many other tissues in the body, the connective tissues of the
musculoskeletal system are adversely affected by smoking. Specifically, smoking
damages the circulation to tendons and bones. This not only places these tissues
at risk for injury but also slows or prevents their healing during a recovery period.

Tennis: with regard to tennis the principal causes are 1)playing too often, 2)
faulty technique; 3) improper equipment; and 4) poor physical conditioning.
Bending the elbow during a backhand stroke is the major technique flaw. Players
who use a one-handed backhand are also at higher risk. A late forehand swing
with a wrist snap may also predispose to tennis elbow. Improper grip size may
also contribute to tennis elbow.
Symptoms and Signs
Symptoms: Pain over the outside of the elbow that radiates
into the forearm region with gripping and squeezing
activities or those require repetitive wrist extension is the
main symptom. This pain may be so severe that people are
nearly unable to perform even simple tasks like writing.
Pain related muscle inhibition may lead to weakness and
some will report inability to lift even light objects like a
coffee cup.
Signs: the physical exam of lateral epicondylitis is usually
very characteristic. Pain on palpation
directly over the area of tendon
degeneration
is
painful.
Pain
is
exacerbated by manually resisting a
patients attempt to extend the wrist
against firm pressure. Patients with
involvement of the finger extensors will
similarly have pain on resisting finger
extension. Patients with irritation of the
elbow joint capsule may have a broader
area of pain that extends toward the back of the elbow. Range of motion is generally well
preserved and there is generally an absence of numbness or tingling that might suggest
a neurologic problem.
Wbat is the Differential Diagnosis of Lateral Epicondylitis: Other conditions that
can mimic lateral epicondylitis and cause pain over the lateral side of the elbow include
the following:

Radial Tunnel Syndrome: like carpal tunnel syndrome, this is a nerve
compression problem involving the posterior interosseous nerve which supplies the
wrist and finger extensors. This compression may be due to fibrous bands in the
supinator muscle or to a ganglion cyst that emanates from the elbow joint. It may
be difficult to accurately diagnose and present in almost an identical fashion to
lateral epicondylitis.

Elbow Arthritis: in rare cases, elbow arthritis may be confined to the outside of
the joint between the head of the radius bone and end of the humerus bone.

Herniated Disc in the Neck: like sciatica in the lower back caused pain in the
leg, a herniated disc in the neck may cause pain the arm. In some cases, this pain
may be fairly localized as in lateral epicondylitis, while in other cases pain may
radiate all the way into the fingers.

Tumor: rarely bone tumors may involve the bones about the elbow and cause
lateral elbow pain. Fortunately, these are usually detected by routine screening xrays.

Idiopathic Arm Pain: this diagnosis refers to pain that has not defined cause.
Pain is a complex phenomenon that has many components some of which are
chemical and some cultural. In some cases of arm pain, an anatomical source
cannot be found despite a thorough work-up.
How is Lateral Epicondylitis Diagnosed?
In a majority of cases, lateral epicondylitis can be diagnosed based on a patient’s history
and physical examination. If these suggest anything atypical of lateral epicondylitis then
further work-up may be needed to rule out other causes.
A routine set of x-rays is generally obtained to screen for the presence of any underlying
conditions that might also cause lateral elbow pain. In typical lateral epicondylitis, these
will be normal. Occasionally there may be some calcification within the injured tendon
To the left is a normal
elbow x-ray. To the right
is an x-ray showing a
bone tumor in the end of
the humerus bone that
extends to just beneath
the surface of the elbow
joint.
Though not generally necessary, an MRI scan may be useful in atypical cases where the
diagnosis lies in question. It may also be useful in longstanding cases that may have
been present for over a year to confirm the diagnosis. This may be particularly important
when considering surgery to predict success.
These MRI scans show typical
findings in lateral
epicondylitis. The the left,
the white signal indicates
tendon degeneration and
partial tearing. The the right,
the tendon appears swollen
with white signal change
within the darker tendon
substance.
What is the Natural History of Lateral Epicondylitis?
In 90% of cases, lateral epicondylitis is self-limiting and slowly resolves over the course
of weeks to months. The time to resolution depends on the severity of tendinosis and the
ability of the patients rest the injured area. It cannot be predicated in any single case.
Some cases may last for up to a year. Once resolved, lateral epicondylitis may recur if
patients re-engage in the same activities that caused the problem in the first place.
How is Lateral Epicondylitis Treated?
The goal of treatment for lateral epicondylitis is fourfold.
1. promote tendon healing by promoting rest and avoidance of aggravating activities.
2. correct any underlying mechanical abnormalities that may have promoted the
development of tendinosis.
3. promote tendon strengthening and remodeling once adequate healing has
occurred.
4. prevent recurrence through a maintenance program of flexibility, strengthening
and aerobic conditioning.
Non-Operative Treatments
Stage 1: Controlling Pain and Inflammation
 Activity Modification and Rest: Tissue healing can only begin when repeated injury
stops. Those activities that result in worsening pain must be avoided to prevent
continued tissue injury during the recovery phase. Overuse and repetitive strain
must be avoided though gentle use of the arm is encouraged to prevent muscle
atrophy.

Ice: Cold therapy acts to decrease tissue swelling, reduce pain and reduce the
chemical irritation that perpetuates tendinosis. It is especially important after
exercise sessions. Apply ice or a cold pack to for 15 to 20 minutes, 4 times a day
for several days to keep swelling down. Wrap the ice or cold pack in a towel. Do
not apply the ice directly to your skin.

Non-steroid Anti-inflammatory Medications (NSAIDS): these medications include
Ibuprofen, Motrin, Advil, Naprosyn, Alleve, Bextra, Celebrex, and many others.
They act both to reduce inflammation and to relieve pain. They may be more
effective in the early phases of lateral epicondylitis when inflammation is more
prevalent. A 10-14 day trial is generally recommended after the onsest of pain.
Long term use of NSAIDS may be associated with risks such as irritation of the
stomach lining, ulcers and kidney problems. Patients should become informed
about the possible short and long-term side effects of each medication prior to
use.

Cortisone Injections: Cortisone is a powerful
anti-inflammatory medication that can be
injected adjacent to the diseased tendons.
Although lateral epicondylitis is not primarily
an inflammatory condition, cortisone acts to
modify pain receptors in the tissue so that
pain is diminished. This effect may last
anywhere from a week to several months
and is variable between patients. Repeated
cortisone injections can cause weakening of
the tendon tissue and may cause more harm
than good. Cortisone shots should be used as
part of a larger conservative treatment plan
rather than as an isolated treatment.

Therapy Modalities: ultrasound and electrical stimulation are physical therapy
modalities that may act to decrease pain from tendinosis. Iontophoresis using
dexamethasone (a steroid) is also often helpful in reducing pain associated with
lateral epicondylitis. As with cortisone injections, these modalities must be
employed as part of a larger treatment regimen.
2. Promoting Tissue Healing and Reconditioning
 Counterforce Bracing: these braces are worn just below
the affected area and act to control force transmission
through the forearm muscles. Pressure applied to the
muscle belly below the tendon helps to diffuse force over
a broader area. This reduces the stress on the involved
tendon by reducing the magnitude of muscle contraction
by constraining muscle expansion.

Physical Therapy: rehabilitation exercises should be
started after an initial period of rest. The goal is to
restore flexibility, strength and endurance. Gentle and
graduated resistive strengthening exercises, stretching
and aerobic conditioning increase blood flow to the
affected area and promote tendon remodeling. Adjacent joints must also be
strengthened, especially the shoulder girdle which helps transmit force generated
by the body to the hand. The ultimate goal is to slowly transition back into the
activities than may have caused the problem to begin with. This may take months
rather than weeks.

Home Exercise Program: Because formal physical therapy may only be performed
2 or 3 times per week, it is essential that patients have a structured home exercise
program to perform on the in-between days.
Stage 3: Technique Improvement and Equipment Modification
 Technique Modification and Improvement: because some cases of lateral
epicondylitis are related to improper technique, treatment must include a
technique assessment for sports-related cases, especially tennis. This is essential
to prevent recurrence and facilitate return to sport. Return to sport, such as tennis
or other racquet sports, must be gradual so that tissues can be reconditioned to
withstand the physical demand. Interval programs that involve a graduated return
are available for racquet sports that prevent early overuse.

Equipment Modification: obtaining the proper
equipment is necessary to reduce overuse
forces at the elbow. This may involve a tennis
racquet with a larger face, different grip and
string tension at the lower end of the racquet’s
recommended range.
Who Should Consider Surgery
Surgery may be considered if a concerted effort at
non-operative treatment has failed to result in improvement in comfort and function after
6-9 months. This equates to failed healing of the diseased tendon tissue. Surgery is
entirely elective. The decision should be based on how the lateral epicondylitis affects a
person’s quality of life and one’s tolerance for waiting out the healing process.
The success of surgery can be maximized if patients are motivated and committed to the
recovery process. Thus, one should not consider this course unless a substantial
allotment of time and effort can be devoted to the goal of recovery. Because healing of
tendons is a slow process, recovery from surgery may take up to three months until
patients can reengage in demanding activities or competitive play. Maximal improvement
may take up to 6 months.
What Does Surgery Entail?
Surgery for lateral elbow tendinosis seeks to remove the degenerated tendon tissue
which has failed to adequately heal and remodel. If there is a bone spur which has
formed adjacent to this tissue, it may be removed as well, though this is less common.
Once all diseased tendon has been excised, the bone beneath the extensor muscle
attachment is roughened to promote the inflow of healing cells. This surgery can usually
be performed through a small incision directly over the problematic area. Surgery is done
on an outpatient basis so patients may return home the same day.
Can Surgery Be Done with the Arthroscope?
As our experience with the arthroscope has evolved to include elbow arthroscopy, we
have developed successful methods of tennis elbow treatment through less invasive
techniques. Arthroscopic tennis elbow debridement can usually be done through 2-3
small incisions that permit insertion of the athroscope and special instruments to remove
diseased tendon tissue.
Advantages of the arthroscopic technique include the ability to inspect the elbow joint for
areas of inflamed joint lining, a torn area of elbow capsule or other potential problems
such as arthritis or loose bodies. Because the normal extensor tendons overlying the
ECRB do not have to be violated in an arthroscopic technique, some surgeons have found
that recovery after arthroscopic debridement is actually faster than after open
debridement. As our experience with this technique as matured, we now favor
arthroscopic treatment over an open incision and this is our preferred technique.
What Does Recovery Involve?
Immediately following surgery the arm is usually splinted with the elbow flexed to 90˚
and wrist free. This is worn for 48 hours and then removed. Gentle range of motion
exercises are begun with elbow flexion, extension, pronation and supination. One week
following surgery, patients can use the arm for gentle activities of daily living but
anything that involves forceful use of the arm is avoided. Active exercises for wrist
extension, flexion, pronation and supination are begin with no resistance around 1-2
weeks depending on patient comfort. At 3 weeks, 1 pound resistance is added using the
counterforce brace. Sequential resistance is added over the next 8 weeks with a focus on
developing endurance and allowing healing and remodeling of the tissue. Repetitive
forceful grip must be avoided for at least 6 weeks. If exercises cause pain then patients
should reduce resistance and frequency to allow further healing. Gradual return to high
level activity is begun around 2-3 months. Patients often continue to improve for 4-6
months and should not be frustrated to find that recovery is a slow process.
Potential Risks and Complications of Surgery
The risks of surgery include, but are not limited to, infection, elbow stiffness, recurrent
pain, bleeding, nerve damage and complications related to anesthesia. While these risks
and complications are infrequent, they can occur in anyone. Patients should consider
these when electing to undergo surgery. Any one of these problems can limit the
outcome of the procedure.
The most common reason for unsuccessful tennis elbow surgery is failure to resect all of
the diseased tendon. There have been reports of elbow ligament damage from overly
aggressive resection as well. These risks underscore the importance of experience in
performing this type of surgery.
What are the Results of Surgery
Surgery can be very successful in patients who have failed to respond to non-operative
measures, assuming that the correct diagnosis has been made. The results of surgery
depend on two important factors. First is that the surgeon has performed an adequate
resection of the diseased tissue. Second is that the patient adhere to the postoperative
regimen. Most reports quote a 90% success rate given these stipulations.
Future Treatments
Tendinosis affects millions of Americans and the cost to society from medical care and
lost productivity is measured in billions of dollars. For this reason, a host of centers are
investigating methods of augmenting the tendon healing response. The studies are
pursuing artificial tendon tissue, therapeutic injections to boost the rate of tendon healing
and other biological remedies. Although none of this research has yet reached fruition in
terms of treating patients with tendinosis, there is a high likelihood that within 5-10
years, we will have novel regenerative approaches to managing this chronic condition.