What happens in the elbow with a tennis elbow?
On the outside of the elbow attach the muscles that extend the wrist. In tennis elbow this tendon attachment has been rebuilt by repeated loading: the collagen fibres lie in disorder and small vessels grow in. Inflammatory cells are hardly found there. So the field today speaks of epicondylopathy and no longer of epicondylitis.
The bony prominence on the outside of the elbow is called the lateral epicondyle. Several forearm muscles come together there in a common tendon. Most often affected is the part of a muscle that extends and steadies the wrist while the fingers grip. Every time you hold something, that tendon pulls at its attachment.
For a long time the picture was called epicondylitis, meaning inflammation. Tissue samples show something else. What is seen is increased connective tissue cells, disordered collagen fibres and small vessels growing in, but no typical inflammatory cells. Technically this rebuilding is called angiofibroblastic hyperplasia. It arises when micro-injuries occur faster than the tendon can repair them.
The difference is not quibbling about words. It explains why anti-inflammatory drugs dampen the pain but do not heal the tendon, and why loading belongs to the treatment: tendon tissue aligns itself along the direction of pull it is exposed to.
- What is affected is the tendon, not the joint and not the bone. Since tendons are the continuations of muscles, the text speaks partly of the tendon and partly of the muscle attachment.
- The rebuilding is degenerative, not inflammatory.
- Only a small share of those affected play tennis; most cases arise at work or in the household.
What does a tennis arm feel like and what hurts?
The pain sits at the bony prominence on the outside of the elbow and runs into the forearm. What hurts is anything asking for force with the wrist extended: holding a cup, wringing out a cloth, pressing a door handle, turning a screwdriver. A firm handshake is unpleasant, and grip strength falls away noticeably.
Typical is a gradual start, often one to three days after an unaccustomed task. At first only the one movement that caused the trouble hurts. Later the coffee cup is enough. The hand does not go numb and does not tingle with it; such signs speak for another cause.
At the examination your doctor feels for the point of greatest tenderness and tests a few targeted movements. The pain can usually be set off when you extend the wrist or the middle finger against resistance. Lifting a chair with the hand turned downwards is also a common test.
Your doctor makes the diagnosis, never the therapy. That counts especially here, because several things hurt similarly on the outer elbow: a narrowing of the radial nerve in the forearm, wear in the elbow joint, instability after a fall, or radiating symptoms from the cervical spine.
Why is resting not enough with a tennis arm?
Rest takes the pain away but does not rebuild the tendon. A degeneratively changed tendon needs pull so that the collagen re-orders itself. Rest the hand for weeks and you lose grip strength and capacity. The first normal working day afterwards overloads the tendon again. Measured re-loading is better established than rest.
Rest is not pointless for all that. Whatever set the symptoms off belongs turned down for a while, or the tendon never settles. The difference lies between adapting the load and leaving it out. Adapted means: less force, fewer repetitions, shorter blocks, a different hand position. Left out means: the arm does nothing at all for weeks.
The second reason is time. Muscles become stronger within weeks; a tendon needs months before it tolerates more load. Anyone who only loads again once nothing hurts at all starts over every time and loses the months the rebuilding would have taken.
So in hand therapy a stocktaking comes first: which task irritates it, how often, how long, with how much force. From that comes an upper limit for daily life and a starting point for the training. Both are readjusted every few weeks.
Which exercises help with tennis elbow?
Best established is strength training of the wrist extensors with slowly increased load. Eccentric exercises, meaning the controlled lowering against resistance, have been studied longest. Holding forms and bend-and-extend forms work too. What decides is less the design of the exercise than the dosing over weeks and the regularity.
The basic pattern is simple. The forearm rests, the hand hangs over the edge, with a small weight in the hand. The hand is raised and then lowered very slowly, over three to four seconds. The slow lowering is the eccentric part, and that is what matters. The healthy hand may help with the lifting, so that only the lowering loads the tendon.
- Choose a starting load such that the last repetitions are demanding and the pain stays bearable.
- Two to three sets, few repetitions, carried out slowly, on most days of the week.
- Stay at the same load for around two weeks and watch the reaction the following day.
- Only increase after that, and in small steps: more weight or more repetitions, never both at once.
- Add grip strength and the movement that bothers you in daily life as soon as the wrist tolerates it.
When the tendon is strongly irritated, the way in is often a hold rather than a movement: the position is held for a few seconds against light resistance without anything moving. That usually works even when every movement stings. A look at the shoulder is worth it too, because a weak shoulder shifts more work onto forearm and hand.
What an exercise programme does not do: work quickly. Before six to twelve weeks a reliable judgement is hardly possible. Written instructions with your own load and your own repetition counts help more than an off-the-peg sheet; templates for that are in the documents for patients.
What do a strap, a brace and tape achieve?
A strap below the elbow or a wrist splint can lower the pain at once during a demanding task. Evidence that it improves the course over months is missing; the guidelines call the evidence contradictory. Useful as help for particular loads, not as the treatment on its own.
The strap sits a few centimetres below the painful point, around the forearm. The idea behind it: part of the pull of the muscles is caught by the band before it reaches the tendon attachment. Some feel that at once, while others find the pressure on the already irritated area unpleasant.
A wrist splint takes a different route. It holds the wrist in slight extension and so takes part of the holding work off the extensor muscles. That can help with screen work or with driving. It is worn during the demanding task and not around the clock, or a loss of strength joins the tendon problem.
- Strap and splint are helps for particular hours, not a replacement for the build-up of load.
- They do not belong worn day and night.
- If the pressure increases the pain, that is a reason to leave them off, not a sign of wrong use.
- For rigid tape there are indications of short-term relief; a long-term benefit is not established there either.
What do cortisone, shockwave and autologous blood achieve?
Cortisone relieves markedly for about six weeks and worsens the result after a year, with a higher relapse rate. Shockwave therapy comes into question in stubborn courses, and the studies on it contradict each other. On autologous blood and platelet-rich plasma the data are to this day not sufficient for a clear judgement.
The cortisone injection is the clearest case in this article, and its result surprises many. In the short term it works very well. Over six to twelve months, those treated do worse than those who did exercises or simply waited. A general practice review reports a relapse rate after an injection of clearly more than half.
A second finding comes with it: the injection appears to cancel out the benefit of an exercise therapy running at the same time. Also described are discolouration of the skin, loss of the fatty tissue under it and, with repeated use, damage to the tendon, which does not forbid the injection but makes it a decision with drawbacks.
With shockwave the picture is less clear. The German-language guideline allows it as an option in courses resistant to treatment, while older systematic reviews found no reliable effect against a sham treatment. The side effects are slight and temporary, usually redness or pain during the application. Anyone who tries it should carry on with the exercise programme alongside.
On autologous blood and platelet-rich plasma there are studies with better results than under cortisone and studies with no difference from a sham injection. The preparation methods differ greatly, which makes comparison difficult. The guideline holds that a final judgement is not yet possible.
How long does a tennis arm last and when is it operated on?
Reckon in months, not weeks. The strongly painful phase usually lasts six to twelve weeks, and more than eighty in a hundred people are markedly better within a year. Imaging is only needed with persisting symptoms. Surgery is discussed at the earliest after six months of unsuccessful conservative treatment.
The course counts as self-limiting, but the span for that reaches up to two years. Depending on the source, a chronic course is spoken of from three to six months of symptoms. Relapses in the first year are common, and some people still have limitations with forceful tasks after two years.
Unfavourable for the course are symptoms lasting more than three months before treatment starts, neck complaints at the same time, physically one-sided work, and involvement of the hand you use most. Starting early to order the load does not shorten the course to weeks, but it can help avoid the spiral of resting and fresh irritation.
Tennis elbow is diagnosed clinically; no image is needed for it. An X-ray comes into question if a bony problem or joint wear is in the picture. With a course over six months the state of the extensor tendons is often documented with ultrasound or magnetic resonance, above all when a procedure is under discussion.
An uncomfortable figure belongs with surgery. The guideline reports high satisfaction after the operation, but also names 5 to 20 per cent without a good result. And a placebo-controlled study found no added benefit for cutting out the changed part of the tendon compared with a sham operation; so the conservative route with targeted movement therapy is clearly preferred.
What can you change at the workplace and on handles?
Two quantities drive the load: force and repetition. Repeated hand movements for more than two hours a day and loads over twenty kilograms count as risks. Against them help thicker and softer handles, tools with less kickback, more frequent short breaks, and switching between tasks rather than hours on the same handle.
A thin, hard handle forces the fingers into a tight bend and asks for more holding force for the same task. A thicker, softer handle spreads the pressure far more evenly over the larger contact surface. The literature yields no specific measurements, so a rule of thumb applies: the handle with which you do the same work with less effort is the right one.
- Carry loads closer to the body and with the elbow bent rather than the arm straight.
- When lifting, turn the palm upwards; that takes load off the extensor tendons.
- Take heavy objects with both hands, even when one would do.
- Use tools with vibration and kickback in shorter blocks.
- With screen work, place mouse and keyboard so that the wrist stays straight and the forearm rests.
- Mix tasks rather than doing one for hours at a stretch.
Smoking and excess weight appear in the guideline as risk factors. Neither can be changed in a therapy session, but both belong in the picture when a course drags on over months.
Only with an actual accident or a recognised occupational disease is accident insurance responsible; otherwise it is your health insurer. A tennis elbow from repeated loading at work does not as a rule count as an accident. For treatment with us you need a doctor’s prescription in either case; arrange an appointment through the booking page.