Tennis and golfer’s elbow

What are the symptoms of tennis and golfer’s elbow?

The elbow joint plays a very important role in our everyday life allowing us to carry out one of the most vital tasks, which is bringing food to our mouth. Along with that it helps us carry out many other daily tasks. However, repetitive movements of the elbow joint can lead to some injuries known as tennis elbow and golfer’s elbow, medically known as lateral and medial epicondylitis respectively.

The pathological mechanism and causation behind this type of injury is said to be due to overuse and irritation of the tendon attachment near the elbow on the lateral and medial compartment (outer and inner part of the elbow). Epicondylitis is believed to be a chronic irritation of the tendon as opposed to an acute inflammatory response following injury.

Research has shown that lateral epicondylitis is 70% more common than medial epicondylitis and both injuries are 75% more common in the dominant arm. Lateral epicondylitis affects middle aged females more than males between their fourth and fifth decades and in total it affects between 1% and 3% of the whole population. Epicondylitis is a self-limiting condition that resolves by 80% within 1 to 3 years. Lateral and medial epicondylitis are not only seen in tennis and golf players but in other racket and bat sports such as badminton, squash, cricket and baseball, as well as in weightlifters, rock climbers and archers. Also, manual workers such as painters, carpenters, plumbers, utility workers and butchers often suffer from one of the two conditions.

Both medial and lateral epicondylitis usually present with several symptoms often around the affected area. Range of motion is not affected but can be painful in advanced stages of epicondylitis. Inflammation is only present in acute episodes of epicondylitis.

Lateral epicondylitis (tennis elbow) symptoms 

Pain on the outside bony part of the elbow with activities such as shaking hands, gripping objects, lifting objects with one hand, turning a doorknob or screw and using the computer mouse.
Weakness due to pain when lifting objects with one hand or general grip weakness.
Muscle trigger points in the lateral compartment of the forearm near the elbow.
Local tenderness on the lateral epicondyle.

Medial epicondylitis (golfers elbow) symptoms 

Pain on the inside bony part of the elbow radiating down the inside of the forearm towards the wrist.
Pain with gripping movements, turning the palm towards the floor and bending the elbow.
Weakness when gripping or shaking hands.
Local tenderness on medial epicondyle.

As mentioned earlier the most common cause of medial and lateral epicondylitis is repetitive movements due to occupation or sport over a long period of time. Another cause can be direct trauma to the elbow joint or to the forearm musculature following a hyperextension type of injury or a direct blow to the attachment of the muscles.

Risk factors include:

• Age between 30 and 50.
• Females are more affected than males.
• Sports such as: tennis, golf, cricket, badminton, squash, baseball, rock climbing, weightlifting and archery.
• Occupation such as: plumbers, carpenters, painters, barbers, butchers.
• Lifestyle: obesity, smoking, lack of exercise.
• Medical conditions: Ehlers-Danlos syndrome, hypermobility syndrome, Marfan syndrome.

The case history and a physical examination followed by a few orthopedic and muscle tests is primarily used to diagnose medial and lateral epicondylitis. From the case history the GP or musculoskeletal specialist such as orthopedic consultant, physiotherapist or osteopath will try to gain information about the injury if there has been one, understand your symptoms and when they occur and finally have an insight of your occupation or sport. The range and quality of the movement of the joint will be examined followed by muscle testing of the muscles of the medial and lateral compartment of the forearm. Resistance testing will aim to reproduce the symptoms, find the exact location and understand the mechanism behind the cause of pain.
In persistent cases of medial and lateral epicondylitis lasting more than 1-3 years or due to very poor recovery or pain affecting the essential daily activities of an individual the specialist or GP may order further examination. This involves an X-ray of the elbow joint to check for arthritis or damage to the bony parts or an MRI which will allow to examine the soft tissue and the innervation of the affected muscles.

Treatment options for the management of medial and lateral epicondylitis include over the counter medication, conservative treatment or manual therapy, corticosteroid or platelet rich plasma (PRP) injection and surgical intervention.

Medication: Non-steroidal anti-inflammatory drugs (NSAIDs) can be used in the acute phase to reduce inflammation and pain levels.

Conservative Therapy: Rest and a brace can help relieve pain. Ice or heat can be used to decrease inflammation, encourage blood flow and relieve pain.

Injection: Corticosteroid injections have shown positive results when used in the acute inflammatory phase (within the first 4 weeks following injury).

PRP injections are used to aid with the healing process of the tendon via the high concentration of growth factor.

Manual Therapy: Hands on treatment including physiotherapy and osteopathy can use different techniques to help reduce pain, increase range of motion and speed up recovery. These may include, but are not limited to muscle stretching, deep tendon friction, muscle and myofascial release and mobilization of the elbow joint.

Acupuncture, radiofrequency thermal therapy, shock-wave therapy and low-level laser therapy can be other techniques used by manual therapists to achieve the desired results (promote healing and decrease pain)

Surgery: If all the conservative treatment options have failed, your GP may refer you to an orthopedic consultant to discuss further surgical interventions. The aim of surgery for golfers or tennis elbow is to repair any tendon or muscle damage and remove any fibrotic tissue. Risks of surgery only presents to one out of ten operations according to research, and these include mild bleeding, lateral elbow instability and potential nerve damage.

According to research 90% of cases recover within one year with self-management, over the counter medication and conservative treatment and exercise plans. In severe cases or recurrent episodes of lateral or medial epicondylitis 80% will recover within 1-3 years with the remaining 10-20% having ongoing symptoms that may eventually require a more direct intervention or lifestyle modification.

Medial and lateral epicondylitis can be prevented with the right management and lifestyle. Your osteopath or physiotherapist can provide you with lifestyle advice and exercise and stretching prescription. Cessation of smoking, having a balanced diet and getting enough exercise in your life can help with the healing and recovery process of any type of injury in your body. On top of that certain repetitive movements due to work or sport could be reduced by learning to adapt or using alternative methods. Finally, good elbow and shoulder joint movement along with good muscle strength and flexibility can help prevent injuries to the elbow joint. Specific muscles that should be often stretched to avoid conditions such as epicondylitis include the forearm flexors and extensors that help us bend our wrist in different directions.

A correct rehabilitation program should be formed by your physiotherapist or osteopath according to the presentation and progression of the condition. This can be broken down into three phases including rest, isometric exercises with progressive tendon loading followed by eccentric and concentric exercises further challenging the tendon along with stretching of the medial and lateral muscle compartment of the forearm.

Rest: Following the onset of discomfort, pain or disability rest for 1-3 days along with the use of ice and NSAIDs to initiate the healing process. Manual therapy can be used alongside too.

Isometric tendon loading medial epicondylitis.

• Bend elbow at 90 degrees whilst your thumb is facing upwards. Use the non-affected hand to resist a downward movement of the wrist, without moving the wrist on the affected side. Hold for 10 seconds and repeat 3 times.
• Bend elbow at 90 degrees whilst your palm is facing upwards. Try and bend your wrist upwards whilst using the non-affected arm to resist this movement. Hold for 10 seconds and repeat 3 times.
  Keep your elbow at 90 degrees whilst holding a small weight in your hand (0.5-2kg). Starting position with your thumb facing upwards slowly turn your wrist 90 degrees clockwise, then back to the center and 90 degrees anti-clockwise. Repeat 5 times on each side.

Isometric tendon loading lateral epicondylitis.

• Bend elbow at 90 degrees whilst your thumb is facing upwards. Use the non-affected hand to resist an upward movement of the wrist, without moving the wrist on the affected side. Hold for 10 seconds and repeat 3 times.
• Bend elbow at 90 degrees whilst your palm is facing downwards. Try and bend your wrist upwards whilst using the non-affected arm to resist this movement. Hold for 10 seconds and repeat 3 times.
• Keep your elbow at 90 degrees whilst holding a small weight in your hand (0.5-2kg). Starting position with your thumb facing upwards slowly turn your wrist 90 degrees clockwise, then back to the center and 90 degrees anti-clockwise. Repeat 5 times on each side.

Eccentric & concentric loading medial epicondylitis.

• Keep your elbow at 90 degrees whilst holding a weight in your hand (0.5-5kg). With your palm facing upwards slowly bend the wrist up, hold at the top for 1 second and slowly lower the weight down to the starting position. Do 3 sets of 10 repetitions.

Eccentric & concentric loading lateral epicondylitis.

• Keep your elbow at 90 degrees whilst holding a weight in your hand (0.5-5kg). With your palm facing downwards, slowly bend the wrist up, hold at the top for 1 second and slowly lower the weight down to the starting position. Do 3 sets of 10 repetitions.

Stretching for medial and lateral epicondylitis.

• Keep your elbow straight and your arm extended in front of you with your palm upwards, use your opposite hand to hold onto the wrist and bend it backwards towards the ground. Hold for 30-60 seconds, then turn palm to face downwards and repeat the same thing.
• Get into a four-point kneeling position with your palms on the floor and fingers pointing forwards. From this position slowly push your body forward until you feel a stretch at the flexors of your forearm (medial epicondylitis). Hold that position for 30-60 seconds and return to the starting position.
• Get into a four-point kneeling position with your palms on the floor and fingers pointing towards your knees. From this position slowly push your body backwards until you feel a stretch on the extensors of your forearm (lateral epicondylitis). Hold this position for 30-60 seconds and return to the starting position.

Osteopaths or physiotherapists are classed as allied healthcare practitioners and can help diagnose and treat your symptoms of tennis and golfer’s elbow. They can also do a few screening tests to rule out any other causation. However, if symptoms arise suddenly on both elbows without obvious reason and there is inflammation, heat and redness around the joints it is better visit your GP or go to the local hospital to rule out other conditions such as rheumatoid arthritis, psoriatic arthritis or septic arthritis.

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