The tendons that extend or straighten our fingers all come from the same point of the elbow. This area is known as the lateral epicondyle or extensor tendon origin. Pain in this region is often described as lateral epicondylitis or tennis elbow. There are a number of tendons all originating from the same point and moving out into different directions to get to the fingers. As these tendons overlap and are working to move the hand and fingers particularly in gripping activities they can rub against each other creating friction, inflammation and eventually become scarred.
The tendon that moves the middle finger sits on top of all the other tendons and is the one that can rub the most. This tendon is called Extensor Carpi Radialis Brevis. In tennis elbow it is this tendon that is affected. There are other tendons that can be affected or other areas of pain on the lateral aspect of the elbow, however it is not tennis elbow unless the middle finger is involved.
Classically the tendon will be rubbing and slowly fraying for months. It usually takes about 6 months for the process to lead to pain or inflammation. Tennis elbow is characterized by pain in the lateral or outer aspect of the elbow. The pain often originates behind the elbow joint and radiates out from there over the outer upper one third of the forearm. It is intermittent at first and gradually deteriorates becoming increasingly stiff and painful. Most patients present with symptoms occurring for approximately 3 months at which time the tendon has become scarred and very weak. In all they have had the problem for 9 months by this time.
It is necessary to establish the source of the problem. With careful questioning a source is usually identified which more than likely will involve an increase in gripping activity in the previous 6-9 months. Classic examples are a short intense spell of DIY, gardening, gripping sports such as tennis or golf or perhaps a lot of right clicking with the mouse using the middle finger.
This intense period of activity may have started the scarring process and although not painful at the time, slowly degenerates resulting in the pain of tennis elbow 6 months later. If the cause can be identified this will greatly improve the chances of recovery.
Physiotherapy can conservatively manage tennis elbow and will result in full pain free and functional recovery in 70-80% of cases. The physiotherapist will break down the scar tissue and start the patient on a graduated exercise program. It will take 12 weeks to fully recover and the patient will need on average 8 sessions in that time.
The physiotherapist may consider a brace to help reduce the pain during treatment. Most of these are ineffective. The best tennis elbow supports are those that stop the hand from moving rather that restrict elbow function as it is gripping of the hand that is responsible for the damage in the first instance. The physiotherapist may also try acupuncture to control the pain during treatment.
If physiotherapy is unsuccessful the next option is to have one or a series of cortisone injections. There is much debate over the effectiveness of cortisone in tennis elbow as there are many who believe that there is no inflammation. There is also debate as to how many and where exactly these injections should be administered. The general consensus is that 3 injections would be the maximum over a 6 month period.
Surgery is the final resort and this will either involve debridement of the scar tissue or a tendon transfer. Tendon transfers are the more successful surgical procedure as it changes the angle at which the tendon pulls. This relieves the stress on the tendon and should reduce it’s recurrence in the future. Post surgical rehabilitation with a Physiotherapist is essential for good long term results.