Why Do I Have Elbow Pain With Gripping? 5 Facts Active People Should Know About Tennis Elbow
Today we will go over the basics of ‘tennis elbow,’ or lateral epicondylitis.
Tennis elbow is an extremely common upper extremity condition. In some populations, the estimated lifetime risk approaches 40-50%! [1]. This article will arm you with the knowledge you need to navigate this condition in yourself or a loved one. You will come away understanding why it occurs and why some treatments work (and others don’t). That way, we get you back to all the activities you love as fast as possible — without doing further damage along the way!
As a brief aside, let me share my dislike for the term ‘tennis elbow.’ It makes it sound like you are spending far too much time at the country club when in reality this is an extremely common tendinitis that can be debilitating and painful. The term itself downplays the impact this can have on the simplest of necessary life tasks.
So don't be offended or read too much into the name.
1. Tennis elbow is a tendinitis of the muscles that extend your wrist (and fingers)
As I mentioned above, the technical term is lateral epicondylitis.
This is a very common tendinitis of the connection between your upper arm bone (humerus bone) and the muscles of your forearm. Specifically, the muscles involved are the muscles that help you extend your wrist and fingers (see Figures 1 and 2).
All of the muscles that help you perform these two actions start at an anchor point on your humerus bone near the outside of your elbow (see Figure 3).
Figure 3 - This is the ‘lateral epicondyle’ where all wrist extensor and finger extensor muscles originate
Your Anatomy
This is one of those conditions that benefits from some 3-D imagination.
I want you to imagine (see Figure 4) a large cylinder of muscle (wrist and finger extensors) that anchors into the bone (lateral epicondyle). This is the bone-muscle interface that I mentioned above.
Figure 4 - The wrist and finger extensors form an outer core (dark red) and inner core (light red) of muscles. Lateral epicondylitis is a result of small tears of the inner core of muscles at the lateral epicondyle.
Throughout our life, we are constantly extending our wrist and our fingers, whether to reach out to grab a coffee cup or to return that perfect backhand in tennis (where the term originally comes from).
It is also an extremely common movement for yard work, snow shoveling, picking up children, or pretty much any other use of our hand. In fact, the strongest position of grip is when the wrist is positioned in 20 degrees of extension.
So, your body will naturally extend your wrist when you go to grab an object.
Over the course of your life, your muscles are pulling, pulling, pulling at the bone each time you do one of these motions. Almost inevitably, at some point, some of these muscles in the inner core will partially tear off the bone. While we don't routinely get an MRI for tennis elbow, you will usually find at least a partial tear of these muscles where they meet the bone.
The problem is the blood supply to this big cylinder of muscle. The blood supply comes primarily from the outside, so if you sustain a tear on the interior of this core, it will take a long time for the blood supply to filter its way in to help heal your injury.
And in the meantime, you are continuing on with your life! Continually pulling off the scab of healing muscle where it is trying to heal back down to bone.
Almost every patient with this condition tells me they can barely lift a cup of coffee. Again, as you reach out to grab the cup of coffee, you extend your fingers and extend your wrist in preparation for grip. This extension rips off the healing scab and the problem continues.
Symptoms
Tennis elbow symptoms are primarily pain, soreness, and a deep ache on the outside of the elbow and upper forearm (see Figure 3 above). This pain is typically made worse with the motions that we described above, such as reaching out to grip objects or extending the fingers. It is common to feel it with simple tasks such as typing or carrying small objects.
The pain is deep and aching. Many patients will feel like they are constantly rubbing or massaging their elbow or upper arm. Many will even feel a sensation of weakness in the hand, wrist, or elbow as a result of this condition.
2. MRI is overkill for diagnosis
Tennis elbow is a clinical diagnosis. This means there are no advanced tests needed.
If you are tender directly over this bone-muscle interface on your outer elbow, you almost certainly have tennis elbow.
A few physical exam maneuvers can also cement the diagnosis. If you extend your wrist against resistance and this recreates your pain, that is consistent with tennis elbow.
A special examination trick that I like is to have the patient extend their middle finger against resistance. This is almost always painful with this condition and makes the diagnosis quite straightforward.
Many patients come to me with an MRI of their elbow performed elsewhere. But this is overkill and not necessary for the diagnosis. Not to mention the expense of the test.
3. Don’t kill the messenger — there is no overnight fix. But it will (almost always) heal.
Remember one thing:
Treatment of tennis elbow is almost entirely non-surgical.
Surgery for tennis elbow is only considered after more than a year of symptoms and failure of all other treatment options. In fact, the natural history of tennis elbow is to gradually resolve over the course of about a year (natural history = what the condition would do if there were no treatment provided whatsoever). This will happen in over 90% of patients.
Obviously, you might not be thrilled about waiting a year to achieve relief of your very painful elbow symptoms. Everything we do for treatment is an attempt to shorten this timeframe. I will be honest, however, that the treatment options are somewhat limited and often fail to produce immediate results.
If you have this condition, you need to understand that you are in it for the long haul
4. Bracing the WRIST (not elbow!) is the key to faster recovery
The first option that I recommend to everybody is bracing. BUT. The internet is full of tennis elbow braces. And in my opinion, most of them miss the point.
The majority of marketed braces involve some sort of wrap around your elbow. At first glance, this would make sense. That's where the pain is.
However, try to remember the anatomy and physiology I explained to you above. The problem here lies in the muscles that extend your wrist and fingers. So, when a patient comes to me with tennis elbow, the first thing I do on everybody is put them in a wrist brace.
I completely understand that your first reaction would be ‘Why on earth would you put me in a wrist brace when I have elbow pain.’ But again, if we can limit the number of times you inadvertently extend your wrist, then we can start to make some progress on our pain. Because we will minimize the number of times you rip off the healing scab as your tendon tries to heal back down to the bone.
Remember. Lateral epicondylitis will go away in nearly everybody — we just have to get you there. A wrist brace is a tremendous tool to move toward this goal.
I typically recommend patients spend the first two to three weeks in the wrist brace — as much as they possibly can. 24/7 is the best. As much as possible is your mantra.
To help with this, you can think of your pain as the dying embers of a fire. Each time you feel pain, you are stirring them up and prolonging the process. Our goal is to extinguish the flame for good. The more time in the brace early on, the faster you will get there.
For more detail on my bracing protocol for tendinitis, please see my framework here.
Physical Therapy is powerful
After an initial two to three weeks of bracing, I encourage all of my patients to spend a few visits with our therapists. There are well-researched therapy protocols that have been shown to shorten the duration of tennis elbow symptoms.
Again, there is no overnight fix for this pain, but you do need to rehabilitate your elbow back to pain-free function in order to shorten the duration of symptoms. Much of what a therapist can teach you in the first few visits can be done on your own going forward.
At this point, it's dogged maintenance until you heal. You can do this!
Repeat the cycle of bracing and therapy until your pain disappears.
The goal is to treat your pain over months rather than years. Commit yourself to this plan and you will avoid doing more damage than good (see below).
5. Injections delay recovery
You may be wondering about injections. There are plenty of providers who still routinely perform injections for this condition.
However, evidence over the last few years [2-5] has shown that while steroid injections will temporarily make you feel better, they may actually prolong the duration of your symptoms or decrease your eventual chance at healing.
That means you'll feel great for about six weeks. But rather than resolving the condition over six months, it may take you nine months to a year. Or worse.
When I discuss this with most patients, the majority decide that the tradeoff is not worth it.
And this actually makes sense from a scientific perspective. When examined under the microscope, lateral epicondylitis is actually not an inflammatory process. This tendon is trying to heal back to bone but there is no significant associated inflammatory tissue in the healing wound bed.
Remember that all steroids are anti-inflammatory medications — so it does not make any clinical sense to use an anti-inflammatory to treat an area that is not inflamed! I have a similar feeling about carpal tunnel injections as you may have seen in previous articles (here).
So, injections are not a part of my typical treatment for tennis elbow. By far the hardest part about tennis elbow is the waiting. It's very difficult to be patient when you're having significant elbow pain. I get it. My goal is to help you trust the process, educate you, and prevent you from doing more damage along the way.
What is the surgery for lateral epicondylitis?
As I mentioned above, a rare subset of patients goes on to need surgery. We typically don’t even consider surgery until nine months to a year of symptoms.
In this surgery, an incision is made over the outside of your elbow. The muscles are retracted out of the way and the inner core of the muscle-bone interface is exposed.
The healing tissue is scraped away until only healthy tissue remains. A suture anchor is then placed into the bone and the partially torn tendons are suture-tied back down to the bone. The goal here is to compress the tendon up against the bone to allow for healing over the next six to eight weeks.
The elbow and wrist are splinted for a brief period of time, followed by two to three months of rehabilitation with our therapists.
The vast majority of patients benefit from this surgery and experience significant pain relief following the procedure.
Wrapping it up
As with any medical condition, we could dive into much deeper levels of detail. But suffice it to say that what I have discussed here should deliver 90% of the understanding of tennis elbow.
I hope this helps you with the knowledge you need to take charge of your healing process and work towards getting rid of your elbow pain for good.
References:
[1]: Sayampanathan, Andrew Arjun, Masoodh Basha, and Amit Kanta Mitra. "Risk factors of lateral epicondylitis: A meta-analysis." The Surgeon 18.2 (2020): 122-128.
[2]: Smidt, Nynke, et al. "Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial." The Lancet 359.9307 (2002): 657-662.
[3]: Olaussen, Morten, et al. "Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial." BMC músculoskeletal disorders 16.1 (2015): 1-13.
[4]: Kachooei, Amir Reza, et al. "Factors associated with operative treatment of enthesopathy of the extensor carpi radialis brevis origin." Journal of shoulder and elbow surgery 25.4 (2016): 666-670.
[5]: Degen, Ryan M., et al. "Three or more preoperative injections is the most significant risk factor for revision surgery after operative treatment of lateral epicondylitis: an analysis of 3863 patients." Journal of Shoulder and Elbow Surgery 26.4 (2017): 704-709.
