Tendon Troubles

Tennis Elbow: Painful, no matter how you get it

It’s called tennis elbow, but less than half of the people who get actually it can blame it on playing the game, says Dr. Jack Siegel of The Jordan Young Institute for Orthopedic Surgery and Sports Medicine. “It’s basically tendonitis of the outside of the elbow,” Siegel says. Anyone who repetitively moves his or her wrist up and down can get tennis elbow, Siegel says. Piano players can get it. Bricklayers can get it. People who work out can get it. Shipyard workers, carpenters and weekend gardeners can get it.

“The landscaper helping me in my yard had it from holding his power equipment in the same position,” he says. Symptoms include a dull, aching soreness on the outer part of the elbow. At first, pain usually goes away within a day of an aggravating activity. Over time, it takes longer for the pain to go away, and even everyday actions such as lifting a jug of orange juice can lead to pain. The pain also could spread to the neck, arm, shoulder or hand.

First, you have to pinpoint the diagnosis— to make sure it’s really tendonitis, Siegel says. “Sometimes, it can mask arthritis or a loose fragment in the elbow.” Once the diagnosis has been made, the first treatment is the time-honored RICE—rest, ice, compression and elevation, says Dr. Ernesto Luciano-Perez of Virginia Orthopaedics and Spine Specialists in Portsmouth. Anti-inflammatory drugs often help too, Siegel says.

The next steps include a counterforce brace to decrease the pull of the tendons pulling on the bones, Luciano-Perez says. “Elbow braces are very effective in decreasing the force where the tendons are pulling,” he says. Physical therapy also can help ease the inflammation, Siegel says. People can also do strengthening exercises on their own, he says.

If those treatments don’t work, the next step is cortisone injections, Siegel says. “After everything else has not worked, we usually can eliminate the pain 90-plus percent of the time with a cortisone injection,” he says. “That doesn’t mean that the pain will never come back. Clearly, people who are high performing with their arms—laborers, athletes—it’s more stubborn.”

After a period of rest, some people can slowly return to the activities that caused tennis elbow, Siegel says. But in 10–15 percent of cases, tennis elbow will return. “It can come back six months later,” Siegel says. “It can come back two years later. There’s no way to predict it.”

If the conservative treatments outlined above don’t alleviate the problem, the next course is surgery. Luciano-Perez considers surgery after six months, Siegel after 18 months. Out of 100 people with tennis elbow, only four or five ever progress to surgery, Siegel says. Surgery releases the main tendon that starts at the elbow bump and comes down the back part of the arm to the top part of the wrist, Siegel says. “By releasing the attachment where it’s inflamed, that often will get rid of the pain permanently,” he says. “The operation removes the chronic, inflamed tissue that was causing the pain.” Never fear—enough attachment remains that the arm still works, he says. “Releasing this one tendon does not make the wrist go limp,” he says. “There are still other attachments working and the patient has full function after the procedure.”

The patient will need two to three months of rehab, and there’s still no 100 percent guarantee that all the pain will go away, Siegel says. For some people, arthroscopic surgery through a smaller incision, without detaching and reattaching muscle, can release the tendon, Luciano-Perez says. An MRI will determine good candidates for this procedure, he says. If the MRI shows only chronic inflammation, he might elect to perform arthroscopic surgery, he says. For a partial tear, Luciano will likely perform the traditional open surgery.

Finally, in some fortunate patients, the tendon releases and detaches on its own. “The patient will say ‘I was just doing something and I felt a pop in my elbow right where it used to hurt me and now the pain is gone,’” Siegel says. “What happens is—the body does what the surgery would do. That is a lucky case.”

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