By: Dr. Barry S. Kraushaar
Tennis Elbow and Golfer’s Elbow are names for similar tendon injuries that occur at the tendon attachments on the outer (lateral) and inner (medial) sides of the elbow joint. If you have pain on or near the points of bone that serve as the origins of the muscles of the forearm, you may have this diagnosis. The forearm muscles, which give power to your grip, attach to these anchoring points called epicondyles. They can tear off of the bone or within their fibers. Tendons are injured throughout our lives, but they usually heal themselves, making it rare to need medical help. When a tendon attachment to your elbow tears and fails to heal it can be Tennis or Golfer’s Elbow.
TENNIS ELBOW is an injury at the outer (lateral) bony prominence of the elbow. You can have this diagnosis even if you do not play tennis, but the name comes from the observation that tennis players get it as part of the sport. This is because the grip of a long tennis racquet and the wrist motions of the tennis swing put strain on the muscles which originate at the lateral epicondyle. Expert tennis players rarely get tennis elbow because they have powerful forearms and good swing mechanics. If you have the wrong grip size, string tension, timing (late swing), racquet type, or stroke mechanics (wrist motion), you are at risk for Tennis Elbow. In fact, any type of forearm overuse can cause tennis elbow, and the treatment options, described below, are the same.
GOLFER’S ELBOW refers to pain on the inner, medial side of the elbow. In this sport, the problem is caused by the combined effect of the long club length being gripped by the trailing arm (the right arm in a right-handed swing) as the club-head strikes the ground, such as in the rough, the sand or when taking a divot to get under the ball. The forearm is driving forward as the hand is held back, causing strain in the muscles that control the wrist. The damage occurs at the tendinous origin on the inner side of the elbow. Ironically, golfers can also get Tennis Elbow, because the leading arm sees strain on the outer, lateral side during the same movement.
There are many additional reasons for tendon injuries about the elbow, usually involving pulling or twisting motions during exertion. It can happen from low level stresses or big motions. From an orthopedic view, the approach is to identify the causes and help the patient adjust activities to allow the tendons to heal themselves. This may involve a period of partial or complete rest from the aggravating activity. It may involve different equipment or technique. During a flare-up, you may benefit by using a brace. If you wear a wrist brace it may help the elbow by limiting the motions that are traumatizing the injured tendon. A tennis elbow strap is different, as it works by re-directing forces coming up the forearm and deflecting the pulling effect on the tendon origin. Pills, such as non-steroidal anti-inflammatory drugs (NSAIDS like ibuprofen) or analgesics (acetaminophen, Tylenol) may temporarily help the symptoms, but they do not cure tendon injuries. Similarly, a steroid (cortisone) injection may relieve pain for now, but the chemical may damage tendon, and after a few months the problem can come back even worse. Sometimes, a small injection is used as part of a bigger plan.
The most effective and lasting way to manage Tennis or Golfer’s Elbow is to perform exercises to strengthen the forearm. Since the elbow is injured, the exercises need to be rehabilitation type, which is different than fitness exercise. Doctors often prescribe Physical Therapy because a therapist should know the gradually increasing exercises that achieve the goal of lasting recovery without a setback. While many videos exist online, there is no substitute for personal guidance. Once you learn these exercise you can do them yourself.
Other non-operative treatments exist but are less commonly used. One promising intervention is Stem Cell Injection Therapy. Currently, this technique involves having your blood drawn and spun in a centrifuge. The provider injects a small volume of your own special stem-cells back into you at the site of the pain, and you grow new tendon in the damage zone. Stem cells can also be harvested from your fat or marrow. The use of Stem Cells is usually not covered by insurance, and the statistics of success are still not high enough for many people to be willing to pay out of pocket (costs hundreds to thousands of dollars). Ask your doctor if you want to know the current trends.
Ultimately, surgery may be necessary for tendon injury at the elbow. There is a minimally invasive technique that requires a brief, light period of sedation and/or local anesthetic injection. The doctor introduces a special needle through your skin over the injured area and activates a device that either causes the tip of the needle to heat up and melt the damaged tendon, or it injects a pressurized water jet into the tendon to break up the scar tissue and cause the tendon to react by developing scar tissue to replace the damaged area. During this process, the surgeon may also use stem cells, described above.
The open surgical technique for Tennis or Golfer’s Elbow is well established and has an excellent success rate. The operation is not usually very long, involves little or no risk to nerves and vessels, and recovers rather quickly, although you may need a period of protection and rehabilitation afterward to give the tendon a chance to heal and the muscle groups time to recover. Basically, the surgeon opens the tendon and removes the bad scar tissue, the tendon is given a chance to grow fresh tissue in the place of the old, painful region, which is usually right where the pain was. In my practice, fewer than ten percent of patients with Tennis or Golfer’s Elbow go to surgery, and nearly every patient reports real improvement from the intervention. Return to sports and full activities is possible in most cases.
If you think you have Tennis or Golfer’s Elbow, try to identify the causes and address them yourself. Try to gently strengthen your muscled without overdoing it. Consider a brace and careful usage of medicines, if you can do so safely. If you do need orthopedic care, you may be discussing physical therapy and the other treatments described above. Know that if you have to go to surgery, the options in most cases are likely to be effective. Hopefully, you can continue to enjoy your active lifestyle, doing what you need or want to do. The specialists at NEOSM are there to help along the way.