Tennis elbow is a combination of chronic exhaustion and strain in the muscles that lift the wrist and fingers (the muscles of the back of the forearm), and/or inflamation of their tendons. One problem may be more prominent than the other. Hot, sharp pain right at the elbow probably indicates more of a tendinitis. A more aching pain that may spread through the whole arm typically may indicate a more muscular case of tennis elbow.
Obviously, this condition earned its name because tennis often causes it, but these days it is more commonly caused by computer usage and would be better described as “computer elbow.”
However, bear in mind that this is a controversial condition. A 1999 scientific paper in Journal of Shoulder And Elbow Surgery titled “Lateral tennis elbow: ‘Is there any science out there?’” complains bitterly that, to that date, “all but one” study of tennis elbow had failed to find the inflamation that supposedly exists in the condition. The authors complain bitterly that, “Numerous nonoperative modalities have been described for the treatment of lateral tennis elbow. Most are lacking in sound scientific rationale.”1
Although a fair bit of science has been done since then, tennis elbow is still a surprisingly mysterious condition.
Tennis elbow is widely regarded as a tendinitis, but it’s become increasingly clear to experts over the years that there is really no such thing as “tendinitis,” meaning “inflamed tendon” — at least, not beyond the early stages.2 Anti-inflamatory treatments are the popular first-line of defense again alleged tendinitises, which would certainly make sense if the tendon were really inflamed. But it isn’t — not really.
Instead of thinking of tennis elbow as a tendinitis, you should think of it as a “tendinopathy” which is Latin for “something wrong with a tendon.”
Tendinopathy is a deliberately broad term, used because we really don’t know what’s going on. According to a 2008 scientific paper by Andres et al, tendinopathy refers to “any painful condition occurring in and around tendons in response to overuse.” They also explain that “recent basic science research suggests little or no inflamation is present in these conditions.”3
For instance, in plantar fasciitis — think “foot tendinitis” — the tissue is not actually inflamed! Inflammation is only present in the early, acute stages of tendinitis.4 Instead it shows signs of connective tissue degeneration.56).
All of this goes a long way to explaining why your standing regimen of icing and ibuprofen doesn’t exactly work miracles with tennis elbow.
Most elbow pain is tennis elbow. Tissues right around and below the bony projection on the side of your elbow will be tender. The muscles on the back of the arm, if you dig into them, will also be tender (see Massage Therapy for Tennis Elbow and Wrist Pain). If you play a racquet sport, it will obviously tend to aggravate the problem. A good test for tendinitis is pain on resisted extension from flexion — which means, in plain English, if you sharply flex your wrist against the wall, and then try to straighten it, and it hurts, you probably have got a case of tennis elbow.
If you’re really serious about your racquet sports or golf, or if you depend heavily on your arms for intensive computer work, then tennis elbow can be a major problem. For most people, however, the condition is usually merely annoying. It can be persistent, but rarely progresses to a serious level unless you really consistently abuse your forearms with overexertion.
There are plenty of non-surgical treatments out there for tennis elbow (lateral epicondylitis) — all of them are reported as having good results, yet none of them is any better than placebo.
Dr. Skeptic, Tennis elbow treatment: perception versus reality
Tennis elbow may respond well to some simple and inexpensive treatment methods. On the other hand, it’s not clear that any of them is anything more than an effective placebo.
Rest — Rest is your first line of defense against this condition. People find it persistent mainly because they don’t take the problem seriously enough. Even a minor injury like this will not just magically go away if you keep doing whatever irritated the forearm muscles and tendons in the first place. A week of resting the arm as much as possible is often enough to make a significant difference.
Stretching and mobilizing — Although stretching is over-rated as a general tonic (see Quite a Stretch), it can useful for specific therapy like this. Muscle trigger points (muscle knots) sometimes respond well to stretch (see Stretching for Trigger Points, and in my experience they tend to do so particularly in this muscle group. Since trigger points are almost always a factor in tennis elbow, I always recommend stretching for this condition. It is tricky to fully stretch the muscles involved in tennis elbow, but you can do it like this: while standing, with your arm in front of you, place the back of your hand against a wall with the fingers pointed out to the side, straighten your elbow, and then press into the wall so that your wrist is flexed sharply. Hold for a minute. Be cautious: do not stretch too hard, and release the stretch gradually, over several seconds at least.
I also recommend mobilizing (see Mobilize!), which is basically just rhythmically stretching the wrists one way and then the other: more stimulating than stretch. With many conditions, I believe that mobilizations are actually better than stretch, but in the forearm for some reason they seem to be about equally therapeutic. To mobilize your forearms, sit on the edge of a couch or bed. Sharply flex your right wrist to stretch the back of the arm, and lean forward a little to add intensity. Then do the same on your left. While you are doing your left, the right hand flips over and sharply extends — bend the wrist back. You then shift your weight back to the right to stretch the inside of the right forearm. While you are shifted to the right, the left side flips over …and so on.
Contrast hydrotherapy — Once the inflamation and swelling has gone down, you need to continue stimulating circulation to the area as much as possible. Do this with contrast hydrotherapy: the alternating application of heat and cold to the area really dramatically increases circulation to the area. By far the best method of doing this is in a double-sink: one filled with cold water, the other with hot water. You should do this regularly until you are fully healed. For more information about contrasting, see Contrast Hydrotherapy.
Ice — Tendinitis hurts because of the inflamation. You can reduce the pain and speed the healing significantly by applying a lot of ice (many times per day). The ideal treatment is the ice cup. For more information, read my article about using ice cups (see Icing for Injuries, Tendinitis, and Inflammation). Bear in mind, though, that icing will only work so far as the condition is actually inflamatory. Cases dominated by muscle dysfunction will not respond especially well to ice.
Self-massage — Your forearm is an easy body part to reach for self-massage! Tennis elbow is probably always aggravated by muscle tension in the forearms, regardless of whether muscle strain is part of the condition or not. It is often helpful to do some simple massage: firm, long, lubricated strokes from hand to elbow on the back of the arm. Be firm but not brutal. Visualize the muscles like a sponge full of dirty water that you are squeezing out! See Massage Therapy for Tennis Elbow and Wrist Pain, which explains exactly where the worst trigger points in the arm usually form.
A muscle in the neck, the anterior scalene muscle, is also known to have a surprisingly strong relationship with trigger points in your forearm muscles.7 Self-massage of this muscle is not particularly easy, but probably worth learning: see Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain for more information.
Friction massage — Like all tendinitises, tennis elbow may respond well to a specific massage technique called “friction massage.” Rub back and forth over the tendon (across it) gently with your thumb or finger pads until the sensitivity fades, which should take no more than a minute or two, and then increase the intensity slightly and repeat. If the intensity doesn’t ease, discontinue. Deep Friction Massage Therapy for Tendonitis.
Ergonomic adjustments — If you use a computer heavily, you may wish to invest in some improvements to your computer workstation to aid in healing from “computer elbow”.
Keyboards are straightforward, as there is really only one important thing to know: don’t lift the back of your keyboard. This is a bizarre anachronism that exists only because early keyboard manufacturers wanted computer keyboards to seem more like typewriter keyboards (i.e. steep). However, the ergonomic problem with this is significant. An elevated keyboard forces you to keep the wrists “cocked” into extension, holding all of the extensor muscles of the forearm in contraction. This is Very, Very Bad, and severely aggravates computer elbow situations. Avoid it at all costs. Mitigate it with a gel wrist pad (to lift the heel of the hand).
The type of mouse you use is a relatively minor factor in repetitive strain injuries, and consequently manufacturers have not responded with “ergonomic” mouse features. However, generally good quality in a mouse is highly recommended, and a wireless mouse is nearly essential.
Although wirelessness is not advertised as an ergonomic feature, it is actually the best ergonomic feature there is for mice. First of all, understand that even relatively minor issues with computer use are amplified amazingly by the hours we spend on them. So although it may sound a bit silly, believe me when I tell you that even the slight tension of a mouse cord folding or snagging results in us failing to move the mouse freely to where we would be more comfortable, or constantly try to adjust for the sake of the cord, rather than for our own sake.One woman’s “ergonomic” mouse is another’s hand torture device!
And we even fail to adjust when the cord outright snags! We get focussed on our work and simply put up with the cord being caught under a book or the corner of the keyboard. It’s not that the mouse is necessarily stuck in a “bad” position, but we aren’t free to move it to a better one. By contrast, wireless mice are surprisingly liberating. If your arm is getting uncomfortable using the mouse in one position, you can simply adjust.
For the same reason, I recommend basically the best quality mouse, which is laser these days.
Mouse shape and button design are pretty trivial factors. Basically, comfort is all you’re looking for, and people’s hand shapes and usage patterns are so different that one woman’s “ergonomic” mouse is another’s hand torture device.
If you went looking, you’d have no problem finding studies that make surgery for tennis elbow sound like a great deal. You don’t even have to go looking, because I’ll share a couple examples: in a classic 1961 article, the late, great British surgeon RS Garden reported that “no patient failed to benefit in some way from the operation.”8 Decades later, a modern paper reports 78 of 80 surgery patients had “improved clinical outcome at both short- and medium-term follow-ups with few complications.”9 But these studies did not compare surgery to a placebo — a common problem with surgical research.10
There’s only one (unpublished) study comparing real surgery to a fake surgery, from 2012, by Dr. Martin Kroslak.11 It was small pilot study, but the results were completely disappointing — hardly what you’d expect if surgery was really effective.
Eleven patients were treated with the Nirschl technique (surgical excision of the macroscopically degenerated portion of ECRB), and 11 received a sham operation: a skin incision, exposing the tendon. Both groups improved equally: “The only difference observed between the groups was that patients who underwent the Nirschl procedure for tennis elbow had significantly more pain with activity at 2 weeks.” Kroslak scathingly concludes:
There is no benefit to be gained from the gold standard tennis elbow surgery over placebo surgery in the management of chronic lateral epicondylitis. In fact, the Nirschl procedure may increase the morbidity of the condition in the immediate post-operative period.
If everyone generally got better, isn’t that a good thing? Quite the opposite: it means the benefit was pure placebo, and it didn’t matter what kind of surgery was done as long as the patient believed they were getting a powerful treatment.
Food for thought, isn’t it?
Wednesday, May 29, 2013 — Added surgery section with fascinating results of placebo surgery.
Monday, March 22, 2010 — Corrected some typographic errors.
Placebo surgery: necessary, ethical? Yes! Here’s a fine short post on this topic from Doctor Skeptic (doctorskeptic.blogspot.com.au). You “need a placebo [surgery] trial when the outcomes are ‘soft’ (subjective: pain).” I’ve been arguing this for many, many years. We really need to compare surgeries for pain problems to shams, because, by golly, that method sure does reveal some useless surgeries. One of the best examples of why is Moseley’s fascinating 2002 knee trial.BACK TO TEXT