Area of pain in tennis elbow shown in red over that outside of an elbow

Tennis elbow: all you need to know

by Aches and PainsGeneral
tennis-elbow

What is tennis elbow?

Tennis elbow is an odd name to give to a problem which affects mostly people who do not play tennis! It is also called lateral epicondylitis, lateral epicondalgia or lateral elbow pain.

The pain from tennis elbow is felt on the outer side of the elbow and the back of the forearm. Sometimes the pain radiates to the wrist or the back of the hand.

How common is tennis elbow and who gets it?

Tennis elbow affects about 1-3% of people and is more common in manual workers (7%). It also includes those using a keyboard or mouse for many hours per day. This is because tennis elbow is a mainly a problem or repetitive movements and of overuse.

Tennis elbow affects men and women equally. It can affect people of any age but is most common in the 30-50 age group.

Types of work

Professions like chefs, butchers, carpenters, and painters which involve repetitive wrist and arm motions are at a higher risk of tennis elbow. It is also common in people using a keyboard and mouse for many hours per day such as IT workers, secretaries and PAs.

Hobbies

Hobbies like knitting, typing, or playing musical instruments for extended periods can also be culprits.

What are tennis elbow symptoms?

Area of pain in tennis elbow shown in red over that outside of an elbow

Pain over the outer part of the elbow.

Many describe the sensation as a persistent ache, especially when lifting.

Pain worse with hand gripping or twisting activities of the hand or forearm.

A weakened grip if the problem becomes more severe.

Stiffness when trying to extend or straighten the elbow.

Tennis elbow tests

Tennis elbow can be diagnosed with examination alone in most cases. Doctors commonly use three different tests to diagnose tennis elbow.

Resisted wrist extension test

This is meant to reproduce the patient’s pain by activating the muscles and tendons that are affected. The patient is asked to extend their wrist against the doctor’s resistance. Pain or discomfort felt on the outside of the elbow during this test indicatives tennis elbow. You can reproduce this yourself using the chair test in which you try to lift a chair with your arm straight and palm facing downwards. Pain felt around the outside of the elbow whilst you do this suggests that you have tennis elbow.

Pain location

The doctor will press on or around the outside of the elbow, looking for the area of maximum tenderness or pain. This is usually around the lateral epicondyle – the bony bump on the outside of the elbow.

Grip strength

This is usually done by asking the patient to squeeze the doctor’s hands. The affected hand will have a weaker grip than the other side and may reproduce the same tennis elbow pain.

X-rays and scans

can be used to make sure you do not have other causes of pain but cannot confirm a diagnosis of tennis elbow. This is why they are rarely used in such cases.

What causes tennis elbow?

We used to think that tennis elbow was due to inflammation of the . However, we now know that it is mostly to chronic changes that occur over months or years in the tendons and muscles around the elbow. It is due to overuse.

Inflammation might still play a part in the early stages of the problem but is not present by the time tennis elbow becomes painful.

1. Repetitive Movements

Tennis and other racket sports:

The repeated motion and stress of hitting balls can strain the forearm muscles and lead to inflammation. Especially, backhand strokes without proper technique can be a significant contributor.

Manual work

Activities like plumbing, painting, carpentry, or even gardening which require repeated movements or gripping tools for extended periods can lead to the condition.

2. Improper Technique

Sports technique

Using improper techniques, especially while playing racket sports, can cause undue stress on the tendons. For example, hitting a tennis ball with a late backhand.

Using inappropriate equipment:

Utilizing rackets with a too small grip or stringing them too tightly can increase the risk. Using tools with a small a grip can have the same effect.

3. Direct Blow or Trauma

A direct blow to the lateral epicondyle, the outer part of the elbow, can lead to inflammation and pain typical of tennis elbow.

4. Lack of Flexibility or Strength

Weak wrist and forearm muscles may not provide adequate support for the tendons, making them more susceptible to injury. Similarly, lack of flexibility can strain the tendons.

5. Previous Elbow Injuries

If you’ve previously injured your elbow or had an elbow surgery, your chances of developing tennis elbow might be increased, especially if you return to repetitive activities without adequate healing.

How long does tennis elbow take to get better?

Typically, tennis elbow takes a number of months to get better. That is because it takes many months or even years of doing an activity for it to develop in the first place before the pain actually starts.

Diagram showing pain within the brain

No painkillers recommended in NICE guidelines for chronic pain

by Aches and PainsDIY HealthGeneral
Photo by freestocks on Unsplash

The NICE guidelines on chronic pain NG193 were published in April 2021 and may have left you scratching your head. That is because they do not recommend any painkillers. That means no paracetamol, NSAIDs (e.g. ibuprofen, naproxen) or opioids (e.g. codeine, morphine).

To understand why, you need to understand the phenomenon of chronic pain and how NICE makes its recommendations.

Chronic pain is any pain that has lasted 3 months or more. It does not include acute pain that lasts hours, days or a few weeks. Therefore you can still take painkillers for your headache and sprained ankle, for example. Pain in these cases is a symptom of the underlying problem and when that heals then you can stop your painkillers. Chronic pain is a much more complicated phenomenon and should be seen as a chronic disease that affects not only a particular body part but the whole person including their nervous system and mood.

NICE makes its recommendations based on hard evidence. That means they found absolutely no scientific evidence that showed painkillers were effective in treating chronic pain. In fact, there were numerous studies showing evidence of harm from painkillers including addiction and deaths from opioids such as morphine.

What did NICE recommend?

NICE recommended the following treatments for chronic pain:

  • Exercise programmes and physical activity
  • Psychological therapies such as Cognitive Behavioural Therapy and Acceptance and Commitment Therapy
  • Antidepressants
  • Acupuncture
Acupuncture

Not much has changed

Since the chronic pain guidelines came out 8 months ago medical practice has not changed. That is not surprising since we are in the middle of a global pandemic and the health service has other more pressing issues. However, the NICE guidelines on chronic pain also lay bare the limitations of the current medical system.

Appointments with doctors are difficult to get and are brief when they do manage to get one. Chronic pain is a complex problem and takes time to solve, not 10 minutes that the government gives for a GP consultation. Painkillers are not allowed so what do doctors do. They are only armed with a prescription pad and an exercise sheet that they can print off for patients. They can prescribe antidepressants but many patients are resistant to this approach as they fear that their doctor thinks it is all in their head.

Physiotherapy waiting times are long and done increasingly by telephone or video that patients do not trust. Patients fear movement because it can make their pain worse so are less likely to engage in it. The result is that they become more disabled and their pain becomes worse.

Specialist appointments are even longer and even less likely to result in any successful treatment. However, specialists do an important job in organising tests and scans that a GP does not have access to in order to rule out serious causes of pain. What they rarely offer is cure which is what patients expect from them.

The psychological services have long waiting times that are even longer now during the pandemic as people try to cope with the psychological consequences. To make matters worse, few psychologists specialise in pain psychology. Numerous pain management services across the UK do not even have a pain psychologist so there is essentially zero access to CBT and ACT that NICE have recommended.

That leaves acupuncture. The majority of medical professionals have a strong bias against acupuncture despite strong evidence of its efficacy. That is despite that fact the NICE applied its same rigor to the evidence base. The medical profession are arrogantly continuing to ignore it despite offering ineffectual, non-evidence based therapies themselves for decades. Even if they do overcome their bias there is no way to offer acupuncture under current NHS provisions. As past President of the British Medical Acupuncture Society I have a bias towards acupuncture, We have done our best to give guidance on how best to introduce acupuncture services in the NHS to commissioners.

Where does that leave patients?

Chronic pain is best treated using a holistic framework instead of a hope of cure by a particular medicine or procedure. Patients should co-ordinate their care from a clinician specialising in pain management. They should avoid all habit-forming drugs which do more long-term harm than good. There are many facets of a person’s life that contribute to them suffering from chronic pain and these should each be addressed. Take a look at this video: