Causes, symptoms and treatments for tennis elbow

Flickr/CC - ozz13x

Flickr/CC – ozz13x

WAKR host Ray Horner is suffering from a common and painful condition called tennis elbow.

As the name implies, it can be caused by tennis, but more often than not, the condition appears due to mulching, raking and other repetitive activities.

Today, I had the chance to visit him in studio and discuss his condition further. We talked about the causes, symptoms and treatment options for tennis elbow. The good news is surgery is very rare.

Below is an audio file and transcript of our discussion.


HORNER: In our studio is Dr. Joe Congeni, Sports Medicine Center at Akron Children’s Hospital. I told Joe last week, I said, “I’m having pains in my elbow, man, and I don’t know what this is.”

He diagnosed me on the phone. He came in a couple of minutes ago, moved my elbow a couple of different ways and said you’ve got tennis elbow. What’s tennis elbow?

DR. CONGENI: Tennis elbow, Ray, is one of those deals where the tendons, [which] are good shock absorbers in the body, get stiff. They get overloaded. You get tendinitis at first and then when it hangs around too long, scar tissue forms in the tendon and they don’t work very [well].

So, just to shake my hand, it hurts you. Just to pick up a coffee cup, it hurts you. Over 20 or 30 percent of adults at some point in their life get tennis elbow.

As I told you last week, did you quit playing tennis?

HORNER: [laughter] I don’t play tennis.

DR. CONGENI: Most people don’t play tennis. They get it from mulching in their yard. They get it from shoveling. They get it from lifting or things they do around [the house] or other recreational things that they do, but tennis is one of the things.

And so this problem snowballs and [the tendon] gets overloaded. You have to kinda work backwards to get the strength back and get rid of the pain and swelling.

It’s very closely related to rotator cuff problems in the shoulder. It’s very closely related to Achilles tendinitis or plantar fasciitis. All those [conditions] are caused by scar tissue in tendons — the shock absorbers that don’t work well anymore. And, the shock absorber in your elbow is not working well right now.

Dr. Joe Congeni

Dr. Joe Congeni

HORNER: For people that get this, is this general wear and tear or did they do something abruptly?

DR. CONGENI: It’s general wear and tear. It’s overload wear and tear of doing something repetitively usually.

Our young athletes get it, but the place they get it is in the bone or the growth plate. They get stress fractures and issues like that.

Where we get it is these stiff muscles and tendons don’t work well anymore and they develop scar tissue in them. And when we’re not getting to where we want to be with stretching and icing and straps and things like that, then we move on to physical therapy or shots.

Rotator cuff, Achilles, tennis elbow, they’re all related.

HORNER: Okay, so treatment options out there for people that get this or for me?    

DR. CONGENI: The first things are the simple things: learning a stretching program, icing, anti-inflammatory medicine (Aleve or Advil) for 7, 10, 14 days maybe, not forever.

[Also], a strap that reduces the stress on the elbow and some gripping, strengthening exercises ‘cause your muscles have gotten weak around that point.

If they’re not getting better with that, formal physical therapy [is recommended]. Therapy works very well. So, stage 2, would be putting you in the hands of a therapist who has ultrasound and massage. They’ll do treatments on ya to get rid of it.

Stage 3 is the old cortisone injections. Cortisone injections are a plus-minus though. They’ll feel real good right away, but then after you get the injections, it actually weakens the tendons further.

So, Chris, was just telling us, man, I went and got several injections ‘cause it would work for awhile and then it would stop working.

So the way cortisone injections — stage 3 — works best is to follow it up with a strengthening program. A lot of people don’t do that. They feel good after the shot, and then they go off and then the thing just gets weaker and weaker.

HORNER: We call it tennis elbow. What do you call it?

DR. CONGENI: You want the medical term? It’s called tendinopathy or tendinosis. It means now it’s not just tendinitis anymore. If you looked under a microscope at your tendon, instead of being a nice shock-absorbing tendon tissue, it’s got all this junkie scar tissue as the body tries to heal this overload injury.

HORNER: Once you have it, do you always have it?

DR. CONGENI: No. The good news about it is there’s this thing called neovascularization, and what that means is new blood vessels go into the area and repair the tendon. It repairs itself, but it takes a long time.

A lot of the things you do at physical therapy jumpstarts the body to get it going quicker so that blood flow will go back in this scarred area. So, if we look at it under a microscope, [we’d ask], “Where’s the blood vessels?” They’re all gone for awhile, and we’re kinda worried, saying, “Oh my gosh, this could be a life-long thing.”

Flickr/CC - Windsor Tennis Club Belfast

Flickr/CC – Windsor Tennis Club Belfast

Then what happens, 3 months, 6 months, 9 months later, the blood flow comes back into the area. And as long as the person …  works on getting the strength and flexibility back, they’ll get the use of that tendon back near 100 percent.

HORNER: I was kinda surprised because I’m left-handed and I pitch a lot of batting practice to Rocco and throw the baseball. But, I didn’t get it in my left elbow, I got it in my right elbow and I’m trying to figure out what in the world that could be.

DR. CONGENI: Well, from you and me talking, I still don’t have the cause yet.

You know, as I told you, so many adults [ask], “Is it raking? Is it shoveling?” Mulch season is a big time, or there are other activities, but in our part of the country, when people are mulching in the spring, I get a ton of adults who get [tennis elbow] related to that.

But, it could be tennis. It can be golf — sometimes with the golf swing. So there’s a whole bunch of different things if you’re overloading it.

HORNER: Okay. So, the steps for treatment for tennis elbow, again, you said, there are 5 stages?

DR. CONGENI: Yeah, really that last stage is surgery. Nowadays, there are so many steps in between that surgery is very rarely done. If we went back 30 years ago, the orthopedic surgeons used to do surgery more frequently without really great results.

They’d get in there and that tendon would look like toothpaste. It’s scarred and it’s not working very well. Actually, they would try and get that blood flow back in there more quickly by doing surgery. But that’s a last, last resort. Rarely is that necessary because, nowadays, physical therapy — stage 2 — cures most of these.

The cortisone injections — stage 3 — helps a lot. The stage 4 is really some of the newer shots that we do called PRP (Platelet-Rich Plasma), where we take out your own blood and inject those into it. That’s kinda for higher-level athletes.

Then the final stage is surgery and very rarely necessary.

HORNER: Okay, [offer us] an example for people listening — and from what Joe says, a lot of people are affected by tennis elbow. They have that pain down there, you mentioned some stretching exercises, you mentioned some ice and maybe some medications. Be a little bit more specific on that.

DR. CONGENI: Yeah, like I did with you, I had you take your hand and stretch it back as far as you can and stretch it down as far as you can to where you feel a good stretch on that muscle tendon that’s overloading the tendon. So, stretching helps.

But also grip strength. That’s what really helped me. It was one of those periods I had to get so many leaves off my yard in the fall and I got a bad case of tennis elbow. I took a gripping ball in my car. Every time I hit a red light, I would grip it 15 times and work on the strength.

You’ve got to work on the strength. Did you see how weak the muscles and tendons were in your forearm? You can’t even grip your coffee cup or anything because of the weakness there.

HORNER: Yeah. [laughter]

DR. CONGENI: Get a gripper, get some putty, get a tennis ball, put a slice in the back of it, and grip it four, five or six times a day and work on getting the strength back. At first it will be a little bit sore. When you get done doing your exercises, ice them.

So stretching and icing, and not needing to see anybody will cure 30, 40, 50 percent of people. If it’s too far gone, that’s the people that need the physical therapy and the referral to a PT center.

HORNER: And medications like the Aleves and Advils and that type of thing?

DR. CONGENI: They lose their effectiveness because it’s not inflamed anymore. It’s not an inflammation like it was for the first three or four weeks. It now has scar tissue.

People are uniformly frustrated that they say, man, I’m taking Aleve and Advil and pain killers and really it helps me for that day and the next morning, I wake up and it’s right back.

Well, that tells us we’ve moved into the stage where there’s scar tissue, not just inflammation.

HORNER: Joe, while I have you in the studio, real quickly. New England lost all pro linebacker Jerod Mayo for the season with a pectoral tear. We’re seeing a lot of this in football. Is that because of the use of the arms in trying to shed blockers? Do we see that a lot in the high-school level as well?

DR. CONGENI: In the high-school level we don’t see that nearly as much. I have to admit.

You’re right. We’re seeing biceps, triceps and pec muscle tears more frequently. Remember, I mean, geez, D’Qwell Jackson (Cleveland Browns), both sides in two different years.

These athletes are kinda pushing the edge of how far they can go with getting themselves as strong as possible, but that’s more of an NFL thing. It’s a very, very rare injury to see in the high-school setting.

HORNER: Alright, Joe, good stuff. Thanks for coming in. Anything else you’d like to touch on.

DR. CONGENI: Yeah, I just wanted to know about your impression of the strike zone and now the tackling being too low on the other end [causing] knee injuries and fractures. We’ve certainly seen it in the NFL this week, who was it?

HORNER: Randall Cobb (Green Bay Packers).

DR. CONGENI: It was Randall Cobb. We had Dustin Keller (Miami Dolphins) a few weeks ago. E.J. Manual (Buffalo Bills) at the stadium got cut pretty low. [Players are saying], “Hey, I’ve gotta tackle somewhere. I’m tackling low, you know, that’s the strike zone area.”

What do you think in high school? Are you seeing a lot more lower tackling in high school and college, too, or no?

HORNER: No, I’m not really. I have to say this, and I’ve said it on the air, better form tackling than I’ve seen in a long time. I think the coaches are doing a good job from the bottom up of working on form tackling.

DR. CONGENI: I agree with ya. Let’s get rid of the crown-of-the-helmet hits. It’s not a weapon. If we do that, that will help.

Hey, one more thing: kickoff rules. Everybody hated ‘em in the NFL and college, and now over 70 percent of kicks aren’t brought out. Now, there’s a 40 percent reduction in concussions in the first two years with the kickoff rules.

HORNER: Very cool. Very nice.

DR. CONGENI: Yeah, so at least in some areas we see some progress, Ray.

HORNER: Alright. Thanks, Joe.

DR. CONGENI: Thanks.

HORNER: Dr. Joe Congeni, Sports Medicine Center at Children’s Hospital, joining us in studio with a little hands-on with me with my “tennis elbow.”

About Dr. Joe Congeni - Director of Sports Medicine

Dr. Joe Congeni is the Director, Sports Medicine; Clinical Co-Director, Center for Orthopedics and Sports Medicine at Akron Children's Hospital. For the past 25 years, Dr. Congeni has been the “go to” source for national and local media looking for information about pediatric sports medicine.