A patient may complain that he cannot pour a cup of tea for himself. He experiences difficulty in closing his fist tightly, or while grabbing and lifting heavy things from the ground with his hands. He has pain on the lateral aspect of the elbow at a prominent point called the lateral condyl of the humerus or arm bone. The pain travels along the back of the forearm and may go as far as the wrist or the back of the hand as far as the ring finger of the hand. It may be severe enough to go to the external aspect of the arm up to the shoulder, but this is less common. Sometimes, there is a constant ache, which gets worse at night, disturbing the sleep. The patient may wake up with stiffness of the elbow.

Tennis Elbow

Pain at the elbow joint is commonly seen among tennis players. That is why this condition is commonly called tennis elbow. Those who do not play tennis may also suffer from elbow pain.

The pain starts due to a strain where the wrist has to be extended again and again as is done while playing tennis or while using the hammer. The patient does not feel any pain even after a slight injury to the elbow joint is sustained during these movements. Later on, certain movements at the wrist joint or elbow start hurting and a fortnight later, a tennis player cannot hit backstrokes at all.

It is not the tear of the tendon which causes the pain. The pain is due to the formation of a painful scar which results from multiple injuries. During the game or due to the active use of the elbow and wrist, the healing process which is accelerated by rest and avoidance of movement, remains incomplete. The strain on the extension ligaments is caused during the extension or backward bending at the wrist joint. The pain is peculiar; occasionally it comes on suddenly and the grip of the hand becomes powerless momentarily. The patient may even drop light objects that he is holding on the ground.

Getting a tennis elbow is frequent between the ages of forty to sixty years, the years when cervical spondylosis is also common. A view is often expresses that elbow pain has some relation with the neck. Sometimes this is true. Pain in the elbow joint can arise from the neck without any injury at the elbow. All cases of elbow pain should be examined for a neck lesion too. Generally tenderness can be located at the level of the fifth, sixth and seventh cervical vertebrae. Marked tenderness is noted in the lower part of the neck on the side of the elbow involved. So if the pain in the elbow joint is due to the neck, manipulation of the latter will result in a spectacular recovery. A distinction must be made between elbow pain due to the cervical spine and pain due to a tennis elbow. Sometimes an elbow pain is due to both a cervical lesion and periarthritis of the elbow. These two causes can be easily distinguished. In a true elbow, the extension of the wrist joint is painful. During this test the elbow must be fully stretched. In a true tennis elbow, the side bending of the wrist towards the thumb side is also painful. Sometimes muscles on the lateral aspect of the forearm feel tender on deep palpation; these muscles help in extension at the wrist joint.

Treatment

A tennis elbow recovers on its own without any treatment in about a year, if a person is under sixty years. However it takes longer when the person is over sixty. Ordinarily it is treated by local hydrocortisone injections. These injections inhibit spontaneous recovery. It is not uncommon for patients to remain well after an injection for a few months and then feel the need for further injections month after month. If left untreated however, there is a possibility that the patient may recover completely in twelve months on his own.

Manipulation

Manipulation is found to be effective for a tennis elbow. The elbow is fixed and deep friction is applied on the epicondyl for five to ten minutes before manipulation. This softens the scar tissue which becomes easier to break by manipulation. Manipulation is repeated once or twice a week for four to six weeks. Such sessions are enough to relieve the pain completely. Manipulation is done in hyperextension. One may hear the cracking sound during manipulation and relief is felt immediately following the manipulation.

Manipulation shortens the time required for recovery, and once the condition is cured, it does not recur.

Case Histories

• A fifty-two-year old man with a good build, employed as a supervisor in building construction, had pain in the elbow for two months. He used to drive a motor cycle for an average of 200 km daily. But the pain made him incapable of driving. He even had a lot of difficulty in lifting and moving the telephone. He had stiffness in the elbow in the mornings, and was not able to sleep well due to the pain. He had a similar pain earlier on and it had subsided with local injection of hydrocortisone. X-rays and laboratory tests were conducted after the problem was diagnosed as a tennis elbow. He felt relief after the first manipulative treatment. The pain decreased gradually and subsided six weeks later. He was advised to use his arm as little as possible during the treatment. He never complained of pain for two years following the treatment.
  
  
  
• A forty-one-year old housewife with five children had pain in the right elbow for five years. The pain had begun following a fall where she had supported herself by the hand. There was a slight swelling over the elbow. She experienced more pain if she used her hand more during work. Sometimes she felt pain in the forearm and upper arm upto the shoulder and neck. She came to me with the above-mentioned complaint. There was a slight swelling over her left elbow. The X-ray showed no abnormality and the laboratory tests were normal. Manipulation of the left elbow was started, along with manipulation of the cervical spine. She felt better following the first treatment. By the third week she was comfortable. The pain became more localised, and there was no pain in the neck and shoulder. The pain in the elbow subsided gradually and in ten weeks she was free of it.