Tennis elbow (Lateral Epicondylitis)

You have been diagnosed with a tennis elbow. This leaflet will explain what tennis elbow is, the signs and symptoms, and how it can be diagnosed. Although the exact method of treatment will differ from patient to patient, the most common treatments used by East Kent Hospitals and their likely outcomes are also covered here. It will also provide you with information about what you need to do throughout the process.

If after reading this leaflet you still have questions or concerns, please speak to your surgeon or anaesthetist at your next appointment.

Contents page

• What is tennis elbow?

• Who is affected?

• What are the symptoms?

• How is it diagnosed?

• What treatment is available?

• How can I prepare for my surgery?

• What happens on the day of my surgery?

• What kind of anaesthetic will I need?

• What are the complications and risks?

• How long will I stay in hospital?

• Will I be in pain after my surgery?

• What painkillers will I be sent home with?

• How do I care for my wound at home?

• How long will my wound take to heal?

• What if my wound bleeds at home?

• Can I have a bath or shower?

• Why am I wearing a sling after my surgery?

• What is the best position to sleep in?

• When can I drive again?

• When can I return to work?

• When can I start my normal activities?

• Will I have a follow-up appointment?

• What if I have any questions or concerns?

• Exercises and physiotherapy advice

• Contact details

What is tennis elbow?

Who is affected?

Tennis elbow has been the term used for this condition since the end of the 19th century, even though most of the people affected are not tennis players. Instead, other common causes are gardening, brick laying, excessive use of a screwdriver, hammering, typing, and shaking hands.

What are the symptoms?

• The main symptom is pain centred on the outside of your elbow, that spreads down into the forearm.

• The forearm muscles may feel tight and sore.

• It feels worse when a person lifts and grips, especially when the wrist is bent backwards with the palm turned upward.

Simple day to day actions like turning a door handle or picking up a bottle can cause severe pain.

How is it diagnosed?

• The diagnosis can usually be made with a simple examination by your GP.

• To begin with, x-rays are not usually needed, but may be requested later on to rule out other problems.

If we suspect you have a tendon tear, we may send you for an ultrasound scan. This will also help us to see signs of wear and tear in the area.

What treatment is available?

• Non-surgical management

  Nine in 10 patients heal on their own within one year using non-surgical treatments. So we ask you to try the following first.

  • Avoid activities where you repeatedly bend your wrist backwards.

  • Change the way you play sports or do other activities, if they make your elbow feel sore.

  • Painkillers (such as paracetamol or codeine) and local steroid injections (up to three injections can be given by your clinician) are useful for short term pain control.

  • A special elbow brace can be used; but you need to make sure you use it regularly for it to be effective.

  • A programme of physiotherapy exercises has been shown to work well in the long term.

• Surgical management

  One in 10 patients do not respond to non-surgical treatment. These patients could have symptoms for more than one year, have more than three steroid injections in the past, and are in constant pain, even when not doing anything. In these cases, surgery is a good option.

  Surgery is usually a small open incision (cut) over the affected tendon. The damaged tendon is cleaned and trimmed to remove all the affected tissue. This will encourage growth of healthy tissue and healing.

  Nine in 10 patients who have surgery say they have good or excellent results.

How can I prepare for my surgery?

You will have a preassessment appointment before your surgery, to check if you are ready and fit for surgery. You will also be swabbed for MRSA and Covid-19, if necessary.

Before surgery it helps if you try to get as fit as possible to avoid anaesthetic risk and/or failure of the surgery. It is important that you lose weight if you are above your ideal weight.

• Smoking advice

  It is important to stop smoking at least 30 days before your surgery. Studies have shown that wound healing is significantly delayed by smoking / nicotine, and the infection rate is much higher. Smoking also harms how your tendon heals following a repair, so smoking after your operation is also not advised.

  If you need support to stop smoking, please contact One You Kent on 0300 123 1220, or email.

• How does eating a healthy diet help my recovery?

  Recovering from surgery can take a long time and it is normal to get frustrated and anxious. But remember that while you are recovering, there are some things you can do to help your wound to heal. We suggest limiting the amount of alcohol you drink, stopping smoking, eating a healthy diet, drinking plenty of fluids (especially water), and staying active. If you need any extra support, do not hesitate to get in touch with us on the contact numbers listed at the end of this leaflet.

  Some painkillers (especially those containing Codeine) can cause constipation. To avoid this, please follow a healthy well-balanced diet rich in fruit, vegetables (including green leafy vegetables), nuts, seeds, wholegrains, and legumes, which contain the necessary fibre, and drink plenty of water. More information is available on the NHS 5 A Day: what counts? web site.

While you wait for your surgery date, you can start preparing for your operation. Research shows that fitter patients, who are able to improve their health and activity levels before surgery, recover more quickly. Taking an active role in planning and preparing for your operation will help you:

• feel in control

• leave hospital sooner, and

• get back to normal more quickly.

To help with this, you may be contacted by a member of the One You Kent (OYK) team. OYK work in the community, and help patients improve their general health. This includes help and advice on:

• Stopping smoking

• Losing weight

• Getting more exercise

More information can be found on the following web sites.

• One You Kent (Kent Community Health)

• Fitter Better Sooner Toolkit (Royal College of Anaesthetists)

What happens on the day of my surgery?

• Please arrange for someone to pick you up from the hospital after your surgery, as you will not be able to drive yourself. Please make sure to arrange this before your surgery.

• To avoid complications with your anaesthetic, you should not eat anything for six hours before your surgery, or drink anything for two hours. You will be given further instructions during your preassessment.

• On the day of your surgery, you can take your usual medication as advised during your preassessment. If possible, do not take non-steroidal anti-inflammatory medication, such as ibuprofen and naproxen, for at least 10 days before your surgery, as they can affect how your wound heals. Please bring any medications that you are taking into the hospital with you.

• If possible, please wear loose-fitting clothes, as after surgery you will be wearing a sling.

• Bring your appointment letter with you, so you know which department to come to when you arrive at the hospital.

• At arrival, you will be asked to put a hospital gown on, and maybe a pair of compression stockings.

• You will see the anaesthetic and surgical team before your surgery to go through the consent form and discuss any questions you may still have. Remember you can withdraw your consent for treatment at any time.

• You may be tested for Covid-19. All appropriate precautions will be taken during your admission to minimise the risk of contracting the illness as per Healthcare England Guidelines.

What kind of anaesthetic will I need?

This procedure is usually performed under general anaesthetic (you will be asleep for the procedure).

In addition, a local anaesthetic or nerve block is used during your operation. As a result, your shoulder and arm may feel numb for a few hours after your operation. It is important to take your pain medications during this time, to allow a gentle and easier control of pain when the nerve block wears off and your shoulder is likely to be sore and uncomfortable.

What are the complications and risks?

As with all surgery, there are a few risks and complications. These are rare and will be discussed with you before your surgery.

Anaesthetic risks will be discussed with your anaesthetist on the day of your surgery.

• Wound infection: we do everything we can to avoid this but an infection might still happen. If your wound becomes increasingly red or swollen after your surgery, please contact your GP or your surgical team for advice as soon as possible.

• Bleeding: this could happen during your surgery; we will do our best to stop it as soon as possible. However, some oozing could still happen after your surgery. For more information, see the What if my wound bleeds at home? section below.

• Deep vein thrombosis (DVT) and / or pulmonary embolism (PE). These are blood clots which form in the blood stream and can be serious conditions. Compression stockings and other measures might be taken by the hospital to avoid them.

• Soft tissue (nerve / tendon / blood vessel) injury could happen during surgery. We will try our best to avoid any damage.

• Stiffness / loss of movement of your elbow due to lack of movement following your surgery. This could be avoided or improved if you take adequate pain relief and do the exercises listed at the end of this leaflet as your pain permits.

• The surgery may not be successful. If your surgeon is unable to complete your surgery successfully or your problem does not improve, other options or further treatment can be discussed after your surgery. This could lead to further surgery.

• Continued pain and Complex Regional Pain Syndrome (CRPS). This is a condition where a person has persistent, severe, and debilitating pain. Although most cases of CRPS are triggered by an injury, the resulting pain is much more severe and long-lasting than normal.

If you have any questions or concerns about any of the complications / risks listed above, please speak to your doctor either during your clinic appointment or before your surgery.

How long will I stay in hospital?

This procedure is usually carried out as a day operation, so you should be able to go home the same day.

You will be taken to the ward until it is safe for you to be discharged home. You will be seen by your surgeon, your nurse practitioner (surgical care practitioner), and / or your physiotherapist before you go home. They will show you what exercises to do and give you further advice to guide you through your recovery.

If you need to stay in hospital overnight, you will usually be told this at your preassessment appointment. If you do have to stay overnight, make sure you bring with you items you may need, such as hygiene items (toothpaste and toothbrush), a dressing gown, slippers, and your usual medication. Also, we suggest you bring a book or magazine, in case there is a delay.

Will I be in pain after my surgery?

This surgery may be uncomfortable, you will need appropriate pain relief in the period after your surgery. If your anaesthetist has given you a nerve block, your shoulder and arm may feel numb and weak. You may not feel any pain immediately after your surgery, as the block may take 12 to 24 hours to wear off completely.

You will be given painkillers when you leave the hospital, to take at home; these should last for at least two weeks. It is very important that you take your pain relief as advised and as early as you can before the nerve block wears off; this will help you to keep on top of your discomfort. It is advisable to take your painkillers regularly for the first few days. If possible, avoid non-steroidal anti-inflammatory medication, such as ibuprofen and naproxen, for at least 10 days before your surgery and six weeks following surgery. This is because anti-inflammatory medication could slow down the healing process.

Take pain relief regularly to try and keep your level of discomfort at a bearable level at all times. This allows the inflammation (redness, swelling, and heat) and pain to settle. Do not wait until your shoulder is very painful to take the pain relief, as it is then more difficult to control.

What painkillers will I be sent home with?

• Surgical patients might be given some of the following painkillers, depending on their age, body weight, and individual circumstances, unless told otherwise by their doctor.

• Take each painkiller as advised on your prescription.

  • Tablet paracetamol, 1g every four to six hours (no more than 4g per day).

  • Codeine Phosphate, 30 to 60mg every six to eight hours.

  • Tablet Tramadol, 50 to 100mg every eight hours.

  • Oramorph, 10 to 20mg every hour, as needed.

  • Anti-inflammatories may be prescribed; but you should try and take as few as possible immediately after your surgery.

  Please note that Codeine, Oramorph, and Tramadol should not be taken together; you should only take one of the three at any one time.

Ice packs or bags of frozen peas may also help reduce your pain. Wrap the pack/bag with a cloth and place it on your shoulder for up to 15 minutes. Do not use these peas for eating once they have defrosted.

If your pain continues and is not controlled with the medication you have been advised to take, then please contact your GP. You may also contact the East Kent Upper Limb Team if you need further help.

If you notice your wound area is becoming more painful, red, hot, and / or discharging pus (thick yellow discharge), you may be developing an infection. Contact your GP or your surgical team for advice as soon as possible.

How do I care for my wound at home?

After your operation, you will have a 5cm wound on the outer side of your elbow, which will be covered with a dressing.

It is important to keep your wound and dressing dry and in place until your wound is well healed, and have your stitches removed at your two week follow-up appointment with your GP practice nurse or at the hospital, with your surgeon or your nurse practitioner (surgical care practitioner). You will be told where your follow-up appointment is going to be before you leave the hospital.

If the dressing gets wet or bloodstained, you can change them yourself by carefully placing a dressing from a pharmacy. If you are unable or have difficulties doing this yourself, you can ask a relative or a friend to change it for you, or you can make an appointment with your GP practice nurse to do it for you.

If you are being seen by your GP practice nurse for a wound check 10 to 14 days after your surgery, please make sure the nurse reads the following. These instructions are for healthy looking surgical wounds only.

• *Colourful stitches are non-absorbable and need to be completely removed to avoid them getting buried under the patient’s skin.

• *White / clear stitches are absorbable. If any suture knots have been made outside the patient’s skin, please remove these to avoid suture abscesses. Thank you.

*The appearance and material of the sutures can be different from Trust to Trust, but these are the most common.

If a wound does not seem to be healing appropriately, please leave the stitches / knots in place and make another appointment to remove them in few days.

How long will my wound take to heal?

Wounds usually take between 10 to 14 days to heal.

The area around your wounds may have some numbness, which is usually temporary. You may feel occasional sharp pains or ‘twinges’, as well as itching near your scar as it settles.

What if my wound bleeds at home?

There may be minor bleeding or clear fluid oozing from your wound in the first day or two following surgery. If your dressing gets wet or bloodstained, you may need to replace it. You can change this yourself by carefully placing a dressing from a pharmacy. If you are unable to or have difficulties doing this yourself, you can ask a relative or a friend to change for you, or you can arrange an appointment with your GP practice nurse to do it for you. You should be able to control this bleeding or oozing by pressing firmly but gently on your wound for 15 minutes.

If you are worried about the bleeding, you can contact the hospital on the number given to you (during normal working hours) or attend a walk-in centre or Emergency Department (after hours).

Can I have a bath or shower?

You should have a ‘dry wash’ or a shallow bath instead of a shower. This keeps your arm in the correct position and prevents your dressing and sling from becoming wet.

You should have a ‘dry wash’ or a shallow bath instead of a shower. This keeps your arm in the correct position and prevents your dressing and sling from becoming wet.

While your wound is still healing:

• do not use soaps, lotions, creams, or powders on your wounds, to avoid any infection getting into your wound(s); and

• keep your wound(s) dry at all times.

You can go back to normal cleaning routine once your wound is completely healed.

Why am I wearing a sling after my surgery?

You will return from surgery wearing a sling.

Your arm should be rested in the sling only until the soreness has settled. The sling is for comfort only. You should remove it and start moving your arm as soon as your pain allows. You can do any activity you want (there are no limits), as long as you follow physiotherapy instructions.

What is the best position to sleep in?

To begin with sleeping will be difficult. Take regular painkillers and try to support your shoulder by placing pillows behind it. If you lie on your back, a pillow under your arm and elbow may make you feel more comfortable. You may find it easier to lay on your non-operated side.

You can start sleeping on your operated elbow as soon as you feel comfortable.

When can I drive again?

You can begin driving once your pain settles down and you feel comfortable

The advice from the DVLA is that you should not drive until you are physically capable of controlling a motor vehicle and can perform an emergency manoeuvre safely and confidently.

Please arrange for someone to collect you from hospital and take you home after your surgery.

When can I return to work?

This will depend on your job. If you are in an office job or have light duties, you may return to work after two weeks and gradually increase your activity levels, as your pain allows. If your job involves heavy lifting, you may need to stay off work for 12 weeks.

Your surgeon will advise you on how long you will need to be off work; you can ask for a sick note before you leave the hospital.

When can I start my normal activities?

You can restart your normal activities as your pain allows but avoid heavy lifting for six weeks.

Your physiotherapist can tailor your treatment depending on your personal objectives.

Will I have a follow-up appointment?

Before you leave hospital, an appointment will be made for you to have a follow-up appointment at the Upper Limb Unit. At this appointment you will be seen by a physiotherapist, surgical care practitioner, or surgeon who will check your progress, make sure you are moving your arm, and give you further exercises as appropriate.

This appointment will usually be three to four weeks after your surgery. You will be monitored by a physiotherapist throughout your rehabilitation

What if I have any questions or concerns?

If you have any questions or concerns, please contact your surgical care practitioner, surgeon, or physiotherapist. Their contact details are listed at the end of this leaflet.

If you notice your wound area is becoming more painful, red, hot, and / or discharging pus (thick yellow discharge) you may be developing an infection. Contact your GP or your surgical care team for advice as soon as possible.

Exercises you can do after surgery, before your first physiotherapy appointment

It is important to get your elbow moving after surgery and avoid stiffness in your shoulder and arm.

These exercises are a guide; specific instructions will be given to you before you leave hospital.

Before starting the following exercises, please take painkillers and use ice, if needed. It is normal to experience some pain and discomfort when you perform any exercises. If you experience prolonged pain or discomfort when moving, then do the exercises less forcefully or less often. If this does not help, speak to your physiotherapist.

It is best if you do a few short sessions (two to four times a day, for five to 10 minutes each time) rather than one long session. Gradually increase the number of repetitions you do.

Physiotherapy guidelines while you are still in the hospital

• An outpatient physiotherapy referral will be arranged by a member of the inpatient physiotherapy team. Outpatient physiotherapy will start within two weeks of you leaving hospital, unless you have been told otherwise.

• You will be shown how to put on and care for your sling.

• You will be shown the following exercises on the ward:

  • elbow, wrist, and hand exercises

  • shoulder girdle and posture exercises; and

  • shoulder range of movement exercises.

Hand exercises

• Open and close your fist 20 times.

Wrist exercises

• Move your wrist up and down 20 times.

Forearm exercises

• Turn your palm up and down 20 times.

Elbow exercises

• Bend and straighten your elbow 20 times.

• This can be completed with help from your other arm.

Shoulder girdle and posture

• Try not to slouch after your surgery.

• Try pulling your shoulder blades back and down 20 times.

Pendular exercises

• Lean forwards, supporting yourself with your other arm.

• Swing your operated arm forwards and backwards gently, like a pendulum.

• Do this 20 times.

Shoulder exercises

• Lay down and lift your operated arm up, with help from your other arm.

• Do this 10 times.

• When you are able, do this exercise sitting up.

Physiotherapy guidelines once you leave the hospital

You will be shown further exercises at your outpatient physiotherapy appointment or clinic appointment. If you have any questions, please contact the physiotherapists listed below.

Contact details

Consultants and their secretaries

• The teams listed below work at Kent and Canterbury Hospital as well.

Physiotherapists

Surgical Preassessment Units

Fracture Clinics