08/27/2014 09:41 am ET Updated Oct 27, 2014

Why Does Tennis Elbow Take So Long to Improve?

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Whether you're a pro competing in this week's US Open or an avid amateur who enjoys tennis for fun, you will likely experience some form of "tennis elbow" in your lifetime. This injury -- so common that it has its own lay term -- is a wear-and-tear effect and inflammation of the tendon for the extensor muscles on the top of your forearm. Formerly referred to as lateral epicondylitis, the clinical term for tennis elbow is more often extensor tendinosus, an injury known for its frustrating persistence. Why does it take so long to improve?

When tennis elbow pain fails to improve, most tennis players seek medical care and, in many cases, a long journey begins. Even the best care won't prevent a lengthy recovery for those whose tennis elbow involves inflammation of the extensor tendon or partial tears in varying degrees of the same tendon. Another contributing factor in effectively managing tennis elbow pain is the shoulder's loss of internal rotation. This loss of rotation -- known as glenohumeral internal rotation deficit (or GIRD) -- is seen most often in overhead athletes. If the internal rotation is diminished in a tennis player, then the follow-through is reduced and deceleration of the serve places more mechanical stress on the elbow tendons. The result is an exacerbated elbow pain (Laban MM, et. al., Am J Phys Med Rehabil 2005).

To further examine this anatomically, the elbow -- similar to the knee -- features collateral ligaments on each side. Extensor tendinosus was found to be associated with ligament injuries on the inner side of the elbow (the ulnar collateral ligament). The severity of the tennis elbow was proportional to the degree of severity of the ulnar collateral ligament injury. The outer ligament (radial collateral ligament) injury has also been associated with extensor tendinosus (Bredella MA, et. al., Am J Roentgenol 1999).

Tennis elbow symptoms may also persist when the pain is being caused by another unknown source. Some patients diagnosed with tennis elbow actually had lateral elbow pain even though the tendon was normal. In these cases, the pain was referred from the neck (cervical spine) as a result of an inflamed nerve root (Bergland KM, et. al., Man Ther 2008; Cleland JA, et. al., J Orthop Sports Phys Ther 2004; Vicenzio B, et. al., Pain 1996; Gunn CC & Milbrandt WE. Can Med Assoc J 1976). When treatment was directed at the neck, these patients improved.

Additionally, patients with tennis elbow may have regions of poor blood supply in the tendon and compromised microcirculation of the extensor muscles (Bales CP, et. al., J Shoulder Elbow 2007; Oskarsson E, et. al., Scand J Med Sci Sports 2007). These are interesting findings for clinicians and researchers that may provide support for the use of orthobiologics in treating tennis elbow (Mishra AK, et. al. Am J Sports Med 2014).

Although readers of this blog should not be expected to remember all of this, my article may at least provide insight on several reasons it may take so long for your tennis elbow to improve. Your best option may be to go back to your doctor for a more functional and physical examination, which could eliminate the possibility of other contributing factors at play, make sure the pain is really originating from the elbow, and -- most important -- help you find a quicker resolution for this often long lasting condition.