Tennis Elbow or Lateral Epicondylosis (Epicondylitis)
Tennis elbow, or lateral epicondylosis, is a painful condition of the elbow, which is typically caused by overuse. It is commonly associated with sports such as tennis but in most people with the condition it is not associated with playing tennis or other sports.
While Tennis elbow is often described as an inflammation of the tendons, which come from the elbow. However, the changes within the tendon are not characteristic of an inflammation and the name epicondylitis is technically a misnomer. The damage within the tendons is attributed to repeated micro- trauma (small scale damage) in which the normal repair process does not function correctly and damage accumulates. This leads to macroscopic (large scale) damage to the tendon with subsequent pain and tenderness on the outer aspect of the elbow.
There are variety of treatment options, including rest, changes in sport technique, physiotherapy, bracing and occasionally surgery.
Structures involved:
The elbow joint is a joint made up of three bones: the Humerus (the upper arm bone) and the two bones of the forearm, the Radius and Ulna. The Humerus widens just above the elbow at 2 bony prominences or epicondyles can be felt on either side of the elbow joint. The prominence on the inside of the elbow is the medial epicondyle and the prominence on the outside of the elbow is called the lateral epicondyle.
The muscles that extend (straighten) the wrist and fingers originate from the lateral epicondyle. The muscles that flex (bend) the wrist and fingers originate from the medial epicondyle. The muscles are attached to the bone by tendons that have a common point of attachment.
Lateral epicondylosis, or tennis elbow, involves the tendons that attach the extensor muscles that straighten the wrist and fingers to the lateral (or outer) epicondyle. The tendon typically involved is the Extensor Carpi Radialis Brevis (ECRB) that is a wrist extensor.
Causes:
Activity.
The epicondylosis is considered to be a consequence of repeated damage to the tendon that does not heal, as it would normally do. Repetitive activities that stress these tendons are more likely to result in the accumulation of micro-structural damage and subsequent symptoms. Racquet sports such as tennis may precipitate the onset of symptoms as a consequence of the repetitive stress in the extensor tendons to ensure wrist stability during a stroke and contact with the ball. The onset of symptoms may be precipitated by a suboptimal technique or equipment, such as striking the ball off centre or an incorrect grip size. In the majority of cases it is not sporting activity that is the cause. Frequently it is occupational or domestic activities that are associated with the onset of symptoms.
Age.
Lateral epicondylosis is most common between the ages of 30 and 50. There is an additional peak of occurrence in the early 20 typically associated with sporting activity.
Unclear or unkown.
In a large proportion of cases there may be no clear precipitating activity and typically no injury.
Symptoms:
Pain.
Pain is typically felt over the lateral (outer) aspect of the elbow. The pain may extend into the forearm. The pain may be perceived as a burning sensation. It is often mild to start and may fluctuate in severity, often depending on activity. Activities such as wringing a towel or gripping a racquet or spanner may precipitate or exacerbate the pain. The pain is often precipitated by gripping of the hand or resisted extension (straightening) of the wrist.
Weakness.
There may be perceived weakness of grip strength or elbow flexion.
Tenderness.
There may be tenderness over the lateral (outer) aspect of the elbow. This tenderness is often most marked over the extensor tendons approximately 2cm from the lateral epicondyle (outer prominence). The tenderness may be attributed to the lateral epicondyle itself.
Diagnosis:
The diagnosis is often apparent from the reported symptoms and examination. However, there are a number of alternative causes of similar pain.
X-Rays (plain radiographs)of the elbow are typically taken. These will typically be unremarkable but may demonstrate arthritis or other damage to the elbow joint.
An Ultrasound scan (USS) or Magnetic Resonance Imaging (MRI) scan may be arranged to identify structural damage but are not routinely indicated.
Nerve conduction studies or EMG (electro-myography) are a means of assessing the function of nerves and may occasionally be requested to exclude or identify nerve dysfunction.
An injection of local anaesthetic often with steroid may be provided to the region of the common extensor origin as confirmation of the diagnosis as well as part of treatment.
Treatment:
Non operative treatment:
The majority of cases (80-89%) respond well to non surgical treatment.
Avoidance of exacerbating activities.
In the first instance activities that exacerbate symptoms should be avoided or minimised for several weeks.
Coaching or activity modification.
Precipitating or exacerbating activities may need to be reviewed to optimise performance. If the lateral epicondylosis is associated with sporting activities such as tennis the advice of a good coach may be crucial. They may be in a position to offer advice about equipment and technique to minimise the stress on the extensor tendons allowing symptoms to settle and avoid recurrence. The grip size, racquet head size and string tension may need to be reviewed.
Rehabilitation.
Physiotherapy and rehabilitation is the mainstay of treatment for lateral epicondylosis and tennis elbow. The type of rehabilitation is important and should include an eccentric rehabilitation programme. An example of an eccentric programme is given in the post-operative rehabilitation guidance for tennis elbow surgery). These programmes need to be pursued diligently for an extended period, typically 3 months but have a success rate of approximately 80-95%.
Bracing.
There are a wide variety of braces available that typically clasp the forearm below the elbow and these may provide symptomatic relief.
Analgesia and anti-inflammatory medication.
While the process within the extensor tendons is not predominately an inflammatory one, anti-inflammatories (eg: Ibuprofen, Diclofenac and VoltarolTM) may be helpful in addition to simple painkillers (analgesia) eg: Paracetamol.
Local injections including steroid.
Injections of steroid, normally given with a local anaesthetic agent typically produce symptomatic relief in the short or long term. These are useful as diagnostic test as well as offering treatment benefits. When providing the injection the needle is typically passed repeatedly through the tendon and this multiple pass technique may in itself promote tendon healing. The use routine use of steroid injections has been questioned but their use remains widespread and useful particularly in a specialist setting. Discomfort for 24-48 hours following a steroid injection is not infrequent and analgesia (pain killers should be taken regularly, if appropriate, during this time). The small risks of skin depigmentation or thinning and very small risk of infection should be noted.
Link to additional information on steroid injections.
Injections of PRP (Platelet Rich Plasma).
Injections of Platelet Rich Plasma have become increasingly popular over recent times and some supporting research has been produced. The treatment is based on the concentration of active naturally occurring chemicals within the blood. The injection is typically painful and given without local anaesthetic and so sedation or partial anaesthetic may be necessary.
Alternative treatments.
Some additional treatments such as Extracorporeal Shock Wave Therapy (ESWT) and laser therapy remain controversial but may be considered by your physician or surgeon.
Operative treatment:
If pain continues or recurs following non-operative management then surgery may be necessary. This typically involves removal of the damaged and abnormal tissue from the extensor tendons. This may be achieved as an open or arthroscopic technique. The surgery typically requires a general anaesthetic and can be undertaken as a day-case procedure or with an overnight stay.
Link to Tennis Elbow or Lateral Epicondylosis surgery.