TENNIS ELBOW

(LATERAL EPICONDYLITIS)

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related talks: swollen elbow; golfer's elbow; broken elbow; children's broken elbow; radial head fracture (type of broken elbow); elbow dislocation; elbow stiffness; broken forearm; broken arm

What is "Tennis Elbow" (lateral epicondylitis)?

Tennis elbow is an degenerative condition along the outside of your elbow and forearm called “lateral epicondylitis”.

The degeneration occurs from the accumulation of microtears in the tendons that extend your wrist (make it bend backward). These microtears are probably too small to feel individually, but over time they add up and become painful.

The most commonly affected tendon and the biggest contributor to the pain is the Extensor Carpi Radialis Brevis (ECRB) muscle.

This condition was first described in the 19th century while people were playing lawn tennis in England, which is how it got its name. However, the condition is now recognized in many athletic and recreational activities. Tennis remains a big risk, and some studies suggest that up to 50% of regular tennis players will experience tennis elbow at some point in their life, usually brought on by the backhand stroke (however, only 13% of professional tennis players are afflicted with the condition, suggesting it is associated with faulty mechanics). The condition can be caused by many inciting events such as local inflammation, muscle or ligament strains, or inflammation within the joint.

Injury to this region can be caused by overuse or by a direct blow, or maybe by another reason to subtle to recognize.

Diagnosing "Tennis Elbow" (lateral epicondylitis):

Tennis elbow causes a lot of pain in the forearm (especially with movements where your wrist is cocked back: like holding a car steering wheel, or revving the engine of your Harley Davidson motorcycle). The diagnosis is based on a doctor's examination findings alone, and x-rays are not helpful. The provocative tests (recreating the pain) include pushing on the area that hurts (duh!), or rotating the palm upward under resistance, or picking up a chair with their palm down (extending the wrist).

MRI and ultrasound, although sensitive to signs of inflammation around the tendon, are not necessary.

Treating "Tennis Elbow" (lateral epicondylitis):

Tennis elbow should be treated in a stepwise fashion from least invasive to more involved if the pain persists.

The condition is usually self-limited (it goes away with time), and by just avoiding aggravating activities, the pain resolves in about 33% of people within 6 weeks, 50% of people by 3 months, 75% of people at 6 months and about 85% in a year.

Activity modification plus physical therapy (deep friction massage, home stretching exercises and strengthen) showed better improvement than activity modification alone, although not by much.

People that got a steroid injection showed immediate improvement (better than people treated with activity modification + physical therapy) and the symptoms resolved in over 90% of people by 3 weeks. However, as the effects of the steroid wore off, patients were feeling only as good the therapy group by 3 months, and then were actually doing worse by 6 months and 1 year (at that time only 70% of people reported improvement). Steroid injections often give short term relief only (although for many it does offer quick and long-lasting treatment).

Another treatment is a forearm counter-tension band to be worn with activities. This brace can relieve some of the stress from the inflamed tendon.

If pain remains significant at 6 months or a year, surgical intervention is available with a high success rate. The procedure removes the inflamed ECRB tendon, which is ok, because there is another tendon that links up with the remaining ECRB tendon further down the arm.

What is the long term outcome?

There are a number of effective treatment options for this condition. If approached in a stepwise manner, its expected that "Tennis elbow" will completely resolve, although it may take a few weeks or even months (but persistence usually pays off). The recent trend of using Platelet-Rich Plasma ("PRP") to treat degenerative and inflammatory conditions has generally failed to live up to the hype. A recent study comparing PRP to placebo showed no difference after 1 month, while another study comparing steroid injects to PRP and placebo showed that steroids were more effective at 1 month.

Reference

1) Mishra AK et al. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med 2014; 42: 463-71. full article.

2) Krogh et al. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013; 95: e66.

3. Tennis elbow. The surgical treatment of lateral epicondylitis. Nirschl RP, Pettrone FA. J Bone Joint Surg Am. 1979 Sep;61(6A):832-9

4. Electromyographic analysis of elbow function in tennis players. Morris M, Jobe FW, Perry J, Pink M, Healy BS. Am J Sports Med. 1989 Mar-Apr;17(2):241-7