Injuries, Sports

Treating Epicondylitis (“Tennis Elbow”) – Richard A. Bernstein, MD

Elbow pain can be uncomfortable and quite disabling. Fortunately, most cases of elbow tendonitis improve with simple noninvasive maneuvers.    The most common tendinopathies involving the elbow are referred to as epicondylitis; we typically refer these common problems as “tennis elbow” and “golfer’s elbow.”  Interestingly, however, most patients are neither tennis players nor golfers, but they develop pain and discomfort in the elbow that falls under the medical term “epicondylitis.”  The bony prominances on the outside or lateral, and inside or medial aspect of the elbow are the origins of the muscle groups that extend to the forearm and are termed “epicondyles”.  The forearm muscles that extend to the wrist and fingers originate at the lateral epicondyle or the outside of the elbow.  Conversely, the muscles that bend or flex the wrist and fingers originates at the medial epicondyle or the inside of the elbow. These same muscles also turn the hand toward the floor, known as pronation. The two muscle groups insert on the bone through the tendon, with anatomic structures specifically known as Sharpie’s fibers.

The term tennis elbow was coined to describe the pain that people develop at the elbow after playing tennis.  In the athlete, this may occur from inexperienced technique, an improperly sized or poorly strung racket, or an injury.    Similarly, golfers elbow, or medial epicondylitis, has been seen in golfers due to poor technique or to miscalculation making a shot. It occurs more typically in amateur rather than professional golfers. It is more common in the trailing arm than the lead arm and usually occurs from poor mechanics, such as when trying to swing without warming up or stretching appropriately.  However, most of the time, tennis or golfer’s elbow occurs from a muscle/tendon imbalance.  The muscles may not be flexible or strong enough to do an activity that someone has attempted. This may also occur after a weekend home improvement project or a “weekend warrior” trying a new sport. In either case, not warming up properly or attempting an activity that one’s body is not accustomed to, may cause these problems.

Symptoms include pain and discomfort from either side of the elbow that radiates into the forearm.  Point tenderness is typically 0.5 cm distal to the involved epicondyle.  On provocative testing, lateral epicondylitis is characterized by pain radiating to the elbow when resisted wrist extension is performed with the elbow extended.  Similarly, for medial epicondylitis, pain occurs at the inside of the elbow radiating to the volar forearm.  Resisted pronation is a provocative maneuver that helps confirm the diagnosis.  In the early phase, diagnostic testing such as an x-ray is typically not needed.  On the other hand, in cases with recalcitrant pain, occasionally there can be an underlying arthritic condition that can mimic tendinitis and can be evaluated radiographically.  MRI scans are typically not needed as the diagnosis can usually be made clinically.

The actual pathophysiologic changes are poorly understood.  In Latin, the suffix “itis”  implies inflammation, such as “bronchitis,” or airway inflammation.  However many studies have investigated the histological tissue from surgical specimens and do not find the typical inflammatory cells that one would expect to see if this was truly an inflammatory condition.  Therefore, some prefer the term “osis” such as “tendinosis”  since histology does not show classic inflammatory cells.  Various studies have questioned what actually occurs physiologically, but damage occurs in the area of the tendinous insertion into the bone or possibly from underlying joint inflammation or synovitis.  This sets up a pathway of pain, inflammation, and symptoms.  The pain typically radiates from the elbow into the forearm as the forearm muscles and tendons become inflamed and damaged from overuse.

Fortunately, more than 90% of patients improve with conservative measures.  The classic intervention of “RICE,”   rest, ice, compression, and elevation is first-line therapy.  First and foremost, stopping the offending activity is paramount.  The logical initial step is to understand why the pain occurred in the first place and to modify the inciting activity.  In the acute setting, ice, and non-steroidal anti-inflammatories, when medically appropriate, help many patients.  As most Orthopedic Surgeons believe, this tendinosis represents a muscle imbalance, therefore, rest, stretching, patience and appropriate strengthening usually help.  Physical therapy exercises can often hasten recovery.   One specific value of physical therapy is to understand the local anatomy, the mechanism of injury, and to discuss ways to avoid aggravating the situation. When medically appropriate, many patients find nonsteroidal anti-inflammatory medications helpful to diminish the inflammatory process.  Splinting is controversial with some studies supporting a benefit and other studies dismissing splinting altogether.  The classic splint for either condition goes by the general term counterforce bracing.  Specifically, a wrap is placed in the proximal forearm over the involved muscle group to provide compression. This diminishes the tension at the tendon insertion at the epicondyles.  Other studies have suggested wrist splints since this may minimize forces across the involved tendons.

Injections of corticosteroids to the affected areas also have their advocates and non-advocates in the scientific literature.  Some randomized and meta-analysis studies have questioned the long-term effectiveness of corticosteroid injections in epicondylitis. Some believe these injections may provide a placebo effect or afford only temporary improvement.  Other studies have demonstrated some efficacy.  If we consider again the histopathologic findings in epicondylitis, and the lack of inflammatory signs on those findings, the question is raised about why corticosteroids would be expected to be efficacious.

In summary, golfer’s and tennis elbow are common conditions that usually present with more forearm pain than tenderness directly in the elbow.  They are overuse conditions that can be seen in the athlete, but more commonly in the general population.  Most cases do have a self-limited course and improve through commonsense and exercise.  As in any situation, unusual or recalcitrant symptoms should eventually be evaluated by the appropriate health care provider.

 

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