Tennis elbow

Tennis elbow is a condition where the outer part of the elbow becomes painful and tender, usually as a result of a specific strain or overuse. Although it is called "tennis elbow", it should be noted that it is not restricted to tennis players. If one hyperextends an elbow in any sport, this may be classified as tennis elbow. Anyone who does a lot of work involving lifting at the elbow or repetitive movements at the wrist is susceptible to tennis elbow. The condition was first described in 1883.^[1]. The medical term is lateral epicondylitis.

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Etiology

With tennis elbow, the extensor carpi radialis brevis tendon has been identified as the primary site of pathological change. There have also been pathological changes found at the extensor digitorum communis, longus and ulnaris tendons. The extensor carpi radialis brevis has a small origin and does transmit large forces through its tendon during repetitive grasping. It has also been implicated as being vulnerable during shearing stresses during all movements of the forearm. There is no evidence relating mode of onset to pathology although it is generally acknowledged that tennis elbow is caused by repetitive microtrauma/overuse. Inflammatory changes have been noted in the acute stages of the condition but have been found to be absent if symptoms become chronic (3 months +). This may explain why approaches such as corticosteroid injections have little impact in the chronic stages of the condition. Although the name suggests otherwise, tennis elbow can affect anyone - not just racquet sport players. However, there are numerous studies that have implicated racquet sports as a cause or contributing factor for tennis elbow. The peak incidence is between 34 to 54 years of age. No difference in incidence between men and women or association between tennis elbow and the dominant hand has been demonstrated. A weak association has been found between work and tennis elbow development. Risk factors for this condition vary from taking up tennis later in life, unaccustomed strenuous activity, decreased reaction times and speed and repetitive eccentric muscle contractions (controlled lengthening of a muscle group).

Symptoms

• Pain on the outer part of elbow (lateral epicondyle).
• Gripping and movements of the wrist hurt, especially wrist extension and lifting movements.
• Tenderness to touch, and elbow pain on simple actions such as lifting up a cup of coffee or throwing a baseball.
• Pain usually subsides overnight.
• If no treatment given, can become chronic and more difficult to eradicate.

Exams and Tests

The diagnosis is made by clinical signs and symptoms, since x-rays are usually normal. Often there will be pain or tenderness when the tendon is gently pressed near where it attaches to the upper arm bone, over the outside of the elbow.

There is also pain near the elbow when the wrist is extended (bent backwards, like revving a motorcycle engine) against resistance. ^[2]

Treatment

The goal of treatment is to relieve pain and swelling. Treatment may include:

• Nonsteroidal anti-inflammatory medications (such as ibuprofen, naproxen or aspirin)
• Local injection of cortisone and an numbing medicine
• Using a splint to keep the forearm and elbow still for 2 to 3 weeks
• Heat therapy
• Physical therapy
• Pulsed ultrasound to break up scar tissue, promote healing, and increase blood flow in the area

To prevent the injury from happening again, a splint may be worn during aggravating activities. Or, you may need to limit certain activities. If the pain persists despite non-surgical treatments, surgery may be necessary. ^[3]

Although not founded in clinical research^[4] , the tennis player's treatment of choice is frequent icing and compression (Cold compression therapy) for inflammation, and taking anti-inflammatory pain-killers, such as ibuprofen. In general the evidence base for intervention measures is poor.^[5] A brace might also be recommended by a doctor to reduce the range of movement in the elbow and thus reduce the use and pain. Also, ergonomic considerations are important to help with the successful relief of lateral elbow pain.

Initial measures

Rest, ice, and compression are the treatments of choice. There are many excellent cold compression therapy products available. Nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce pain and inflammation.

Exercises and stretches

Stretches and progressive strengthening exercises are essential to prevent re-irritation of the tendon^[6]. Progressive strengthening for this condition involves using weights or elastic theraband to increase pain free grip strength and forearm strength. Racquet sport players also are commonly advised to strengthen their shoulder rotator cuff, scapulothoracic and abdominal muscles by Physiotherapists to help reduce any overcompensation in the wrist extensors during gross shoulder and arm movements. Soft Tissue Release or simply Massage can help reduce the muscular tightness and reduce the tension on the tendons. Strapping of the forearm can help realign the muscle fibers and redistribute the load.

Physiotherapy

With physiotherapy, ultrasound can be used to reduce the inflammation and promote collagen production although the current evidence for its efficacy is inconclusive. Manual therapy (a form of physiotherapy) is an important part of the treatment; and can take the form of elbow joint mobilisations/manipulations and/or extensor muscle tissue mobilisations. Nerve mobilisation can also be helpful if the Physiotherapist finds a positive nerve tension test in their assessment. The most common upper limb nerve found to be sensitive is the radial nerve for this condition. Elbow clasps are also found to give temporary relief of symptoms.

Local steroid injections

Intra-articular glucocorticoid steroid injections can resolve episodes for several months, but there is a risk of later recurrence. Following an injection, the patient normally experiences increased pain over the subsequent day before the steroid starts to settle the condition over the next few days^[7] . As with any steroid injection, there is a small risk of local infection and tendon rupture. Most doctors will restrict giving further courses after two injections, as there is less likelihood of effectiveness but increased risk of side-effects.

As opposed to short-term effect^[8] , the longterm benefits of local steroid injection are less clearly established.^[9]

Surgical intervention

If conservative measures fail, release of the common extensor origin may be helpful. It may be undertaken under general anaesthesia or regional block.

Alternative treatments

Laser Therapy

The Use of Laser Therapy (Low Power or Low Intensity Laser Therapy) is a currently used treatment. The approach was spun off of research on how light affects cells. The findings, that light stimulates and accelerates normal healing, sparked the creation of several devices. The dosage often determines the extent of the success with this treatment, so it is generally recommended that experienced clinicians apply the therapy with a device that can be 'customized.' Professional athletes have used the therapy and it has gained attention in the media lately, on shows like the Canadian health program "Balance" on CTV. However, studies evaluating the efficacy of laser therapy for tennis elbow are currently contradictory.

One study has alleged that electrical stimulation combined with Acupuncture is beneficial but evaluation studies are inconclusive.^[10]

Prognosis

Most people improve with non-surgical treatment. The majority of those that do have surgery show an improvement in symptoms. ^[11]

Possible Complications

• Recurrence of the injury with overuse
• Rupture of the tendon with repeated steroid injections
• Failure to improve with nonoperative or operative treatment; these may be due to nerve entrapment in the forearm

^[12]

References

See also

• Golfer's elbow
• Repetitive strain injury
• Radial tunnel syndrome

acquired deformities of fingers and toes (Boutonniere deformity, Bunion, Hallux rigidus, Hallux varus, Hammer toe) - other acquired deformities of limbs (Valgus deformity, Varus deformity, Wrist drop, Foot drop, Flat feet, Club foot, Unequal leg length, Winged scapula)

patella (Luxating patella, Chondromalacia patellae)

synovium and tendon: Synovitis - Tenosynovitis (Stenosing tenosynovitis, Trigger finger, DeQuervain's syndrome)

bursitis (Olecranon, Prepatellar, Trochanteric)

fibroblastic (Dupuytren's contracture, Plantar fasciitis, Nodular fasciitis, Necrotizing fasciitis, Fasciitis, Fibromatosis)

enthesopathies (Iliotibial band syndrome, Achilles tendinitis, Patellar tendinitis, Golfer's elbow, Tennis elbow, Metatarsalgia, Bone spur, Tendinitis)