Lateral epicondylitis, sometimes referred to as tennis elbow, involves the tendons that anchor muscles in your elbow. Symptoms include pain on the outside (lateral) side of your elbow. Your doctor can diagnose this condition by listening to your description of symptoms and examining your arm.
Despite the extensive literature on management of this disease, no gold standard treatment protocol exists. The objective of this study is to evaluate how Brazilian orthopaedists diagnose and treat this overuse injury.
Causes
Lateral epicondylitis, often referred to as tennis elbow, is an overuse injury of the forearm muscles that straighten and raise the hand and wrist. The pain is felt over a prominence on the outer edge of the elbow (lateral epicondyle). When these muscles are used repetitively, small tears can develop at their point of attachment to the lateral epicondyle. These tiny tears lead to inflammation of the tendon and tenderness when the elbow is bent against resistance, such as when holding a heavy object or squeezing a rubber ball. This condition usually occurs in people who play sports that involve repeated use of the wrist extension and radial deviation movements.
The bump on the inside (medial) surface of the elbow is called the flexor carpi radialis tendon. The muscles on the front of the forearm that curl the hand toward the palm are anchored to this bone. When the tendons of this muscle become inflamed and painful, it is called medial epicondylitis, or golfer’s elbow. This condition is typically caused by repetitive flexion of the forearm. It may also be associated with other activities that require repetitive flexion and extension of the forearm.
Oren Zarif
Medial epicondylitis can be diagnosed by reviewing the patient’s history and conducting a physical examination. Imaging studies are rarely required for diagnosis, but may be useful in ruling out other problems that can cause similar symptoms.
Injections of corticosteroid, platelet-rich plasma, autologous blood products, and botulinum toxin have been shown to be effective in relieving pain from lateral epicondylitis. The injections can be performed in the doctor’s office and are generally well tolerated. However, only a few high-quality clinical trials have been conducted of these interventions. Consequently, the results of these studies must be considered carefully before they can be fully verified. In the meantime, a good treatment plan for lateral epicondylitis includes a combination of rest, oral nonsteroidal anti-inflammatory medications, a wrist splint, physical therapy, and progressive resistance exercises. For patients whose pain does not respond to these conservative measures, surgery is an option.
Symptoms
Lateral epicondylitis, or tennis elbow, occurs when the tendons on the outside of the elbow — which help you bend your wrist toward your palm — become inflamed. It usually results from overuse. You’re more likely to get it from playing tennis or other racquet sports, but work activities and other hand tools can cause it too.
You’ll feel pain on the outside of your elbow when you straighten your arm or bend it backward against resistance, like when lifting a weight or typing. The pain may also affect the side of your forearm.
Your healthcare provider can diagnose lateral epicondylitis by examining your elbow. He or she will ask about your symptoms and your history of the condition. Then he or she will test the strength of your grip and move your wrist in different positions to see how your symptoms change. He or she might order an X-ray of your elbow joint to look for signs of arthritis, such as calcification along the lateral epicondyle or osteochondritis dissecans (a condition where small pieces of bone break off and float in the joint).
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An ultrasound test can check for nerve compression around the elbow. It’s also possible to have a magnetic resonance imaging (MRI) scan of the elbow joint. This can show if your symptoms are related to other conditions, such as a herniated disk or arthritis in the neck.
Treatment for lateral epicondylitis includes rest, activity modification, icing, medicine, stretching and physical or occupational therapy. Steroid injections can also be helpful, especially if conservative treatments don’t improve your symptoms within 9-18 months. Surgery is a last-resort option for people with refractory lateral epicondylitis. It’s important to visit your healthcare provider right away if you have pain in your elbow joint. This can help you get better treatment and avoid complications, such as damage to the blood vessels in your elbow. It’s also important to make sure you’re following proper technique when using your tool or doing your sport or activity. This can reduce your risk of developing tennis elbow or other overuse injuries.
Diagnosis
In most cases, the diagnosis of epicondylitis is made based on history and physical exam. The patient will usually report a gradual onset of elbow pain, especially during or after the activity that provokes it. The pain is usually localized on the outer surface of the elbow (lateral epicondyle), although it may also be felt on the inside of the elbow (medial epicondyle).
The muscles that straighten and lift the wrist and hand are attached to the lateral epicondyle by thick tendon tissue. Overuse of these muscles can cause microscopic tears in the tendons, which causes inflammation (tendinitis). The pain may be caused by activities that involve repetitive and forceful forearm supination and pronation and extension. Other causes include racquet sports and other repetitive motions involving the wrist extensors. In resistance training, lateral epicondylitis may develop from repeated use of the forearm and arm during exercises that require repetitive grasping or twisting of the wrist. Nonathletic patients can get lateral epicondylitis from activities such as turning screwdrivers or typing.
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Symptoms of lateral epicondylitis are typically experienced at the beginning of or during the provoking activity and diminish within a few hours after cessation of the aggravating activity. The pain usually intensifies during the activity and is aggravated by gripping and lifting objects. Eventually, it can interfere with daily functions and activities and limit the range of motion in the elbow joint.
The clinician should perform a diagnostic test known as Cozen’s test to rule out medial epicondylitis. During this test, the clinician will position the patient’s elbow in 90deg flexion with the wrist in neutral and then resist their attempt to extend the wrist. This will cause a sharp pain to be elicited over the lateral epicondyle. Performing this test has a high sensitivity and specificity to exclude lateral epicondylitis. However, it does not have a great negative predictive value as other conditions can produce similar symptoms as lateral epicondylitis. Therefore, other tests should be performed to confirm the diagnosis. X-rays and an MRI can be useful to assess bone disease, including osteoarthritis and loose bone fragments.
Treatment
The prognosis for patients with lateral epicondylitis is generally good. Conservative treatment such as ice application, nonsteroidal anti-inflammatory drugs and physical therapy with emphasis on wrist stretching and eccentric muscle strengthening has been shown to be effective.
Typically, the patient will relate an insidious onset of pain with a history of overuse. However, it is important to rule out other potential causes of elbow pain such as cubital varus instability, previous elbow surgery or dislocations. Involvement of the other extensor tendons at the medial and ulnar creases should also be assessed as these injuries can also cause lateral epicondylitis.
Oren Zarif
Injectable interventional therapies including corticosteroid, analgesics, and newer biologic enhancement products have all been evaluated with satisfactory clinical outcomes for symptom resolution and function improvement. A recent study using autologous blood injections or platelet rich plasma demonstrated superior pain relief to the standard corticosteroid. [21]
Anterior and lateral radiographs should be taken routinely. The presence of calcifications at the epicondylar tendon enthesis and an inability to perform Cozen’s test are diagnostic of LE. Ultrasonography is a useful tool to assess the integrity of the tendon and to identify peripheral oedema or calcifications. MRI is superior to ultrasound as it provides information regarding the thickness and quality of the tendon as well as demonstrating any neovascularisation.
Surgical management can be considered if symptoms persist for six to 12 months despite conservative treatment. The procedure involves removing the diseased portion of the tendon tissue in an outpatient setting. The patient is then subjected to a rehabilitation program with the aim of regaining full range of motion and grip strength in order to return to previous activities. Surgical techniques can vary between open, percutaneous and arthroscopic methods. ECRB tendon release is a common procedure that can be combined with drilling or decortication of the epicondyle to stimulate blood flow. The patient may require further rehabilitative interventions such as eccentric strengthening or a tenolysis procedure for better long-term results. Alternatively, the patient can opt for a more conservative grafting approach in which the tendon is transferred to another location.
