Lateral Epicondylitis (Tennis Elbow)
Lateral epicondylitis (tennis elbow) is the most common affliction of the elbow. It is an inflammatory condition producing pain localized around the lateral elbow and dorsal forearm region. Though often put in the category of tendonitis, it is actually a result of an injury to the extensor musculotendinous origin at the lateral humoral epicondyle. This condition may also involve degenerative changes of the annular ligament and/or pinching of hypertrophied synovium in the radial humoral joint.
What is it?Tennis elbow is a tear in the common extensor tendon as it originates from the lateral epicondyle. These tears are produces by mechanical overload during activities that stress tendon fibers. Persons of middle age, 35 to 60, are afflicted with this condition most often. Pain develops gradually and escalates depending on activity. Symptoms are aggravated by wrist extension against resistance.
Contributing FactorsAlthough commonly known as tennis elbow, few people who present with this problem play any type of racquet sports. The common contributing causes are activities that require gripping and pulling with the palm in a downward position (overhand posture). Occasionally, it may arise from a direct blow to the area.
DiagnosisThe diagnosis is confirmed by the consistent finding of well-localized pain on the lateral aspect of the elbow produced with wrist extension against resistance. The diagnosis should not be established based on vague, nonspecific pain of the forearm.
Nonsurgical Treatment Options
Tennis elbow usually responds to nonsurgical treatment. Initial treatment must emphasize REST. Exercises and strengthening of the forearm and hand muscles only aggravate the condition and perpetuate the pathology during the early phases of healing. Occupational and physical therapy are helpful to monitor the patient’s progress. Various modalities, including iontophoresis, may help to control symptoms. An appropriate wrist brace and/or tennis elbow brace often help. It should be emphasized that it may take many months for this condition to resolve. For the tennis player, changes in racquet grip size, weight, composition, and stiffness as well as instruction, will help avoid this injury. In the workplace, ergonomic evaluation that assists the worker in avoiding patterns of activity that require overhand gripping and pulling will decrease the incidents of this injury. Unfortunately, it is difficult to completely rest this anatomical area. True lateral epicondylitis will respond promptly to a cortisone injection. How long the benefit lasts varies from a few weeks to several months. Injections may be repeated up to three times if there is a good response. After injections, patients are advised to wear a brace and be monitored with regards to their symptoms. Many resume normal activities and work without restrictions. Patients who respond to a cortisone injection, but then have recurrence of symptoms, are faced with the choice of accepting the limitations these symptoms bring or considering surgery. Patients who have responded to a steroid injection have an excellent prognosis to improve with surgery.
Surgery & Recovery
The operative procedure consists of detachment of the extensor muscle origin and partial resection of the lateral epicondyle. Hypertrophic synovium, if present, is also removed. This is done as an outpatient surgery using general anesthesia. Following surgery, the patient is placed in a long arm splint for two weeks followed by gentle range of motion. At four weeks following surgery, gradual strengthening exercises are added. The majority of patients feel comfortable to engage in most activities at home as well as at work eight to ten weeks after surgery. Recurrence of lateral epicondylitis is rare, and it is very unusual that repeat surgery is necessary. However, it is not uncommon for patients to express some level of musculotendinous discomfort in the forearm region. Most of this pain is probably secondary to fatigue weakness from deconditioning.
Medial Epicondylitis (Golfer's Elbow)
Medial epicondylitis, sometimes known as golfer’s elbow, is no different from its counterpart on the lateral aspect of the elbow. Fortunately, it is less common and less recalcitrant to nonoperative treatment. Medial epicondylitis is best managed by a well-organized treatment plan. It should be remembered that it takes six to eight months for it to fully resolve. The cooperation and communication between the patient, employer, physician and therapist is necessary for a successful outcome. Surgery is indicated for patients who have responded to a Cortisone injection but have recurrent symptoms. Therapy after surgery is essential for a complete recovery. Ergonomic changes in the workplace play a major role in prevention.