Patient Information Guide
Lateral Epicondylitis or
“Tennis Elbow”
Summary:
Lateral epicondylitis is an overuse condition that results in pain and loss of function of the affected arm. It occurs in people who use their hands for activities that require repetitive gripping and squeezing. Pain on the outside of the elbow with grip and wrist extension may be severe and prevent even simple tasks. This pain may radiate into the forearm. Lateral epicondylitis results from tendon degeneration of the extensor carpi radialis brevis tendon (a wrist extender muscle). Treatments are aimed at allowing this tendon to heal while preventing further damage. This condition tends to be self-limited in the majority of cases and fewer than 10% of patients require surgery. The sections below will discuss the diagnosis and treatment options in greater detail.
Tendon Anatomy:
Tendons are composed of collagen which is the building block of our connective tissues. In tendons, this collagen is arranged into fibers and fibers are arranged into bundles much like a rope. This highly organized arrangement allows tendons to transmit the force generated by a muscle to the adjacent bone. Collagen is manufactured by cells within the tendon called tenocytes. These cells are responsible for maintaining tendon health and for tissue repair and remodeling. Most tendons have relatively little blood supply. Consequently, tendon healing can be very slow. When tendons heal, new collagen must be formed through a repair process. This collagen must then mature from early scar tissue into organized tendon tissue. Not until this reorganization process is complete and the tissue reconditioned are tendons capable of withstanding the demands of everyday activities.
Definitions of Tendon Injury
Tendinosis refers to internal tendon degeneration. This occurs because on an imbalance between tendon breakdown and tendon repair. Thus, tendinosis can result either from an increase in breakdown such as from overuse or injury, or from a decrease in the healing response.
Tendonitis refers to tendon inflammation. While this term is commonly used to describe activity related pains in various joints of the body, recent studies have shown that there is very little inflammation present in the majority of cases of tendon-related pain. This conditions like lateral epicondylitis and rotator cuff tendonitis are actually not inflammatory but degenerative in nature and should be referred to and treated as tendinosis.
When tendons are exposed to repetitive stress and overuse, their capacity for internal repair may be exceeded and injury occurs at a microscopic level within the tendon substance. This is similar to individual strands tearing within the substance of a piece of rope. As individual collagen fibers separate and tear, the ability of the tendon to transmit force from the muscle is compromised and pain results. The highly arranged organization of the tendon substance becomes disorganized as shown in the picture to the right. Notice how there are no longer well defined bundles of collagen.
In response to repeated insult and injury, the tendon undergoes a healing response. Blood vessels invade the damaged area to bring in new building blocks. In the face of continued use, however, this healing response leads to the formation of fibrous scar tissue rather than an organized tendon. Thus, areas of intact tendon fibrils are separated by areas of disorganized scar. Several studies have verified that process occurs with little or no inflammatory response.
Anatomy of Lateral Epicondylitis
The lateral epicondyle is the projection of bone on the outside of the elbow. This point serves as an attachment for several muscles which extend the wrist and fingers. The extensor carpi radialis brevis (ECRB) tendon is the one most commonly involved. This tendon aids in wrist extension. The extensor digitorum communis (a extendor of the fingers) may also be involved.
Because the involved tendons lie directly against the outside of the elbow joint itself, many patients will develop irritation of the lining of the joint, called synovitis.
Causes/Risk Factors:
Lateral epicondylitis has many possible causes that may act alone or in combination to result in tendon degeneration. The causes are listed as follows:
· Overuse: Repetitive use is the main cause of lateral epicondylitis. Activities that involve forceful grip and those that involve prolonged wrist extension place people at risk for this problem. If the rate of tissue breakdown exceeds the rate of tissue healing, tendon degeneration may occur. This may be know as Repetitive Strain Injury (RSI). Giving the damaged tissue sufficient time to heal is essential to recovery. Continued pain during activity is an indicator of internal tissue damage and should not be ignored. Efforts to “work through” the pain will likely only result in further injury. A significant problem in today’s busy world is the inability to avoid the activity that causes lateral epicondylitis especially if it is work-related.
· Age: as we age, our tendons and ligaments lose strength and their internal capacity for tissue repair and healing decreases. Thus, they are equally more prone to injury and less likely to recover quickly. Age greater than 35 is considered a risk factor for tennis elbow.
· Weakness/Inadequate Fitness: many people who engage in repetitive motion activities, whether through work, sport or recreation, develop fatigue in the lateral elbow muscles. Muscle fatigue results in weakness that can predispose to injury. With continued use, fatigue can lead internal damage to the muscle and tendon.
· Improper Technique: for some work and sport related causes, faulty technique may result in excessive stress to the wrist extensors. In tennis, improper grip size, a single-handed back predispose both recreational and competitive players to “tennis elbow.”
· Tendon Healing: Tendons have a poor blood supply and thus do not heal as readily as other tissues such as skin. Thus, when tendinosis ensues, internal tendon repair and remodeling can take many months
· Smoking: as with many other tissues in the body, the connective tissues of the musculoskeletal system are adversely affected by smoking. Specifically, smoking damages the circulation to tendons and bones. This not only places these tissues at risk for injury but also slows or prevents their healing during a recovery period.
· Tennis: with regard to tennis the principal causes are 1)playing too often, 2) faulty technique; 3) improper equipment; and 4) poor physical conditioning. Bending the elbow during a backhand stroke is the major technique flaw. Players who use a one-handed backhand are also at higher risk. A late forehand swing with a wrist snap may also predispose to tennis elbow. Improper grip size may also contribute to tennis elbow.
Symptoms and Signs
Symptoms: Pain over the outside of the elbow that radiates into the forearm region with gripping and squeezing activities or those require repetitive wrist extension is the main symptom. This pain may be so severe that people are nearly unable to perform even simple tasks like writing. Pain related muscle inhibition may lead to weakness and some will report inability to lift even light objects like a coffee cup.
Signs: the physical exam of lateral epicondylitis is usually very characteristic. Pain on palpation directly over the area of tendon degeneration is painful. Pain is exacerbated by manually resisting a patients attempt to extend the wrist against firm pressure. Patients with involvement of the finger extensors will similarly have pain on resisting finger extension. Patients with irritation of the elbow joint capsule may have a broader area of pain that extends toward the back of the elbow. Range of motion is generally well preserved and there is generally an absence of numbness or tingling that might suggest a neurologic problem.
Wbat is the Differential Diagnosis of Lateral Epicondylitis: Other conditions that can mimic lateral epicondylitis and cause pain over the lateral side of the elbow include the following:
· Radial Tunnel Syndrome: like carpal tunnel syndrome, this is a nerve compression problem involving the posterior interosseous nerve which supplies the wrist and finger extensors. This compression may be due to fibrous bands in the supinator muscle or to a ganglion cyst that emanates from the elbow joint. It may be difficult to accurately diagnose and present in almost an identical fashion to lateral epicondylitis.
· Elbow Arthritis: in rare cases, elbow arthritis may be confined to the outside of the joint between the head of the radius bone and end of the humerus bone.
· Herniated Disc in the Neck: like sciatica in the lower back caused pain in the leg, a herniated disc in the neck may cause pain the arm. In some cases, this pain may be fairly localized as in lateral epicondylitis, while in other cases pain may radiate all the way into the fingers.
· Tumor: rarely bone tumors may involve the bones about the elbow and cause lateral elbow pain. Fortunately, these are usually detected by routine screening x-rays.
· Idiopathic Arm Pain: this diagnosis refers to pain that has not defined cause. Pain is a complex phenomenon that has many components some of which are chemical and some cultural. In some cases of arm pain, an anatomical source cannot be found despite a thorough work-up.
How is Lateral Epicondylitis Diagnosed?
In a majority of cases, lateral epicondylitis can be diagnosed based on a patient’s history and physical examination. If these suggest anything atypical of lateral epicondylitis then further work-up may be needed to rule out other causes.
A routine set of x-rays is generally obtained to screen for the presence of any underlying conditions that might also cause lateral elbow pain. In typical lateral epicondylitis, these will be normal. Occasionally there may be some calcification within the injured tendon
Though not generally necessary, an MRI scan may be useful in atypical cases where the diagnosis lies in question. It may also be useful in longstanding cases that may have been present for over a year to confirm the diagnosis. This may be particularly important when considering surgery to predict success.
What is the Natural History of Lateral Epicondylitis?
In 90% of cases, lateral epicondylitis is self-limiting and slowly resolves over the course of weeks to months. The time to resolution depends on the severity of tendinosis and the ability of the patients rest the injured area. It cannot be predicated in any single case. Some cases may last for up to a year. Once resolved, lateral epicondylitis may recur if patients re-engage in the same activities that caused the problem in the first place.
How is Lateral Epicondylitis Treated?
The goal of treatment for lateral epicondylitis is fourfold.
1. promote tendon healing by promoting rest and avoidance of aggravating activities.
2. correct any underlying mechanical abnormalities that may have promoted the development of tendinosis.
3. promote tendon strengthening and remodeling once adequate healing has occurred.
4. prevent recurrence through a maintenance program of flexibility, strengthening and aerobic conditioning.
Non-Operative Treatments
Stage 1: Controlling Pain and Inflammation
· Activity Modification and Rest: Tissue healing can only begin when repeated injury stops. Those activities that result in worsening pain must be avoided to prevent continued tissue injury during the recovery phase. Overuse and repetitive strain must be avoided though gentle use of the arm is encouraged to prevent muscle atrophy.
· Ice: Cold therapy acts to decrease tissue swelling, reduce pain and reduce the chemical irritation that perpetuates tendinosis. It is especially important after exercise sessions. Apply ice or a cold pack to for 15 to 20 minutes, 4 times a day for several days to keep swelling down. Wrap the ice or cold pack in a towel. Do not apply the ice directly to your skin.
· Non-steroid Anti-inflammatory Medications (NSAIDS): these medications include Ibuprofen, Motrin, Advil, Naprosyn, Alleve, Bextra, Celebrex, and many others. They act both to reduce inflammation and to relieve pain. They may be more effective in the early phases of lateral epicondylitis when inflammation is more prevalent. A 10-14 day trial is generally recommended after the onsest of pain. Long term use of NSAIDS may be associated with risks such as irritation of the stomach lining, ulcers and kidney problems. Patients should become informed about the possible short and long-term side effects of each medication prior to use.
· Cortisone Injections: Cortisone is a powerful anti-inflammatory medication that can be injected adjacent to the diseased tendons. Although lateral epicondylitis is not primarily an inflammatory condition, cortisone acts to modify pain receptors in the tissue so that pain is diminished. This effect may last anywhere from a week to several months and is variable between patients. Repeated cortisone injections can cause weakening of the tendon tissue and may cause more harm than good. Cortisone shots should be used as part of a larger conservative treatment plan rather than as an isolated treatment.
· Therapy Modalities: ultrasound and electrical stimulation are physical therapy modalities that may act to decrease pain from tendinosis. Iontophoresis using dexamethasone (a steroid) is also often helpful in reducing pain associated with lateral epicondylitis. As with cortisone injections, these modalities must be employed as part of a larger treatment regimen.
2. Promoting Tissue Healing and Reconditioning
· Counterforce Bracing: these braces are worn just below the affected area and act to control force transmission through the forearm muscles. Pressure applied to the muscle belly below the tendon helps to diffuse force over a broader area. This reduces the stress on the involved tendon by reducing the magnitude of muscle contraction by constraining muscle expansion.
· Physical Therapy: rehabilitation exercises should be started after an initial period of rest. The goal is to restore flexibility, strength and endurance. Gentle and graduated resistive strengthening exercises, stretching and aerobic conditioning increase blood flow to the affected area and promote tendon remodeling. Adjacent joints must also be strengthened, especially the shoulder girdle which helps transmit force generated by the body to the hand. The ultimate goal is to slowly transition back into the activities than may have caused the problem to begin with. This may take months rather than weeks.
· Home Exercise Program: Because formal physical therapy may only be performed 2 or 3 times per week, it is essential that patients have a structured home exercise program to perform on the in-between days.
Stage 3: Technique Improvement and Equipment Modification
· Technique Modification and Improvement: because some cases of lateral epicondylitis are related to improper technique, treatment must include a technique assessment for sports-related cases, especially tennis. This is essential to prevent recurrence and facilitate return to sport. Return to sport, such as tennis or other racquet sports, must be gradual so that tissues can be reconditioned to withstand the physical demand. Interval programs that involve a graduated return are available for racquet sports that prevent early overuse.