Tennis Elbow (Lateral Epicondylitis)

Definition

Lateral epicondylitis, commonly referred to as tennis elbow, is a condition where the tendons that attach to the bony bump on the outer side of the upper arm bone are irritated. The muscles of the tendons involved are also strained and both structures undergo some degree of degeneration. Tennis elbow arises with overuse of the hand. Contrary to its common name, tennis elbow more frequently affects people who do not play the sport of tennis. Most cases are due to occupational rather than recreational activities. Tennis elbow causes elbow and forearm pain with the most tender area being at the lateral epicondyle of the humerus (upper arm bone) where the affected tendons attach.

Incidence

Tennis elbow is the most common repetitive strain injury and may affect as much as 3% of the population in the United States. It is mainly seen in the 30 to 50 year age group with most cases occurring after the age of 40 years. Although some reports indicate that more men are affected, the condition may affect both males and females equally. However, men are often more likely than women to be involved in occupations where tennis elbow is a hazard.

Pathophysiology

A group of muscles in the forearm known as the extensor muscles extend the hand at the wrist and the fingers. Simply, these muscles are responsible for moving the hand away from the inner part of your forearm or moving the fingers away from the palm. Muscles attach to bones by means of tendons. In terms of the extensor muscle tendons, it attaches to the outer bony part at the end of the humerus (upper arm bone). This bony protrusion is known as the lateral epicondyle.

Tendon injury

Although the term lateral epicondylitis indicates an inflammatory condition, further studies of the tendons involved show that it is not inflamed but rather undergoes degeneration. Initially the tendons become inflamed and may develop micro-tears as a result of overuse and muscle strain. Ultimately the tendon is damaged (tendinosis).

Muscle injury

More recent research has shown that it is not the tendons alone that are involved. The forearm muscles, and particularly a muscle known as the extensor carpi radialis brevis (ECRB), is damaged and also undergoes degeneration.  Constant friction experienced by the muscle during repetitive movements essentially wears down the muscle. Weakness of the muscle also damages its tendon with overuse.

Picture from Wikimedia Commons

Symptoms

The two main symptoms of tennis elbow are pain and weakness. These symptoms tend to become evident or worsen with certain common activities such as :

  • Shaking hands.
  • Turning a doorknob.
  • Holding a cup.
  • Lifting the back of a chair.

It may also worsen with certain occupational activities like when using a wrench.

Pain

The pain is felt from the outer part of the elbow and may extend down the back of the forearm to the wrist. The most tender area is at the lateral epicondyle of the humerus. In milder cases a person may experience a burning sensation which gradually develops into pain. More severe cases presents with a persisting pain that can at times be excruciating although this is largely dependent on the patient’s level of pain tolerance.

Weakness

Most patients also report weakness in grip strength. This is most notable with many of the activities listed above such as turning a doorknob and holding a cup. In the early stages of condition, weakness may not be as noticeable. Older patients tend to associate the weakness with age and a more sedentary lifestyle, however, it is directly related to the pathophysiological changes of tennis elbow.

Complications

The symptoms of tennis elbow often prompts patients to seek treatment at some point and complications are often prevented. The most common complication is chronic pain. It also tends to arise among patients who undergo treatment but do not rest for significant periods of time to allow the condition to ease substantially or resolve before continuing activities. Less commonly, there may be a complete rupture of the tendon which requires surgery.

Causes

Overuse of the extensor muscles with strain injuries to the muscle and tendons that attach to the lateral epicondyle is the reason for tennis elbow. This may arise with repetitive movements during recreational or occupational activities. Many of the associated movements also requires the input of other muscle groups like the shoulder muscles. Poor conditioning of these muscles, especially in people who are unfit, increases the strain on the extensor muscles.

Improper equipment and technique are other major contributing factors to the development of tennis elbow among people who perform these repetitive movements. The elderly are more prone due to a host of factors, such as lifelong wear and tear, reduced mobility contributing to greater strain on the extensor muscles and age-related loss of muscle strength. Despite these known contributing factors, some people develop tennis elbow for no obvious reason.

Risk factors

Certain people are at a greater risk of developing tennis elbow as a result of repetitive movements on a regular basis. This includes :

  • Plumbers
  • Carpenters
  • Handymen
  • Painters
  • Auto mechanics
  • Meat workers who manually cut meat
  • Chefs

Playing certain sports like tennis and excessive use of a computer mouse are other known risk factors.

Diagnosis

Tennis elbow is the most common repetitive movement injury and should therefore be considered first in patients with lateral elbow pain. The diagnosis is more likely if these patients partake in occupational or recreational activities that are known to increase the risk of developing tennis elbow. Often the diagnosis is reached with the medical history and clinical examination. This involves providing resistance to the hands and fingers during extension with subsequent worsening of the pain and identifying the greatest tenderness at the lateral epicondyle of the humerus.

Other tests that may be conducted, often to exclude other possible causes and note structural changes, includes an x-ray, computed tomography (CT) scan and magnetic resonance imaging (MRI). An electromyography (EMG) is another useful investigation to rule out compression of nearby nerves. The diagnosis of tennis elbow may be further confirmed when patients report that the symptoms resolve with local anesthesia block.

Treatment

Not all cases of tennis elbow requires specific medical treatment. Patients who experience the symptoms of tennis elbow after a single episode of repetitive movements often find improvement with rest alone. In these cases the patient usually reports the onset of pain within 1 to 3 days after undertaking certain activities. Inflammation can be treated with non-steroidal anti-inflammatory drugs for the short term until the symptoms resolve.

Non-Surgical

Chronic cases of elbow pain, especially among people who partake in repetitive movement for long periods as a result of work commitments, may require a combination of therapies.

  • Topical and oral nonsteroidal anti-inflammatory drugs.
  • Corticosteroid injections.
  • Use of counter-force braces.
  • Extracorporeal shock wave therapy.

Patients should also undergo physical therapy to manage pain without drugs and learn suitable exercises to increase muscle strength. Occupational therapy is also advisable. Learning the proper technique for certain repetitive movements that are unavoidable in life and understanding the benefits of using the proper equipment can greatly assist the patient in managing the symptoms and preventing recurrence.

Surgery

The majority of patients will respond to medication and conservative measures. In the event that these measures are not yielding the desired effect and the condition is worsening, surgery may be necessary. Surgical procedures should only be considered after 6 months of employing non-surgical measures without significant benefit. Open or arthroscopic surgery may be conducted to remove damaged tissue. However, there is risk of a host of complications, some of which may be permanent. Surgery is necessary when the tendon ruptures, a complication of severe and untreated tennis elbow.

Recovery Time

The recovery time depends on the severity of the condition and the course of treatment. A major determining factor is the patient’s ability to rest the affected arm. With tennis elbow that develops due to occupational activities, this is often difficult and bracing is therefore essential for these individuals. Most patients who utilize medication, bracing and physical therapy experience notable improvement within 6 weeks although the symptoms may ease significantly within he first week or two of treatment.

However, tennis elbow requires long term management for anywhere between 9 to 18 months. This is largely due to the fact that patients are unable to totally avoid the causative activities. Both physical and occupational therapy are therefore of significant benefit for the long term management of the condition and to prevent a recurrence.

References :

www.mayoclinic.com/health/tennis-elbow/DS00469

orthoinfo.aaos.org/topic.cfm?topic=a00068

emedicine.medscape.com/article/96969-overview

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