Lateral Epicondylitis (Tennis elbow)


The muscles of the forearm that bend the wrist back (extensors) begin at the lateral epicondyle, from a common tendon attachment. Bending the wrist back (extension), turning the hand palm side up, and lifting an object with the elbow straight are the more common activities that affect these tendons. More about Anatomical Terms

Anatomy of the Elbow

Arrow points to the left lateral (outside) epicondyle

Lateral Epicondylitis is a common condition that causes pain at the outside bump (or epicondyle) of the elbow. Tennis is not the only cause of this condition (it is common in all racquet sports), but tennis players do get the condition usually as a result of overuse of the muscles/tendons used to hit a backhand shot.

Causes of Lateral Epicondylitis

One theory on the cause of lateral epicondylitis is that small tears in the tendon occur through overuse. They begin to heal but when reinjured by continued use, the tendons seem to finally give up on trying to heal and a condition called angiofibroblastic degeneration begins to take over. Think of this as scar tissue that never reaches maturity and remains weak and painful. Others feel that the tendon changes are primarily a result of decreased blood flow in the area, a sort of heart attack of the tendon. The end result is still the formation of the angiofibroblastic tendinosis tissue. The same events can happen with repeated strains like hammering a nail, picking up a heavy bucket, or pruning shrubs.

Other causes are from overuse from the repetitive motions of racquet sports like tennis and squash.

Symptoms Lateral Epicondylitis

Symptoms include tenderness and pain at the lateral epicondyle, made worse by extending the wrist or gripping. Tenderness and pain usually begin at the lateral epicondyle. Pain may spread down the forearm with soreness felt in the forearm muscles. Activities like grasping can make matters worse. Activities such as reaching into the refrigerator to get a gallon of milk can be a painful process! Some patients actually lose some motion in the elbow, usually a few degrees of extension (meaning they can’t completely straighten the elbow.)

Diagnosis of Lateral Epicondylitis

The diagnosis can usually be made from your history—how you got hurt—and physical examination alone. X-rays of the bones in the elbow may be needed if your symptoms suggest the possibility of a serious problem with the joint. Depending on the findings you may need an ultrasound or MRI to see the soft tissues in the elbow.

Preventing and Treating Lateral Epicondylitis

Self Management

Treatment usually begins with first aid. Some of the common modalities of management include the following:

  • Ice:

Ice decreases the size of blood vessels in the sore area, halting inflammation and relieving pain. Choices of application include cold packs, ice bags, or ice massage. Ice massage is an easy and effective way to provide first aid. Simply freeze water in a paper cup. When needed, tear off the top inch, exposing the ice. Rub three to five minutes around the sore area until it feels numb.

  • Rest:

Resting the sore area will prevent further injury while allowing time to heal. A nonelastic elbow wrap (sometimes refferred to as a tennis elbow strap or lateral epicondylitis band) can help rest the damaged area of the tendon. These straps work by spreading the muscle forces to a larger area of the elbow. A neutral wrist splint holds the wrist in a safe position while limiting stresses at the elbow. In the early stages of healing, finger movement should also be minimized due to potential forces placed on new scar formation. Pain with activity is a sign that irritation of the area is occurring. Avoid movements and activities that increase pain. Decrease repetition and try to lift or pull with your palms upward.

  • Specific rest:

Performed slowly, lateral epicondylitis exercises including range of motion at the wrist, forearm, and elbow will keep these joints from becoming stiff while preventing further injury to the elbow.

Wrist: Move the wrist in one of four directions.

Forearm: Turn the forearm up or down.

Elbow: With the forearm resting outward on a smooth surface, slowly bend and straighten the elbow.

  • Isometric Exercises:

This means “same length.” Though the muscle tightens, no movement takes place at the joint. The resistance may be applied with the joint in neutral, at the limits of motion, or at various angles in between. Avoid pain.

Multiwrist: Block movement in the hand of the sore arm. Attempt to move it in one of four directions (ie. up, down, side, side).

Forearm: Holding the forearm, attempt to turn it either up or down.

Elbow: Without allowing it to move, try to bend the elbow up, then down.

Medical Treatment
Anti-inflammatory medications prescribed by your doctor work well in conjunction with home first aid techniques of local ice and rest. An injection of cortisone into the area may reduce the inflammation and control the pain. Your doctor may use ultrasound to make sure the shot is put in the right spot.
Short term splinting of the elbow, wrist and fingers limits movement and stress on the extensor muscles. Problems can be avoided by taking frequent breaks as you work or play, improving overall arm muscle condition, and limiting heavy pushing, pulling or grasping. Tennis players should consider decreasing tension on the racquet strings, and using a racquet with a more flexible shaft and larger head.

Supervised Treatment:

Following an evaluation, physical therapy treatment may begin with anti-inflammatory modalities. Several choices are available to limit inflammation and pain associated with tennis elbow. Examples include ice, heat, iontophoresis, TENS, ultrasound, or phonophoresis.

Treatment Approaches

The presence of tennis elbow may be due to a decreased blood supply to the area. Methods to increase blood flow to the area include heat, ultrasound, friction massage, and soft tissue mobilization. To assist in breaking up the cycle of inflammation and scarring, treatment is focused on keeping the scar pliable. The theory is that this way the scar has some give in it, which keeps it from tearing each time the elbow is straightened or the wrist and forearm tendons are used. Choices available include friction massage, forearm stretching, soft tissue mobilization, and manipulation. As healing continues different types of exercises are used. Early on, isometrics help maintain muscle mass without over stressing tissue. Later, progressive resistive exercises are used to increase endurance and strength. As pain resolves, emphasis will be placed on the wrist extensors. These muscles need to be able to control the forces that would cause these muscles and tendons to lengthen in what is called an eccentric contraction. Key areas of strengthening are the wrist, forearm, and elbow. Later, hand and shoulder exercises may be added as well.

Surgery for Lateral Epicondylitis
If all else fails, surgery is available to treat tennis elbow. The surgery usually involves making a small incision (about 3-4 inches) over the lateral epicondyle. The tendons that attach to the lateral epicondyle are then split to reveal the area of angiofibroblastic tendinosis in the tendon. This tissue is removed, and any bone spurs that have formed on the lateral epicondyle are removed as well. This gives a fresh bed of healthy bone for the tendon to reattach itself to. The split in the tendon is then sutured together, as is the skin. It usually takes about 3 months for everything to reach maximal healing.

 If your surgeon suggest surgery, you may want to get a second opinion for surgery.

Comments

  1. Media Partners says:

    I started playing squash on Jan 1, 2012 as part of my new fitness program. Loved the game so much I was playing 5 days a week for an hour. After about 6 weeks, I decided I was going to stick with it and wanted to take lessons. So I signed up for lessons with the club pro. During the first lesson we were doing backhand drills and I was hitting the ball much harder than I had been hitting it. All of a sudden pain shot from the outside of my elbow up my shoulder and I couldn’t move my arm without terrible pain. So I stopped the lesson and treated it with RICE immediately.

    After some research, I figured out I had tennis elbow, but an acute injury probably from overuse. The information said to rest the elbow and do RICE therapy at first and then some stretching and strengthening exercises. I thought rest meant not to play squash. So I quit squash and only avoided movements that made the elbow hurt. After 10 days the pain was so bad I couldn’t sleep so I went to see a sports medicine orthopedist. After an xray and physical exam he said I had tennis elbow or in my case squash elbow. That there was a small bone chip that could have been the result of the injury. He gave me a cortisone shot into the joint and a padded strap that looks just like the one in the image on this page. The strap relieves much of the pressure on the elbow. I’m to take an anti-inflammatory. I am to avoid all repetitive movements with my right hand, especially typing, which is hard since I write all day, and to use my left hand as much as possible. That was yesterday. Today the pain is much better already from the shot. I have to start physical therapy tomorrow, 3 times a week for 4 weeks. Hopefully by then I’ll be healed. Dr. said that if I start playing before the pain is gone and the elbow healed, it can easily turn into a chronic condition with constant pain and treatment. I don’t want that so I will do what I can to follow the doctor’s orders.

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