Monday, May 9, 2016

Tennis elbow? But I don’t even play tennis

By: Julian Carlo, M.D. with The Brookwood Orthopedic Sports Medicine Institute

Despite the name, only a small fraction of those afflicted with tennis elbow actually play tennis. This very common condition, also called lateral epicondylitis, causes elbow pain and typically affects those between the ages of 30 and 50, with men and women equally affected. It is a notorious condition that is one of the more difficult orthopedic conditions to treat.
The cause of tennis elbow is thought to be a breakdown of the normal tendon origin of the wrist and finger extensor muscles on the lateral epicondyle of the elbow. Repetitive forceful firing of these muscles is thought to result in microtrauma to the tendon. Reinjury from repeated overuse disrupts the normal healing process, resulting in abnormal, pain-generating tissue.

Although overuse is a common factor, many patients may not recall any particular overuse activities leading to their symptoms. Patients typically present with sharp pain on the outside of the elbow associated with gripping, lifting, or squeezing. Pain can radiate down the forearm, and the elbow may be sore to move.

The pain is often severe in comparison to the inciting stimulus. For example, seemingly minor acts such as lifting a cup of coffee can cause debilitating pain. As a result, patients often have functional limitations and interference with their work, hobbies, and domestic activities.

A physical exam usually reveals an elbow with normal range of motion, tenderness on and just distal to the lateral epicondyle, and reproduction of pain with resisted finger or wrist extension. Radiographs are typically normal. Advanced imaging studies are not required for diagnosis.

Tennis elbow can be a frustrating condition to treat, both for patient and physician. The condition can last months or even extend beyond a year, so patience is required. Despite the availability of multiple treatment options, there is no strong evidence supporting the efficacy of any treatment. Approaches to treating tennis elbow also vary considerably. Some consider it a benign, self-limiting condition that should “burn itself out” with time, and therefore advocate benign neglect.

I feel there is a benefit to treatment and that a multimodal approach is most helpful. Modification of activities is important. I find it difficult for patients to improve if they continue to aggravate the injury on a daily basis. I recommend that use of a wrist splint at night, and if possible, during the day to protect and rest the involved muscles. Other wearable options include a tennis elbow strap or taping of the elbow. Oral over the counter medication such as acetaminophen and NSAIDS can help improve pain. A therapist can help by devising a stretching and conditioning program and by employing other pain-reducing modalities such as iontophoresis or ultrasound. A steroid injection to the lateral epicondyle area may help provide short-term pain relief, but studies tend to show no long term benefit. Platelet-rich plasma injections have shown promise in some studies, though they are generally expensive. I find it helpful to initiate treatment with a few of these options, while keeping others ready in the back pocket should escalation of care be necessary.

The majority of cases resolve with conservative management. If severe symptoms continue after six or more months of treatment, surgery can be considered. The typical surgery involves debridement of abnormal tissue at the origin of the extensor muscles. This can be performed on an outpatient basis in an open, arthroscopic, or percutaneous fashion. Another surgical option is denervation of the lateral epicondyle area. It is unclear which, if any, of these procedures is best. A surgeon will tend to choose the procedure he is most comfortable with and that gives him the best results. Most patients improve after surgery, though some may need additional therapy or treatment.

Tennis elbow is a common overuse injury. Although the best treatment is uncertain, many find relief with treatment options available. In the future, we hope that well-designed trials can help refine the management of this condition.

Julian Carlo, M.D. is an orthopedic hand and upper extremity surgeon at The Brookwood Orthopedic Sports Medicine Institute. For appointments, please call 205-877-BONE (2663) or visit .

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