Tennis elbow

Tennis Elbow
Classification and external resources
File:Epicondyluslateralishumeri.png Left elbow-joint, showing posterior and radial collateral ligaments. (Lateral epicondyle visible at center.)
ICD-10	M77.1
ICD-9	726.32
DiseasesDB	12950
eMedicine	orthoped/510 pmr/64 sports/59
MeSH	D013716

Tennis elbow (also known as "hooter's elbow" and "archer's elbow") is a condition where the outer part of the elbow becomes sore and tender. It is commonly associated with playing tennis and other racquet sports, though the injury can happen to almost anybody.

The condition is also known as lateral epicondylitis ("inflammation of the outside elbow bone"), a misnomer as histologic studies have shown no inflammatory process. Other descriptions for tennis elbow are lateral epicondylosis, lateral epicondylalgia, or simply lateral elbow pain.

Runge is usually credited for the first description in 1873 of the condition. The term tennis elbow was first used in 1883 by Major in his paper "Lawn-tennis elbow".

Symptoms

• Pain on the outer part of elbow (lateral epicondyle).
• Point tenderness over the lateral epicondyle – a prominent part of the bone on the outside of the elbow.
• Gripping and movements of the wrist hurt, especially wrist extension and lifting movements.
• Activities that use the muscles that extend the wrist (e.g. pouring a pitcher or gallon of milk, lifting with the palm down) are characteristically painful.
• Morning stiffness.

Etiology

The strongest risk factor for lateral epicondylitis is age. The peak incidence is between 30 to 60 years of age. No difference in incidence between men and women or association between tennis elbow and the dominant hand has been demonstrated.

The pathophysiology of lateral epicondylitis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the extensor carpi radialis brevis (ECRB) muscle are identified in surgical pathology specimens. It is unclear if the pathology is affected by prior injection of corticosteroid.

Among tennis players, it is believed to be caused by the repetitive nature of hitting thousands and thousands of tennis balls which lead to tiny tears in the forearm tendon attachment at the elbow.

The extensor digiti minimi also has a small origin site medial to the elbow which can be affected by this condition. The muscle involves the extension of the fifth digit and some extension of the wrist allowing for adaption to “snap” or flick the wrist – usually associated with a racquet swing. Most often, the extensor muscles become painful due to tendon breakdown from over-extension. Improper form or movement allows for power in a swing to rotate through and around the wrist – creating a moment on that joint instead of the elbow joint or rotator cuff. This moment causes pressure to build impact forces to act on the tendon causing irritation and inflammation.

The following speculative rationale is offered by proponents of an overuse theory of etiology: The extensor carpi radialis brevis has a small origin and does transmit large forces through its tendon during repetitive grasping. It has also been implicated as being vulnerable during shearing stresses during all movements of the forearm.

While it is commonly stated that lateral epicondylitis is caused by repetitive microtrauma/overuse, this is a speculative etiological theory with limited scientific support that is likely overstated. Other speculative risk factors for lateral epicondylitis include taking up tennis later in life, unaccustomed strenuous activity, decreased reaction times and speed and repetitive eccentric muscle contractions (controlled lengthening of a muscle group).

Examination and tests

The diagnosis is made by clinical signs and symptoms, which are usually both discrete and characteristic. There should be point tenderness over the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (ECRB origin). There should also be pain with passive wrist flexion and also with resisted wrist extension (Cozen's test), both tested with the elbow extended.

An easy at-home test can be performed to determine whether you have tennis elbow. Stand behind a chair, place your hands on top of the chair back with your palms down, and try to lift the chair up. If this causes pain on the outside of your elbow, the culprit is most likely tennis elbow.

MRI typically shows fluid in the ECRB origin. There may also be a defect in this tissue. The use of the word "tear" to refer to this defect can be misleading. The word "tear" implies injury and the need for repair – both of which are probably inaccurate and inappropriate for this degenerative enthesopathy.

Depending on the severity and number of small tendon injuries that build up, the ECRB may not be able to fully heal. Nirschl defined four stages of lateral epicondylitis, showing the introduction of permanent damage beginning at Stage 2. The stages are:

1. Inflammatory changes that are reversible
2. Nonreversible pathologic changes to origin of the ECRB muscle
3. Rupture of ECRB muscle origin
4. Secondary changes such as fibrosis or calcification.

Treatment

In general the evidence base for intervention measures is poor.

Non-specific palliative treatments include:

• Physical Therapy- most important part of the treatment. it includes various modalities for preventing and treating tennis elbow.
• Non-steroidal anti-inflammatory drugs (NSAIDs): ibuprofen, naproxen or aspirin
• Heat or ice
• A counter-force brace or "tennis elbow strap" to reduce strain at the elbow epicondyle, to limit pain provocation and to protect against further damage.

Rest is the tennis player's treatment of choice when the pain first appears; the rest allows the tiny tears in the tendon attachment to heal. Tennis players treat more serious cases with ice (although the effectiveness of ice treatment has been challenged in clinical research), anti-inflammatory drugs, soft tissue massage, stretching exercises, and ultrasound therapy.

In recalcitrant cases surgery may be indicated. Many techniques have been described using open, percutaneous or arthroscopic approaches. Most techniques aim to release the strain on the extensor carpi radialis brevis muscle, remove degenerative tissue and promote healing.

Other treatments with limited scientific support include:

• Blood injection (possibly augmented by plateletpheresis)
• Botulinum toxin
• Extra-corporeal shock wave therapy (lithotriptor)
• Heat therapy
• Immobilization of the forearm and elbow using a splint for two to three weeks
• Local injection of cortisone and a numbing medicine
• Low level laser therapy
• Occupational therapy, primarily for stretching and strengthening of the wrist extensor musculature.
• Platelet-rich plasma
• Pulsed ultrasound to break up scar tissue, promote healing, and increase blood flow in the area
• Sclerotherapy
• Trigger point therapy

There are clinical trials addressing many of these proposed curative treatments, but the quality of these trials is generally poor.

One study has alleged that electrical stimulation combined with acupuncture is beneficial but evaluation studies are inconclusive.

One recent presentation at a scientific meeting described the Tyler Twist Protocol, a physical therapy intervention. Although the study has yet to be published to verify claims made in the newspaper.

Cortisone injections

In four clinical trials comparing corticosteroid injection to placebo (lidocaine) injection that show no effect of the steroids. Complications from repeated steroid injections include skin problems such as hypopigmentation and fat atrophy leading to indentation of the skin around the injection site.

Exercises and stretches

There are several recommendations regarding prevention, treatment, and avoidance of recurrence that are largely speculative including:

1. Stretches and progressive strengthening exercises to prevent re-irritation of the tendon;
2. Progressive strengthening involving use of weights or elastic theraband to increase pain free grip strength and forearm strength;
3. Racquet sport players also are commonly advised to strengthen their shoulder rotator cuff, scapulothoracic and abdominal muscles by Physiotherapists to help reduce any overcompensation in the wrist extensors during gross shoulder and arm movements;
4. Soft tissue release or simply massage can help reduce the muscular tightness and reduce the tension on the tendons; and
5. Strapping of the forearm can help realign the muscle fibers and redistribute the load.
6. Use of a racket designed to dampen the effect of ball striking.

There is little evidence to support the value of these interventions for prevention, treatment, or avoidance of recurrence of lateral epicondylosis.

See also

• Golfer's elbow
• Repetitive strain injury
• Radial tunnel syndrome

Further reading

ca:Epicondilitis sv:Tennisarmbåge