Tennis Elbow (Lateral Epicondylitis)

Summary & Treatment

Area Of Pain In Tennis ElbowTennis elbow (also called lateral epicondylitis) is a painful condition that occurs when tendons in the elbow are overloaded, usually by repetitive motions of the wrist and arm.

Despite its name, athletes aren’t the only people who develop tennis elbow. People whose jobs feature the types of motions that can lead to tennis elbow include plumbers, painters, carpenters and butchers.

The pain of tennis elbow occurs primarily where the tendons of the forearm muscles attach to a bony bump on the outside of the elbow. Pain can also spread into the forearm and wrist.

Cause

The part of the muscle that attaches to a bone is called a tendon. Some of the muscles in the forearm attach to the bone on the outside of the elbow.

When these muscles are used over and over again, small tears develop in the tendon. Over time, this leads to irritation and pain where the tendon is attached to the bone.

This injury is common in people who play a lot of tennis or other racquet sports, hence the name “tennis elbow.” Backhand is the most common stroke to cause symptoms.

But any activity that involves repetitive twisting of the wrist (like using a screwdriver) can lead to this condition. Painters, plumbers, construction workers, cooks, and butchers are all more likely to develop tennis elbow.

This condition may also be due to constant computer keyboard and mouse use.

Signs & Symptoms

Tennis elbow causes pain and tenderness on the outside of the elbow. There may also be pain in the forearm and in the back of the hand.

The pain of tennis elbow can range from mild discomfort while using the elbow, to severe pain that can be felt when the elbow is still.

The pain is often worse when the arm is used, particularly for twisting movements. Repetitive wrist movements, such as extending the wrist and gripping, can also make the pain worse.

Patients suffering from tennis elbow experience pain:

  • On the outside of the upper forearm, just below the elbow – the pain may also travel down the forearm towards the wrist
  • When lifting or bending the arm
  • When writing or gripping small objects – for example, when holding a pen
  • When twisting the forearm – for example, when turning a door handle or opening a jar
  • When fully extending your arm – there’s stiffness too
Tennis Elbow X-ray

Calcification at Lateral Epicondyle

Diagnosis

The diagnosis of tennis elbow is usually made by history and clinical examination:

  • Pain or tenderness when the tendon is gently pressed near where it attaches to the upper arm bone, over the outside of the elbow
  • Pain near the elbow when the wrist is bent backwards

X-rays are not always necessary but occasionally may show pathologies such as focal calcification at the common extensor tendon origin.

A bedside ultrasound examination can confirm the diagnosis – hypoechogenic areas in the common extensor tendon, which implies an area of tendon substance degeneration. Occasionally, focal areas of calcifications can be detected. It is also good to examine the contralateral pain-free elbow to look for differences.

Treatment

Non-Surgical Treatment

The initial treatment of tennis elbow is conservative using rest, ice, oral analgesics, stretching exercises, counter-force braces and in patients with significant pain, cortisone injection.

Counter-force braces can be purchased off-the-shelf in most pharmacies. This is a strap that is applied around the forearm just distal to the painful elbow. It acts to offload the pull of the forearm extensors from the lateral epicondyle to the area under compression. The patient has to wear it at all times and compliance may be an issue.

Cortisone injection to the lateral epicondyle region is an excellent method to treat the pain symptoms by reducing the inflammation.

The pain will become worse over the next day due to the trauma of the needling and it is useful to continue oral anti-inflammatory medications for the next few days. The tennis elbow pain usually subsides and resolves from the 3rd day onwards. The pain may recur after a few weeks or months in some patients. Such injections are usually limited to 2 times.

Open Tennis Elbow SurgerySurgical Treatment

Recalcitrant tennis elbows refer to patients with pain that has failed conservative treatment including pain killers, cortisone injections and physiotherapy.

Traditional Open Method:
Traditional surgical treatment for tennis elbow involves a large incision measuring about 5 to 6 cm centred over the lateral epicondyle of the elbow. The surgeon split the overlying ECRL (extensor carpi radialis longus) to expose the ECRB (extensor carpi radialis brevis) below. The surgeon releases the ECRB tendon insertion off the lateral epicondyle and burr the bone at the insertion of the tendon.

Most patients have some problems achieving good range of elbow motion post-operatively initially due to the pain from the large incision and trauma to the muscles. Time away from work is usually in the region of weeks to months.

Minimally Invasive Method (arthroscopy):
The main aim of tennis elbow surgery is to release the ECRB tendon off the lateral epicondyle. As this tendon is the deepest structure from the skin, it makes sense to approach it from the inside rather than through the skin and muscles.

Tennis Elbow Release via Arthroscopy

Tennis Elbow Release via Arthroscopic Approach

Elbow arthroscopy is a fast and easy way to approach the ECRB tendon from the inside of the elbow joint. This procedure is done under general anaesthesia and it takes about 25 to 30 minutes to complete.

It involves making 2 small puncture holes (about 3mm in size) on either side of the elbow joint. A small TV camera (called the arthroscope) is inserted into the elbow joint from the inner aspect. A 2nd small hole is made on the outer aspect of the elbow joint to allow a shaver device to be inserted into the elbow joint.

This shaver allows me to remove a small portion of the joint capsule to expose the diseased ECRB tendon near the insertion into the lateral epicondyle. The diseased ECRB tendon is carefully removed with the shaver.

The elbow can be moved almost immediately after this surgery. The time off from work is markedly reduced from a couple of weeks to just a few days.