Tennis elbow or lateral epicondylitis is a condition which brings about pain and discomfort on the outer side of the elbow. This is the part of the elbow where the extensor muscles of the forearm originate on the humerus(bone) through a common extensor origin. The most commonly involved tendon is the one of the Extensor Carpi Radialis Brevis. Usually degeneration is noticed at the attachment of the tendon on the bone.Weakening of the attachment leads to greater stress in the area as there is a compromise on the tendon’s bony anchor point. Sports such as tennis or other activities requiring repetitive gripping, grasping or lifting activities are the usual culprits in the progression of tennis elbow.
Preponderance- It is commonly seen in the age groups of 30-50 and relatively equal incidence in both gender groups.
Etiology/Causes of Tennis Elbow
Any activity leading to overuse of the extensor tendons of the forearm especially with the palm facing down can predispose an individual to micro tears and inflammation characteristic of Lateral epicondylitis/tennis elbow.
Some of these activities include
- Constant gripping tasks riding a two wheeler, athletic activities like tennis or pushing or carrying heavy loads.
- Activities such as typing use of tools on a daily basis bringing about repetitive load on the extensor muscles.is a painful condition involving the tendons that attach to the bone on the outside (lateral) part of the elbow.
- Trauma resulting from a direct impact or blow to the elbow can cause inflammation of the tendon leading to degeneration.
Symptoms
Pain on the outer aspect both elbow is the most pressing symptom. The bony point of tenderness is over the lateral epicondyle. Pain is aggravated by movements involving gripping, pushing and grasping. Patient may complain of pain limited to the lateral epicondyle but in some cases patients can be seen experiencing radiating pain down to the forearm.
Diagnosis
Usually History and Clinical examination are very suggestive but diagnosis can be confirmed by imaging such as Ultrasound or MRI of the elbow.
Treatment
Conservative approaches include limitation of offending activity like typing or gripping. Patients can be offered anti-inflammatory medications.Tennis elbow splints/ braces are useful in reducing the strain on the elbow extensors. Physical therapy involving manual massage, ice massage and modalities like Ultrasound can be used to soothen the symptoms of lateral epicondylitis. Taping of the affected elbow can be tried in conjunction with these other approaches.
Exercise Protocol for Tennis Elbow
Stretching and strengthening of the affected muscle groups forms a very important part of the rehabilitation regime. Exercises broadly include
Forearm extensor stretch
Eccentric wrist extensors strengthening
Isometric wrist extensor strengthening
Isotonic wrist extensor strengthening
(Images for the different exercises)
Anti-Inflammatory injection- Corticosteroids can be injected blind or with image guidance on the inflamed surface to help relieve the inflammation so that the patient can start rehabilitation. Care should be taken not to give successive steroid injections at the same site
Platelet Rich Plasma with Phototherapy
Treatment with Ultrasound guided Platelet Rich Plasma with Prolotherapy is an excellent treatment option as it brings about healing of the damaged tendon. Generally 2-3 sittings of Prp with prolotherapy coupled with regular exercises has been seen to be very effective in controlling the troublesome symptoms of tennis elbow.
Stem Cells- Stem Cell injection into the damaged tendon has been tried for some chronic cases.
Surgery- Arthroscopic or open surgery can be used to remove the degenerated tendon in chronic , resistant cases not responding to non operative means.
Forearm extensor stretch
- Hold the affected arm out in front of you with the elbow slightly bent.
- Curl the fingers of your affected arm and place your other hand over the knuckles. Gently pull the hand and wrist of the affected arm inward until you feel a slight stretch along your arm. You should feel some tension along your arm, but do not pull so hard that your arm hurts.
Eccentric wrist extensor strengthening
- Rest your affected arm on a table, allowing your hand to hang freely over the edge.
- Use the other hand to lift the hand of the affected arm until the hand is raised. Hold the hand in this position while you release the helping hand.
- Slowly allow the hand of your affected arm to lower back to the position of hanging freely. This slow movement is called a “controlled release” or an “eccentric muscle contraction.”
Isometric wrist extensor strengthening
- Rest your affected arm on a flat surface holding your wrist out straight over the edge.
- Use the other hand to apply a downward pressure on the hand of the affected arm while keeping the wrist out straight.
Isotonic wrist extensor strengthening
- Rest your affected arm palm down on a table or your lap allowing your hand to hang over the edge.
- Bend your wrist to raise your hand up, then down.
Tendons anchor the muscle to bone. The muscle involved in this condition, the extensor carpi radialis brevis, helps to extend and stabilize the wrist.
With lateral epicondylitis, there is degeneration of the tendon’s attachment, weakening the anchor site and placing greater stress on the area. This can then lead to pain associated with activities in which this muscle is active, such as lifting, gripping, and/or grasping. Sports such as tennis are commonly associated with this, but the problem can occur with many different types of activities, athletic and otherwise.
Cause
Tennis elbow is caused by repeated use of the forearm muscles that extend your wrist and fingers. The repeated stress to the tissue may cause tiny tears in the tendons that attach to the outside of the elbow.
Any activity repeatedly done with palms facing downward can cause tennis elbow. These activities include:
• Repetitive tasks such as typing, using tools etc.
• Prolonged gripping tasks such as riding a motorcycle or a bicycle, pushing or carrying heavy loads.
Trauma – A direct blow to the elbow may result in swelling of the tendon that can lead to degeneration. A sudden extreme action, force, or activity could also injure the tendon.
Who gets it?
The most common age group that this condition affects is between 30 to 50 years old, but it may occur in younger and older age groups, and in both men and women.
Signs and Symptoms
Pain is the primary reason for patients to seek medical evaluation. The pain is located over the outside aspect of the elbow, over the bone region known as the lateral epicondyle. This area becomes tender to touch. Pain is also produced by any activity which places stress on the tendon, such as gripping or lifting. With activity, the pain usually starts at the elbow and may travel down the forearm to the hand. Occasionally, any motion of the elbow can be painful. Tennis elbow pain can appear slowly or suddenly. Symptoms can include:
Treatment Home care You may try these methods to care for tennis elbow
Activity modification and rest– Initially, the activity causing the condition should be limited. Limiting the aggravating activity, not total rest, is recommended.
Medication – anti-inflammatory medications may help alleviate the pain.
Brace – a tennis elbow brace, a band worn over the muscle of the forearm, just below the elbow, can reduce the tension on the tendon and allow it to heal.
Taping — Tape your elbow to help provide support to the soft tissues. Seek the help of a physical or occupational therapist to show you how to tape your elbow.
Ice application— using ice several times daily can relieve pain.
– Ice pack application. Place a towel between your skin and the ice pack. Leave the ice pack on the painful area for 10-15 minutes. Check your skin every five minutes to ensure you are not injuring your skin.
– Ice massage. Using an ice pack, massage directly on the outside of your elbow in a circular motion for about 5 minutes.
– Manual massage. Massage may help increase blood flow, reduce sensitivity and relieve pain. Ask a physical or occupational therapist to show you how to perform massage.
Exercises
Stretching and strengthening can be effective treatments for tennis elbow. The goal of exercising is to strengthen the muscles to prevent pain and promote a healthy recovery.
Surgery
Surgery is only considered when the pain is incapacitating and has not responded to conservative care, and symptoms have lasted more than six months. Surgery involves removing the diseased, degenerated tendon tissue. Arthroscopic (key hole surgery) and traditional open surgical techniques are utilized to treat tennis elbow.
