Lateral Epicondylitis (Tennis Elbow)
Background
Lateral epicondylitis (tennis elbow) is defined as a pathologic condition of the wrist extensor muscles at their origin on the lateral humeral epicondyle. The tendinous origin of the extensor carpi radialis brevis (ECRB) is the area of most pathologic change. Changes can also be found in the musculotendinous structures of the extensor carpi radialis longus, extensor carpi ulnaris, and extensor digitorum communis (Fig. 2–24A). Overuse or repetitive trauma in this area causes fibrosis and microtears in involved tissues. Nirschl referred to the microtears and the vascular ingrowth of the involved tissues as angiofibroblastic hyperplasia. He also suggested the degenerative process should be termed tendinosis rather than tendinitis.
Most patients with lateral epicondylitis are between the ages of 30 and 55 years, and many have poorly conditioned muscles. Ninety-five percent of tennis elbow occurs in non–tennis players. Ten to 50% of regular tennis players experience tennis elbow symptoms of varying degree some time in their tennis lives. The most common cause of tennis elbow in tennis players is a “late,” mechanically poor backhand (Fig. 2–25) that places excess force across the extensor wad, that is, the elbow “leads” the arm. Other contributing factors include incorrect grip size, string tension, poor racquet “dampening,” and underlying weak muscles of the shoulder, elbow, and arm. Tennis grips that are too small often exacerbate or cause tennis elbow.
Often a history of repetitive flexion-extension or pronation-supination activity and overuse is obtained (e.g., twisting a screw driver, lifting heavy luggage with the palm down). Tightly gripping a heavy briefcase is a very common cause. Raking leaves, baseball, golfing, gardening, and bowling can also cause lateral epicondylitis.
Physical Examination
Point tenderness typically occurs over the ECRB origin at the lateral epicondyle (see Fig. 2–24B).
The tenderness may be more generalized over the common extensor wad insertion at the lateral epicondyle (just distal and anterior to the lateral epicondyle).
The pain is often exacerbated by wrist extension against resistance with the forearm pronated (palm down).
Elbow extension may be mildly limited.
Mill’s test may be positive. With this test, pain occurs over the lateral epicondyle when the wrist and fingers are completely flexed (Fig. 2–26).
With Maudsley’s test, the patient may feel pain on resisted extension of the middle finger at the MCP joint when the elbow is fully extended (Fig. 2–27).
Evaluation should note possible sensory paresthesias in the superficial radial nerve distribution to rule out a radial tunnel syndrome. Radial tunnel syndrome (Fig. 2–28) is the most common cause of refractory lateral pain and coexists with lateral epicondylitis in 10% of patients.
The cervical nerve roots should be examined to rule out cervical radiculopathy.
Other conditions that should be considered include bursitis of the bursa below the conjoined tendon, chronic irritation of the radiohumeral joint or capsule, radiocapitellar chondromalacia or arthritis, radial neck fracture, Panner’s disease, Little League elbow, and osteochondritis dissecans of the elbow.
Nonoperative Treatment
Activity Modification
In nonathletes, elimination of the activities that are painful is key to improvement (e.g., repetitive valve opening).
Treatments such as ice and NSAIDs may lessen the inflammation, but continued repetition of the aggravating motion will prolong any recovery.
Often, repetitive pronation-supination motions and lifting heavy weights at work can be modified or eliminated. Activity modifications such as avoidance of grasping in pronation (Fig. 2–29) and substituting controlled supination lifting instead may relieve symptoms (Fig. 2–30).
Lifting should be done with the palms up (supination) whenever possible, and both upper extremities should be used in a manner that reduces forcible elbow extension, supination, and wrist extension.
Correction of Mechanics
If a late or poor backhand causes pain, correction of the mechanics of the stroke is warranted.
Avoidance of ball impact that lacks a forward body weight transference is stressed.
If typing with unsupported arms exacerbates the pain, placing the elbows on stacked towels for support will help.
Nonsteroidal Anti-inflammatory Drugs
If not contraindicated, we use Cox-2 inhibitors (rofecoxib [Vioxx], celecoxib [Celebrex]) for their improved safety profile.
Icing
Ten to 15 minutes of ice, four to six times a day.
Stretching
ROM of exercises emphasizing end-range and passive stretching (elbow in full extension and wrist in flexion with slight ulnar deviation) (Figs. 2–31 and 2–32).
Counterforce Bracing
Bracing is used only during actual play or aggravating activity.
The tension is adjusted to comfort while the muscles are relaxed so that maximal contraction of the finger and wrist extensors is inhibited by the band (Fig. 2–33).
The band is placed two fingerbreadths distal to the painful area of the lateral epicondyle.
Some authors recommend 6 to 8 weeks’ use of a wrist splint positioned in 45 degrees of dorsiflexion.
Tennis players may reduce racquet string tension, change the size of the grip (usually to a larger grip), and change to a better dampening racquet. For grip size, Nirschl recommended measuring the length from the proximal palmar crease to the tip of the ring finger with a ruler (Fig. 2–34). If the distance is 4.5 inches, the grip should be a 4½.
Cortisone Injection
We have had excellent results with injection of cortisone for tennis elbow.
We recommend injecting no more often than every 3 months, and no more than three injections a year to avoid possible tendon rupture.
Technique
Use 2 ml of lidocaine in a 25-gauge 1-inch needle centered at the point of maximal tenderness at the ECRB origin, not entering the tendon.
The needle is left in place, and then the syringe is changed and 0.5 ml of betamethasone (Celestone) is injected. This is preferred rather than skin infiltration with cortisone to avoid skin and subcutaneous tissue atrophy from the steroid.
Range of Motion Exercises (see Figs. 2–31 and 2–32)
Exercises emphasize end-range and passive stretching (elbow in full extension and wrist in flexion with slight ulnar deviation).
Soft tissue mobilization is done with and perpendicular to the tissue involved.
Phonophoresis or iontophoresis may be helpful.
Strengthening Exercises
A gentle strengthening program should be used for grip strength, wrist extensors, wrist flexors, biceps, triceps, and rotator cuff strengthening.
However, the acute inflammatory phase must have resolved first, with 2 weeks of no pain before initiation of graduated strengthening exercises.
Development of symptoms (i.e., pain) modifies the exercise progression, with a lower level of intensity and more icing if pain recurs.
The exercise program includes:
Active motion and submaximal isometrics.
Isotonic eccentric hand exercises with graduated weights not to exceed 5 pounds.
Wrist curls
Sit with the hand over the knee. With palm up (supination), bend the wrist 10 times holding a 1- to 2-pound weight. Increase to two sets of 10 daily; then increase the weight by 1 pound up to 5–6 pounds. Repeat this with the palm down (pronation), but progress to only 4 pounds.
Forearm strengthening
Hold the arm out in front of the body, palm down. The patient clenches the fingers, bends the wrist up (extension), and holds it tight for 10 seconds. Next, with the other hand, the patient attempts to push the hand down. Hold for 10 seconds, 5 repetitions, slowly increasing to 20 repetitions two to three times a day.
Weight on the end of a rope (Fig. 2–35) can be used to strengthen wrist flexors and extensors. The patient rolls up a string with a weight tied on the end. The weight can be progressively increased. Flexors are worked with the palms up; extensors with the palm down.
Elbow flexion and extension exercises (Figs. 2–36 and 2–37).
Squeeze a racquetball repetitively for forearm and hand strength.
Progress strength, flexibility, and endurance in a graduated fashion with slow-velocity exercises involving application of gradually increasing resistance. A “no-pain–no-gain” philosophy is incorrect here.
Galloway, DeMaio, and Mangine also divide their approach to patients with epicondylitis (medial or lateral) into three stages: The initial phase is directed toward reducing inflammation, preparing the patient for phase 2. The second phase emphasizes return of strength and endurance. Specific inciting factors are identified and modified. Phase 3 involves functional rehabilitation designed to return the patient to the desired activity level. This protocol is also based on the severity of the initial symptoms and objective findings at initiation of treatment.
Surgical Treatment
Surgical treatment of tennis elbow is not considered unless the patient has recalcitrant symptoms for more than 1 year despite the nonoperative treatment previously discussed. Various operations have been described for tennis elbow pain. Many authors have recommended excision of torn, scarred ECRB origin, removal of granulation tissue, and subchondral bone drilling for neovascularization stimulation. The elbow capsule is not violated unless intra-articular pathology exists. We prefer to treat these patients arthroscopically whenever possible. Arthroscopic release of the ECRB tendon and decortication of the lateral epicondyle are analagous to the open procedure. Arthroscopic treatment of lateral epicondylitis offers several potential advantages over open procedures, and its success rate is comparable. The lesion is addressed directly, and the common extensor origin is preserved. Arthroscopy also allows for an intra-articular examination for other disorders. It also permits a shorter postoperative rehabilitation period and an earlier return to work or sports.
Postoperatively, we encourage our patients to begin active ROM within the first 24 to 48 hours. The patient is usually seen for follow-up within the first 72 hours. At this time, she or he is encouraged to begin extension and flexion exercises. After the swelling subsides, usually 2 to 3 weeks after surgery, the patient can rapidly regain full ROM and begin strengthening exercises. Return to throwing sports is allowed when the patient has regained full strength.
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