Makindo Medical Notes

Bilateral disease suggests a systemic condition such as a spondyloarthropathy. Early diagnosis and appropriate management are essential to prevent chronic pain and functional impairment.

About Tennis Elbow

Tennis Elbow, medically known as Lateral Epicondylitis, is a common musculoskeletal condition characterized by pain and tenderness on the outer part of the elbow. It is caused by overuse and repetitive strain of the forearm muscles and tendons near the lateral epicondyle. Although it is frequently associated with tennis and other racquet sports, it can affect anyone engaging in repetitive arm and wrist activities.

• Tennis Elbow is also known as Lateral Epicondylitis.
• It is a significant cause of elbow pain and disability in both athletes and non-athletes.

Aetiology

• Tennis Elbow results from repetitive overloading of the extensor muscles of the forearm, particularly the Extensor Carpi Radialis Brevis (ECRB) tendon. This leads to microtears and degeneration at the tendon’s attachment to the lateral epicondyle.
• Overload Injury: Chronic repetitive motions and overuse of the forearm muscles.
• Extensor Carpi Radialis Brevis: The primary tendon involved in Tennis Elbow, susceptible to strain and injury.
• Occupational Factors: Jobs requiring repetitive arm and wrist movements, such as carpentry, plumbing, and painting.

Clinical Presentation

• Patients with Tennis Elbow typically present with pain and tenderness in specific areas of the elbow and forearm, often affecting daily activities and occupational performance:
• Repetitive Strain: Common in workers with repetitive skills, such as manual laborers, office workers, and athletes.
• Localized Tenderness: Exquisite tenderness over the lateral epicondyle of the elbow.
• Forearm Pain: Pain radiating down the forearm, often exacerbated by wrist extension or gripping activities.
• Weakness: Decreased grip strength and difficulty performing tasks requiring forearm muscle use.
• Stiffness: Morning stiffness and limited range of motion in the elbow.

Differential Diagnosis

• Golfer’s Elbow (Medial Epicondylitis): Pain on the inner side of the elbow due to inflammation of the forearm muscles and tendons.
• Radial Tunnel Syndrome: Compression of the radial nerve, causing pain and weakness in the forearm.
• Triceps Tendinitis: Inflammation of the triceps tendon, leading to pain at the back of the elbow.
• Ulnar Nerve Entrapment: Nerve compression causing numbness and tingling in the ring and little fingers.
• Septic Arthritis: Infection in the elbow joint, presenting with acute pain, swelling, and redness.

Investigations

Diagnosis of Tennis Elbow is primarily clinical, based on history and physical examination. However, imaging and other tests may be utilized to rule out other conditions or assess the extent of tendon damage:

• Clinical Examination:
  • Palpation of the lateral epicondyle to identify tenderness.
  • Resisted wrist extension and middle finger extension to reproduce pain.
  • Range of motion assessment to evaluate elbow flexibility.
• Ultrasound: Can detect tendon tears, thickening, and inflammation.
• Magnetic Resonance Imaging (MRI): Provides detailed images of the tendons and surrounding structures, useful in severe or atypical cases.
• Electromyography (EMG): Assesses nerve function if nerve entrapment is suspected.

Management

• Conservative Treatments:
  • Rest: Reducing or modifying activities that exacerbate symptoms to allow tendon healing.
  • Ice Therapy: Applying ice packs to reduce inflammation and pain.
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): To alleviate pain and decrease inflammation.
  • Physiotherapy:
    • Stretching and strengthening exercises for the forearm muscles.
    • Manual therapy to improve tendon flexibility and reduce tension.
    • Modalities such as ultrasound or laser therapy to promote healing.
  • Elbow Support: Use of braces or straps to reduce strain on the affected tendons during activities.
• Steroid Injections:
  • Intra-articular or peritendinous corticosteroid injections can provide temporary pain relief.
  • They may increase the risk of tendon rupture if overused or used inappropriately.
• Alternative Therapies:
  • Acupuncture: May help in pain relief and promoting tendon healing.
• Surgical Intervention:
  • Arthroscopic Surgery: Minimally invasive procedure to remove damaged tendon tissue and promote healing.
  • Open Surgery: Reserved for cases where conservative treatments have failed, involving debridement of the tendon.
• Self-Limiting Nature:
  • Tennis Elbow is often self-limiting once the underlying cause is addressed and the tendon heals.
  • Most patients recover with appropriate treatment within 6-12 months.

Prognosis

The prognosis for Tennis Elbow is generally good with appropriate and timely management. Most individuals experience significant improvement and eventual resolution of symptoms. However, some cases may become chronic, especially if underlying risk factors are not addressed:

• Early Intervention: Leads to quicker pain relief and restoration of function.
• Chronic Cases: May require more intensive treatments, including surgery, to achieve symptom resolution.
• Recurrence: Preventive measures, such as ergonomic adjustments and strengthening exercises, are essential to minimize the risk of recurrence.

References

• American Academy of Orthopaedic Surgeons. Lateral Epicondylitis (Tennis Elbow). Available at: https://orthoinfo.aaos.org
• Mayo Clinic. Tennis Elbow. Available at: https://www.mayoclinic.org/diseases-conditions/tennis-elbow/symptoms-causes/syc-20351987
• Fitzpatrick, J. F., & Ryan, J. (2014). Rehabilitation of Tennis Elbow: An Evidence-Based Approach. Sports Health.
• Ryan, J. P., & Roy, J. C. (2008). Lateral Epicondylitis (Tennis Elbow). In: Orthopaedic Knowledge Update: Musculoskeletal Tumors, Trauma, and Arthritis.
• Sevier, T. L., & Portas, W. A. (2016). Management of Lateral Epicondylitis. Curr Rev Musculoskelet Med.
• National Institute for Health and Care Excellence (NICE). Patellofemoral Pain in Adults: Assessment and Management. Available at: https://www.nice.org.uk/guidance/cg88