Tennis Elbow
by David Oster, M.D.
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Lateral epicondylitis, or tennis elbow, is a common cause of elbow pain in adults. The cause of this pain is related to a partial tear, or degeneration, of one of the tendons that extends the wrist. Frequently the pain will resolve with non-surgical management. Print Version- click here
Lateral epicondylitis is fairly common and effects 1 to 3% of adults each year. Despite how common this disorder is there is no single effective or consistent management. Management of this disorder includes non-surgical as well as surgical treatment. It is best to exhaust all non-surgical treatment options before considering surgical management.
Symptoms
The common symptom of tennis elbow is pain over the lateral (outside)
aspect of the elbow. It usually occurs insidiously and gradually worsens.
Although, there may be a dull ache, a sharp pain occurs with activities
involving wrist extension and gripping objects. Frequently people
will note that opening up a door, lifting up a briefcase, pulling
or lifting luggage or picking something up will cause pain.
Physical Examination
The pain of lateral epicondylitis is located over the outer aspect
of the elbow. Usually, there is one area that is significantly tender
to palpation. The pain is also exacerbated with resistance against
wrist extension and straightening the fingers, particularly the long
finger. Usually, it is not associated with any swelling or numbness.
The range of motion of the elbow is usually full, however, pain may
be noted when extending the elbow fully.
Imaging
Radiographs, or x-rays, are taken of the elbow. Most of the time the
x-rays will be normal, however, occasionally a small area of calcification
may be noted in the area of tenderness. Unlike an x-ray MRI’s
are much better evaluating soft tissue disorders. An MRI is usually
not recommended initially, however, if the pain continues it is an
excellent test to evaluate the elbow. If lateral epicondylitis is
the problem it will show a partial tear or degeneration of the tendon.
It is also helpful in ruling out any other disorders, which could
be causing the pain.
Nonsurgical Treatment
Initial treatment includes rest (avoidance of exacerbating activities),
and anti-inflammatory medications. Although lateral epicondylitis
is characterized as a non-inflammatory condition, anti-inflammatories
may help relieve pain from acute inflammation in the surrounding tissues
and may act as an analgesic. There are some scientific studies that
showed anti-inflammatories were helpful in alleviating pain.
Physical therapy is another modality that can be used. Therapy focuses in on increasing forearm strength, flexibility, and endurance. Bringing the wrist into flexion with the elbow straight performs stretching of the extensor origin. Strengthening exercises are done in an eccentric manner. Eccentric exercises are those exercises in which strengthening occurs as the muscle lengthens. These types of exercises are taught by a physical therapist and can then be done at home.
Injections can also be beneficial. If this problem has been going on for more than a month then a steroid injection can be considered. This involves injecting an anti-inflammatory steroid into the area of tenderness. Pain relief can be expected from six weeks to many months or it may cure the problem. Multiple injections (more than 2 to 3) are not recommended, as there can be side effects. Side effects include atrophy of the tissue in that area as well as weakening the tendons and ligaments.
Other treatment options include a cock up wrist splint. It is thought that by immobilizing the wrist that it will reduce the tension on the partially torn tendon. Another splint or strap that can be effective is a tennis elbow strap. This goes around the forearm just below the elbow. It is thought that this strap can diminish the tension on the injured tendon.
Surgical Management
When non-surgical management is not effective after approximately
3 months then surgical management is an option. If surgical management
is to be considered I recommend evaluating the elbow with an MRI.
An MRI can help confirm the diagnosis as well as locate the area where
the tendon is partially torn. The goal of surgical management is to
clean up and debride the area where the tendon is partially torn.
The muscle and tendon is also partially released from its attachment
onto bone. Small drill holes are made into the bone to release stem
cells that will initiate a healing response. The fascia (covering)
of the muscle is then closed. A splint (partial cast) is then placed
with the elbow at a right angle and the wrist straight.
The splint is then removed 10 to 14 days after the surgical procedure and the sutures are removed. At this point, range of motion, straightening and bending the elbow is encouraged. It is not recommended that any lifting or grabbing be performed for the first six weeks after surgery. At 2 to 4 weeks after surgery physical therapy is initiated to assist in regaining range of motion and strength. At 8 to 12 weeks following surgery one can gradually return back to full activities as pain allows.
The surgery is usually successful. Approximately 75 to 90% of patients will note improvement in their pain.
Other Options
One new option that is being evaluated is injecting growth factors
into the area of the damaged tendon. This procedure involves drawing
blood from the patient and then concentrating the platelets. Platelets
are cells that help clot blood but they also have growth factors.
The idea behind this procedure is to inject a concentrated clot of
platelets into the area of the damaged tendon. The growth factors
in the platelets are thought to have the ability to initiate healing
within the tendon. Although there have not been any large studies
evaluating this technique, smaller preliminary studies look encouraging
with results similar to surgical management.
If you have any questions about this or other knee problems please call Dr. David Oster’s office and make an appointment 303-214-4500.