Tennis Elbow or Lateral Epicondylitis

Tennis elbow or lateral epicondylitis is a term for a painful condition of elbow because of tendinosis of extensors of the wrist at the attachment on the lateral epicondyle. Lateral epicondyle is part of the distal humerus on the lateral or outer side of the elbow. Extensor carpi radialis brevis tendon is most commonly involved followed by the extensor digitorum and extensor carpi ulnaris.

Tennis elbow or lateral epicondylitis mostly affects people older than 40 years and there is no predilection for any sex. Tobacco users have been noted to be at increased risk.

Tennis, squash and badminton players, carpenters, masons, tailors, pianists, drummers, and people who do a lot of computer work, typing are at increased risk.

Other contributory factors are fatigue of the core and shoulder muscles, improper training, wrong technique, substandard equipment, and nonergonomic furniture.

Clinical Presentation

There is an insidious onset pain in the elbow and often a prior history of overuse, usually 1-3 days before the onset of the symptoms.

The pain worsens with activity and improves with rest. It may radiate down the posterior aspect of the forearm. Pain can vary from being mild which aggravates with activity or so severe that even picking and holding a cup causes the pain [coffee cup sign].

On examination, there is tenderness mostly distal to extensor origin or vaguely at lateral condyle. Resisted wrist extension with the wrist radially deviated and pronated and the elbow extended causes pain. So does the resisted supination, gripping and hand shaking. The range of motion of the radiohumeral joint is not affected. If it is, the joint should be x-rayed.

The condition needs to be differentiated from the pains of cervical radiculopathy, and radial nerve entrapment.

Lab Studies

These are usually normal and not required.

Imaging Studies

Imaging studies are rarely needed but help to evaluate osteophytes and degenerative joint disease in case of refractory cases. Other imaging modalities are not needed routinely.

Treatment of Tennis Elbow

For tennis elbow, there are many treatment options but no single treatment is completely effective

Treatment options include NSAIDs [topical and oral] and rest, corticosteroids injections, tennis elbow braces or counterforce braces.

Many patients respond to rest and NSAIDs. Corticosteroid injections are effective in the short term but not be as effective in the long term.

Braces are used in an attempt to reduce the tension forces on the wrist extensor tendons and are approximately 10 cm distal to the elbow joint. It decreases pain and increases. Wrist splints also help to reduce pain.

Recently ultrasound-guided percutaneous radiofrequency thermal lesioning has been reported to be an effective method

Hyaluronate injections, autologous blood, and platelet-rich plasma injections have been reported to cause pain reduction.

Physical therapy involves strength training, exercise, and stretching.

Ultrasound-guided intratendinous injections with polidocanol in the extensor origin have shown promising clinical results.

In refractory cases [6 months of conservative treatment has failed to relieve the patient’s symptoms arthroscopic or open release can be successful.]

In case of sportspersons, gradual return to play is recommended.

Prognosis

Tennis elbow generally gets better in 9-18 months, though the treatment may be prolonged in some cases. Tendon rupture is the most common complication and generally requires surgical treatment.