Tennis elbow
–Other potential diagnoses
-Testing
-Treatment options
Many health practitioners are familiar with the very common, yet very stubborn condition – tennis elbow. Technically this is called lateral epicondylitis (LE). HOWEVER, perhaps the name for this condition will soon become redundant. The suffix “itis”, meaning inflammation, could be somewhat misleading. Classically, LE was considered an inflammatory process, however, scientific investigation does not show many inflammatory cells.
A review article, released in 2016, summarizes the findings of 51 different sources around the condition.
• Authors consider tennis elbow as a TENDINOSIS; a symptomatic degenerative process of the tendon.
• The condition affects MAINLY middle aged patients, at approximately 1-3% of the population.
• Diagnosis is usually with clinical testing. Specific imaging could be used for checking other potential problems.
• The disease is self-limiting in nature, usually lasting 12-18 months.
• Most patients can be well managed with non-operative treatment and activity modification.
When repeated stress to the tendon exceeds its tolerance, micro-tearing may occur. This leads to degenerative changes (tendonosis). The creation of new repair tissue that disturbs normal tendon structure can occur, making the tendon weak.
Most commonly, there is one muscle involved called the Extensor carpi radialis brevis (ERCB), however, the supinator and other wrist extensors can also be involved.
Diagnosis
Typically, pain can be reproduced by resisting upwards movement of the wrist and finger. Pain can range from dull to severe. The cause for such difference in pain levels is largely unknown, however, could be related to local nerve irritation.
It is also sometimes helpful to test grip strength for tennis-elbow, in which case it is often decreased and likely to reproduce pain.
Other potential elbow problems mimicking tennis elbow
1) Referred pain from the neck – the level of C6, a spinal bone in the neck, can refer pain to the lateral forearm and first two fingers. It will also give weakness in the biceps, and an absent bicep reflex.
2) It is estimated that 59% of lateral elbow problems that do not respond to conservative treatment have some form of cartilage changes in part of the elbow joint.
This is called osteochondrosis dissecans and it is often seen in adolescent, overhead athletes. It is an acquired injury.
Patients are usually 11-17 years old. X-ray is a great way to look for problems, however, MRI is the best scan.
3) PIN – Posterior interosseous nerve entrapment, also known as radial tunnel syndrome. This only occurs in about 3 per 10000 per year. It is common in males, bodybuilders and labourers.
In this problem, nerve compression produces pain in the forearm, however, when we test wrist strength, it is not painful as it would be in tennis elbow.
During physical examination of the elbow and wrist, it will be noted that there is weakness in the finger and wrist movements.
4) Anconeus muscle oedema can be the cause of lateral elbow pain. This muscle is between the two bone of the forearm, near the bony part of the elbow. This muscle can be treated with massage and dry needling as a first approach.
Treatment
There is no tried and tested regime that is agreed to be the “better” method for treatment of tennis elbow. Modifying behaviour is perhaps the most convenient, inconvenience for the frustrated person. Listed are treatment options, going from conservative, to more invasive.
• Rest – avoid painful, loading activities
• Physiotherapy – strengthening and stretching is applied.
• Brace – can relieve pain in short term but can also cause compression to nerves.
• Anti-inflammatory medications – can be useful short term.
• Acupuncture / dry needling
• Corticosteriod injections – short term benefits with long term disadvantages. Avoid where possible.
• Platelet rich plasma
• Extracorporeal shockwave treatment
• Low level laser therapy
Surgical approach can be considered for tennis elbow that will not improve. There are numerous surgical techniques but there seems to be no consensus on which is the best technique to manage the condition.
Thank you for reading about the Lateral Elbow
By Paul Michael
MOVING WITH EASE PHYSIOTHERAPY
References
Choi SH, Ji SK, Lee SA, Park MJ, Chang MJ. Magnetic resonance imaging of posterolateral plica of the elbow joint: Asymptomatic vs. symptomatic subjects. PLoS One. 2017;12(6):e0174320. Published 2017 Jun 16. doi:10.1371/journal.pone.0174320
Churchill RW, Munoz J, Ahmad CS. Osteochondritis dissecans of the elbow. Curr Rev Musculoskelet Med. 2016;9(2):232–239. doi:10.1007/s12178-016-9342-y
Javed M, Mustafa S, Boyle S, Scott F. Elbow pain: a guide to assessment and management in primary care. Br J Gen Pract. 2015;65(640):610–612. doi:10.3399/bjgp15X687625
Lai WC, Erickson BJ, Mlynarek RA, Wang D. Chronic lateral epicondylitis: challenges and solutions. Open Access J Sports Med. 2018;9:243–251. Published 2018 Oct 30. doi:10.2147/OAJSM.S160974
Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev. 2017;1(11):391–397. Published 2017 Mar 13. doi:10.1302/2058-5241.1.00004
