Tennis Elbow
Written by Devon Patel with Dr. Ebraheim
Lateral
epicondylitis, also known as tennis elbow, is an overuse injury that results in
inflammation, tendinosis, and lateral elbow pain. It is the most common cause
of pain in the lateral elbow, affecting between 1 and 3% of the general
population (1). The primary structure impacted in tennis elbow is the extensor carpi
radialis brevis, which originates at the lateral epicondyle (2). This condition is primarily seen in middle-aged individuals,
especially those between the ages of 40 and 50 (3). Tennis players (up to 50% of regular players) and workers who engage
in heavy lifting or repetitive gripping are more likely to develop tennis elbow
(2). Other conditions, such as rotator cuff pathology or De Quervain’s
diseases, and lifestyle factors, such as smoking, are associated risk factors
for lateral epicondylitis (4). Rotator cuff pathology could be a risk factor because lateral
epicondylitis can also be caused by biomechanical stress, but it is unclear
exactly why it and other conditions are associated with each other (4). In terms of histology, disorganized collagen, dense fibroblasts, and
vascular hyperplasia are primarily seen (2). Immature fibroblastic and vascular infiltration of the origin of the
extensor carpi radialis brevis has consistently been identified during surgery (5). A physical exam and history are typically used to diagnose this
condition. Clinical tests to assist in diagnosis include grip strength,
Cozen’s, Maudsley’s, and Mill’s tests (3). Lateral epicondylitis is indicated if the previous tests are
positive along with reduced grip strength or reproduced pain (3). If necessary, diagnostic scans can be obtained. Majority of patients
show altered signal around the lateral epicondyle on MRI scans and hot focus on
infrared thermography (6, 7). Radial
tunnel syndrome is a differential diagnosis of tennis elbow. This syndrome is
seen in 5% of patients who have compression of the posterior interosseous
nerve. The pain associated with radial tunnel syndrome is approximately 3-4 cm
distal and anterior to the lateral epicondyle, which differentiates it from
tennis elbow.
Non-surgical
treatments are the primary mode of treatment and there is a 95% success rate
with treatments to relieve pain. The most frequently used treatment is
corticosteroid injection (2). Oral or topical non-steroidal anti-inflammatory drugs (NSAIDs) can
also be prescribed, but their effectiveness is variable (8). Patients can also undergo physical therapy to relieve their
symptoms. Eccentric exercises have been shown to be especially effective in
pain management (9). Using an inelastic, nonarticular proximal forearm brace could also
be recommended (10). Two relatively newer treatments for tennis elbow are ultrasonic (US)
and extracorporeal shock wave therapy (ESWT). There are minimal side effects to
US and ESWT, thus making them preferable for patients and clinicians (11). Even though there is no difference between US and ESWT in elbow
function evaluation scores, ESWT has been shown to have greater efficacy in
pain relief (12). Surgical procedures are a last resort for treatment of tennis elbow
and only indicated if patients are unresponsive to conservative treatments
after an extended period of time. Debridement is the most common surgical
intervention, but it can result in injury of the lateral collateral ligament
and subsequent posterolateral rotary instability of the elbow.
References
1. Shiri R, Viikari-Juntura
E, Varonen H, Heliovaara M. Prevalence and Determinants of Lateral and Medial
Epicondylitis: A Population Study. American Journal of Epidemiology.
2006;164(11):1065-74. doi: 10.1093/aje/kwj325.
2. Cutts S, Gangoo S, Modi N, Pasapula C.
Tennis elbow: A clinical review article. Journal of Orthopaedics.
2020;17:203-7. doi: 10.1016/j.jor.2019.08.005.
3. Speers CJ, Bhogal GS, Collins R.
Lateral elbow tendinosis: a review of diagnosis and management in general
practice. British Journal of General Practice. 2018;68(676):548-9. doi:
10.3399/bjgp18x699725.
4. Titchener AG, Fakis A, Tambe AA, Smith
C, Hubbard RB, Clark DI. Risk factors in lateral epicondylitis (tennis elbow):
a case-control study. Journal of Hand Surgery (European Volume).
2013;38(2):159-64. doi: 10.1177/1753193412442464.
5. Nirschl RP, Pettrone FA. Tennis elbow.
The surgical treatment of lateral epicondylitis. The Journal of bone and joint
surgery American volume. 1979;61(6A):832-9. PubMed PMID: 479229.
6. Steinborn M, Heuck A, Jessel C, Bonel
H, Reiser M. Magnetic resonance imaging of lateral epicondylitis of the elbow
with a 0.2-T dedicated system. European Radiology. 1999;9(7):1376-80. doi:
10.1007/s003300050851.
7. Thomas D, Siahamis G, Marion M, Boyle
C. Computerised infrared thermography and isotopic bone scanning in tennis
elbow. Annals of the Rheumatic Diseases. 1992;51(1):103. doi:
10.1136/ard.51.1.103.
8. Pattanittum P, Turner T, Green S,
Buchbinder R. Non‐steroidal anti‐inflammatory drugs (NSAIDs) for treating
lateral elbow pain in adults. Cochrane Database of Systematic Reviews. 2013(5).
doi: 10.1002/14651858.CD003686.pub2. PubMed PMID: CD003686.
9. Croisier J-L, Foidart-Dessalle M,
Tinant F, Crielaard J-M, Forthomme B. An isokinetic eccentric programme for the
management of chronic lateral epicondylar tendinopathy. British Journal of
Sports Medicine. 2007;41(4):269. doi: 10.1136/bjsm.2006.033324.
10. Johnson GW, Cadwallader K, Scheffel SB,
Epperly TD. Treatment of lateral epicondylitis. Am Fam Physician.
2007;76(6):843-8. Epub 2007/10/04. PubMed PMID: 17910298.
11. Coombes BK, Connelly L, Bisset L,
Vicenzino B. Economic evaluation favours physiotherapy but not corticosteroid
injection as a first-line intervention for chronic lateral epicondylalgia:
evidence from a randomised clinical trial. British Journal of Sports Medicine.
2016;50(22):1400-5. doi: 10.1136/bjsports-2015-094729.
12. Yan C, Xiong Y, Chen L, Endo Y, Hu L, Liu
M, et al. A comparative study of the efficacy of ultrasonics and extracorporeal
shock wave in the treatment of tennis elbow: a meta-analysis of randomized controlled
trials. Journal of Orthopaedic Surgery and Research. 2019;14(1). doi:
10.1186/s13018-019-1290-y.
