Tennis elbow, or lateral epicondylitis, is one of the most common elbow problems seen by an orthopedic surgeon.
It is actually a tendinitis of the muscle called the extensor carpi radialis brevis which attaches to the lateral epicondyle of the humerus. It may be caused by a sudden injury or by repetitive use of the arm.
Many doctors feel that micro tears in the tendon lead to a hyper-vascular phenomenon resulting in pain. The pain is usually worse with strong gripping with the elbow in an extended position, as in a tennis back hand stroke, but this problem can occur in golf and other sports as well as with repetitive use of tools.
Before surgery is considered a trial of at least six months of conservative treatment is indicated and may consist of a properly placed forearm brace and modification of elbow activities, anti-inflammatory medication and physical therapy. If the above treatment is not helpful, a cortisone injection can be beneficial but no more than three injections are recommended in any one location in a year.
Conservative treatment is in two phases and after Phase I (Pain relief) has been successful, Phase II (Prevention of recurrence) is equally as important and involves stretching and then later strengthening exercises, so the micro tears will not occur in the future.
When conservative treatment has failed, then surgery is indicated. Many procedures have been described. Procedures as simple as percutaneous release of the tendon off of the bone have been described and more recently arthroscopic procedures or other procedures involving the joint and resection of a ligament as well have been described.
The most popular procedure today is a simple excision of diseased tissue from within the tendon, shaving down the bone and re-attachment of the tendon. This can be performed as an outpatient procedure with regional anesthesia (where only the arm goes to sleep) and through a relatively small incision of approximately 3” long. 85-90% of patients with this technique are typically able to perform full activities without pain after a recuperation of two to three months. Approximately 10-12% of patients have improvement but with some pain during aggressive activities and only 2-3% of patients have no improvement.
Tennis Elbow Golfers Elbow
Lateral epicondyltis also called tennis elbow and medial epicondylitis called golfers elbow is a condition affecting the forearm muscles’ on the humeral bone at the elbow called the lateral and medial epicondylitis respectively. This condition, as well as, biceps tendon ruptures occurs in patients between the ages of 30-50 years. Although lateral and medial epicondylitis is often associated with a minor traumatic event andrupture of the distal biceps tendon with a major traumatic event, all three conditions are considered the result of a degenerative process in the muscle tendon structure and not the result of an inflammatory process, as the names lateral and medial epicondylitis would imply.
Lateral epicondylitis and biceps tendon ruptures occur in about 1-2% of the population while medial epicondyltitis occurs1/10th as often. The use of the hands in mostactivities occurs in the palm down position (pronation) which may help explain whytennis elbow is ten times more common than golfers elbow. Rupture of the biceps tendon occurs when aheavy eccentric load is placed over the elbow as occurs when lifting a heavy object. On the other hand, tennis and golfers elbow occurs with repetitiveuse of the hands and forearms when manual laborers perform their routine job requirements requiring repetitiveand forceful forearm rotation and wrist extension and flexion movements.
The tendons affected with the degenerative process in tennis elbow are the extensor carpi radialis brevis in all cases, and the extensor digitorum communis origin in some of the cases. In golfers elbow, the pronator teres and the flexor carpi radialis tendon origins are the involved tendons. Cubital tunnel syndrome or compression of the ulnar nerve at the elbow can occur in association with golfers elbow in as much as 30% of the cases. Partial or complete rupture of the biceps tendon at its insertion occurs secondary to an eccentric load on the biceps tendon as a result of forceful contraction of the biceps while the elbow is simultaneously extending. The use of oral steroids has been associated with an increase incidence of distal biceps tendon ruptures. Lateral epicondylitis and medial epicondylitis both present with pain as the initial complaint. The severity of the pain typically correlates with the severity of the condition and will dictate which treatment options are initially taken. Associated weakness of grip, radiation of the pain down the dorsal forearm or towards the shoulder is not uncommon.
The treatment of tennis elbow, golfers elbow and a partial biceps tendon ruptures is often successfully treated with activity modification, splinting, anti-inflammatory medication, and therapy. Therapy includes stretching exercises followed by isometric strengthening, then concentric muscle strengthening and finally eccentric muscle strengthening. These strengthening exercises are done sequentially and not advanced until the previous exercises can beaccomplished without pain. A conservative approach can take six to nine months to be successful. If pain persists beyond this time, surgery is required which has an excellent success rate. There are two types of surgical techniques performed, the direct and indirect approach. Each category has several different techniques described and which technique is used will depend on the surgeon’s experience and how quick the wants to return to heavy lifting.