Tennis elbow (lateral epicondylitis)

Lateral epicondylitis is a degenerative (wear and tear) condition of the tendon insertion on the lateral (outside) side of the elbow. It was commonly associated with tennis players, hence the name, but it is really no more common in tennis players than anyone who performs relatively repetitive tasks with their elbow. It should really be called lateral epicondylosis since the problem is not inflammatory (which gives the ending – itis). However, both names have stuck with clinicians and the general public alike.

The lateral epicondyle is a bony lump on the outer edge of the end of the humerus. Here the muscles that extend the wrist (bend the wrist back) insert. When the muscles are over used, small tears (micro-damage) is caused in the tendon and this tries to heal. The healing process is very complex and may not have time to complete before further damage occurs with repetitive activity. Scarring (a result of the damage-healing process) occurs and then there is further damage and a vicious cycle develops. Scar is poorly vascularised (supplied with blood) tissue which means when further damage occurs it is even less likely to repair. The actual scarred tendon is just down (towards the wrist) from where the bony lateral epicondyle is.

The symptoms can start suddenly after a period of heavy activity with the elbow, for example breaking up rocks in the garden. This could indicate a tear in the tendon and may be repairable with a good chance of resolution of the symptoms. If the symptoms begin insidiously (not sure exactly when they started and no particular triggering event can be recalled), then the cause is likely to be due to micro-trauma as indicated in the paragraph above. The pain starts gradually and is on the lateral side of the elbow. The pain improves with rest and worsens with activity. Pain can be felt down the forearm.

Tennis elbow is a self-limiting condition. This means that if left alone untreated, it is likely to resolve itself with time. The trouble is, this could be 18 months to 2 years which is a long time to be in discomfort. The treatments that are available aim to fast-track patients along the timeline of natural history of recovery. Unfortunately none of the treatments have much evidence behind them to either back them up or disprove their worth. There is lots of anecdotal evidence that lots of treatments can be effective.

Rest can be very effective although not always that practical. Steroid injections into the local area can give good, although often only temporary, relief. A side effect of steroid injections is thinning of the skin which can occur quite dramatically after just a couple of injections. This would make possible surgical intervention in the future more prone to healing problems including infection. An alternative to steroid injection is needling of the area. This involves something very similar to an injection but not with steroid but with local anaesthetic only, and the needle to moved back and forth on the bone (not in and out of the skin) to encourage a small amount of bleeding at the site. The bleeding and healing reaction may trigger a fresh healing process which could lead to a break in the vicious cycle of tennis elbow.

Poorly directed physiotherapy is unlikely to have much effect and would probably worsen the symptoms. The only exercises I recommend are eccentric exercises which are a special type of movement which puts the muscle units under strain whilst they are lengthening. This type of exercise has been known to have good effect but it is necessary to perform the exercise several times a day for 12 weeks before judging whether it has been a success or not.

Clasps are special types of support which are C-shaped and fit around the forearm, just below the elbow. The idea is that the position of insertion of the tendon is shifted from its natural position on the epicondyle to just below it, effectively shortening the tendon. This gives the real insertion site a rest and time to heal. Again, some good results have been reported with this method. They can be supplied form your specialist or can be bought on the internet but when starting to use it you should take advice from a specialist about whether it is appropriate and fitted correctly.

Tennis elbow release is an operation done usually under general anaesthetic as a day-case. An incision is made on the outer aspect of the elbow and the tendon is opened as it inserts into the lateral epicondyle. Any excess scar tissue is removed and any excessive lumps on the bone can be removed also. The tendon is stitched back together and the skin is close with stitches. The results can be very variable. It is thought to be successful about 50 to 70% of the time.

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