Tennis elbow: What’s in a name?
Monday, November 21, 2016
Most people will know the condition lateral epicondylitis by its more common name: "tennis elbow." This term is used to describe a pain that develops on the outer aspect of the elbow, usually with a gradual onset, in the absence of a definitive moment of injury. Pain is often described as sharp or burning and is usually aggravated by picking up a relatively light item, such as a kettle.
Symptoms aside, tennis elbow has to be the most inappropriately named injury out there. In more than a decade of work in the soft tissue therapy field, not once has someone presented to me with a case of tennis elbow from playing tennis! It's easy to see why.
What's in a name?
Clinically, a patient with lateral epicondylitis will demonstrate pain on resisted wrist and middle finger extension. The common extensor origin (just distal to the lateral epicondyle) will be tender to palpate.
This condition develops due to repetitive wrist extension. When playing tennis, the wrist should be held fairly static, with all the power coming from the elbow, shoulder and torso. It may be more appropriately known as "badminton elbow," as the shots involved when hitting a shuttle are certainly more "wristy" than the tennis equivalent.
Even better than that, would be DIY elbow. That's what most of my patients have been doing when they come through the door displaying these symptoms. Lots of screwdriving or painting, etc., can easily overstress the tissues of the forearm.
Even the medical name (lateral epicondylitis) is now falling out of favor. The "-itis" suffix refers to an inflammatory condition. As with most gradual onset tendon injuries, biopsies taken from individuals displaying symptoms of this ailment have shown no inflammatory cells are present. Instead, symptomatic tissue displays angiofibroblastic degeneration and collagen disarray.
These findings along with the relative hypovascularity proximal to the insertion, which could predispose the tendon to hypoxic tendon degeneration, indicate a pathology matching the etiology of a tendinosis, rather than a tendinitis. As a result, many clinicians and researchers are now using alternative names such as epicondylosis or even epicondylalgia.
How should it be treated?
There are various methods that have been used in the treatment of lateral epicondylosis.
Physical therapists promote conservative management in the form of soft tissue therapy (massage, active tissue release, etc.), electrotherapy (ultrasound, laser), acupuncture and exercise rehabilitation.
Other more invasive treatments can also be used. These include injection therapies such as corticosteroid, autologous blood, prolotherapy or platelet rich plasma (prp) injections. Extracorporeal shockwave therapy is also sometimes an option used in the treatment of lateral epicondylosis.
Surgery to release the ECRB tendon (extensor carpi radialis brevis — shown to be the most frequently involved) is possible but is usually kept as a last resort.
There is no single protocol that has been proven to be effective in the treatment of this condition. What has been shown, however, is that the best results come from using more than one form of therapy, alongside an exercise program.
Soft tissue techniques, electrotherapies and acupuncture aim to increase blood flow to the affected tendon(s), reduce muscle tension and promote a healing response. An exercise program should focus on the use of eccentric contractions as shown to be the best form of loading in cases of tendinopathy. Eccentric wrist extensor and supinator exercises will target the correct muscle group.
Corticosteroid injections are the most commonly used injection therapy for treating tendon injuries. A dose of steroids is injected directly into the site of injury, to reduce inflammation and allow a healing response.
Autologous blood injections involve the use of the patient's own blood, usually taken from the arm. It is mixed with a local anesthetic and injected back into injury site. The theory for its use centers around the presence of growth factors within the blood which encourage a healing response.
Platelet-rich plasma (PrP) injections take this theory one step further, by separating the blood out into its components and increasing the concentration of platelets. These are the cells within blood that contain the growth factor. This solution is then injected back into the tendon.
Prolotherapy (short for proliferation therapy) involves the injection of a mixture of dextrose and a local anesthetic. The aim is to stimulate the body's natural ability to repair itself and encourages new growth of tendon tissues. Unlike the other injection therapies, prolotherapy can be administered up to every two weeks.
A quick PubMed search revealed two review studies that looked in to the efficacy of these treatment methods. The consensus from both appears to be that corticosteroid injections were the least effective, demonstrating no significant improvement over placebo groups.
The conclusion of Arirachakaran et al was that PrP injections appear to produce the best results with a low risk of complications. Krogh et al favored the use of prolotherapy, although only one such study was included in their review. This showed statistically superior results against placebo with a low risk of bias. Prolotherapy was not included in the Arirachakaran review.
Extracorporeal shockwave therapy
ESWT is a procedure whereby mechanical shock waves are passed through the skin to the injured tissue. The aim is to increase blood flow to stimulate healing.
Research on its use is conflicting with some studies demonstrating a positive effect and others finding no benefit. A review from the International Journal of Surgery in 2015 found the mix to be slightly in favor of ESWT in cases of lateral epicondylosis.
Surgery is a last resort if all previous treatments have failed and symptoms have been present for an absolute minimum of six months.
There are a variety of procedures that have been used to surgically manage this condition. Some are open surgeries and others are performed as an arthroscopy. The general aim is to debride the diseased tissue from the tendon of the ECRB with decortication (removal of the fibrous layer covering) of the lateral epicondyle.
Surgeries are usually performed on an outpatient basis with no need for an overnight stay. Rehabilitation should start within days of the procedure to regain full movement and then strength in the elbow, wrist and hand. An individual can expect to return to normal daily tasks within 4-6 weeks and return to sporting activities within 3-6 months.
As with all operations, there are of course risks — mostly from anesthesia and infection — but these risks are low. The results of surgical management of lateral epicondylosis are good, with approximately 85 percent of patients reporting complete resolution of their symptoms.
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