Tennis Anyone?

By Peter Galvin, MD

Lateral epicondylitis, more commonly known as tennis elbow, is a condition that is characterized by the insidious onset of lateral elbow pain, usually in the absence of trauma. It affects about 1 to 3% of adults. The lateral epicondyle is the bony protrusion on the side of the elbow (behind it is the ulnar notch, where the ulnar nerve is located, otherwise known as the “funny bone”). The extensor muscles, which are in the forearm, are attached to the lateral epicondyle and they extend (the opposite of flex) the hand and fingers. The cause of lateral epicondylitis is not well understood, but pathological studies have shown that it causes degenerative changes in the extensor tendons that attach to the epicondyle. It is an inflammatory condition of unknown cause. Risk factors include former or current cigarette smoking, obesity, and high physical load (as with manual labor). Studies have shown that work-related risk factors include heavy lifting and forearm rotation for more than four hours a day, but not gripping or repetitive movements.

Persons with lateral epicondylitis usually present with a gradual onset of pain without a defined trauma or injury. The most common physical findings are tenderness at the lateral condyle and weakness or pain with resisted wrist extension (the Thomsen test – the examiner holds back the dorsum [top] of the hand while asking the patient to extend, or raise, the wrist). Lateral epicondylitis is a clinical diagnosis. In the absence or trauma, X rays or imaging studies are not needed unless a fracture or arthritis is suspected as an alternate diagnosis. The primary treatment is education of the patient. A study of orthopedics surgeons who had diagnosed their own lateral epicondylitis showed that 97% had complete resolution of their symptoms within two years without any treatment. This study is in agreement with other studies that show that lateral epicondylitis usually resolves by itself without treatment. In addition, there is no evidence that using the arm, despite pain, causes additional harm.

Topical nonsteroidal anti-inflammatory drugs (NSAIDs, i.e., Voltaren gel) may give a modest short-term benefit with respect to pain relief and patient comfort. Oral NSAIDs should be avoided due to the risk of gastrointestinal bleeding. Wrist braces and counterforce forearm braces are sometimes used but studies have shown that physiotherapy (physical therapy) is more beneficial than bracing. Steroid injections have been used for years to treat this condition, but studies have shown that long-term outcomes are worse with regard to pain and function as compared to a wait-and-see approach. Also used are injections of botulinum toxin (Botox), but studies have shown a worse outcome regarding weakness of grip and finger extension.

Approximately two to four percent of patients will have persistent pain despite treatment and will opt to undergo surgery but studies have shown that surgery, whether open or arthroscopic, did not improve outcomes at 12 months post-op. Lastly, denervation, or severing of the nerves at the elbow as a last resort did improve pain outcomes, but worsened the use of the arm and disability. If you or someone you know has been diagnosed with tennis elbow, the best plan is to wait-and-see because the odds are it will improve on its own.

Please direct questions and comments to editor@rockawaytimes.com