Lateral Epicondylitis, or Tennis Elbow, is a painful condition whereby the extensor tendons of the forearm become degenerative at their attachment site at the elbow. The site of pain is the extensor carpi radialis brevis (ECRB) muscle, which is on the lateral condyle side of the humerus. Most people who get tennis elbow are in their 30s-50s.
Causes
You don’t have to play tennis to get Tennis Elbow. Actually, most people who get it don’t. Typically, this condition is caused by overuse activities that place stress on the ECRB tendon attachment at the elbow. The ECRB helps stabilize the wrist when the elbow is extended. Often, stress from repetitive gripping and grasping activities, such as racquet sports, prolonged hammering or lifting heavy objects such as shopping bags, luggage, laptop computer or a gallon of milk, increase the strain on the ECRB and cause microscopic tears. These eventually lead to greater damage because blood supply to this area of the arm is so poor and a healing response is limited. Even with a slightly irritated tendon early on, light daily activities such as opening doors, shaking hands, cooking, brushing your teeth or turning a wrench become enough to perpetuate the irritation. When the inflammation becomes severe, any motion of the wrist or fingers can cause agony. Trauma from a direct blow to the elbow can create a tear of the ECRB. The degenerative or torn tendon causes severe pain, which is what brings patients into the office.
Signs and Symptoms
In most cases, the symptoms of tennis elbow develop gradually. There is usually no specific injury (unless there is a direct blow to the lateral side of the elbow) and the pain begins as mild and slowly worsens over the ensuing weeks and months. Most people experience burning pain on the lateral side of their elbow. Weakened grip strength can also accompany the pain. Symptoms worsen with continued forearm activity.
Diagnosis
A detailed history of the patient’s occupation and activities, examination of the arm with special tests will help diagnose this condition. Dr. Viola prefers to follow the diagnosis with an MRI to quantify the level of tendon injury, which will give patients more definitive treatment options.
Treatment
Many patients who visit the clinic have already tried conservative measures such as anti-inflammatory medications, activity modification and rest without much improvement. So, as this point, it is important to obtain an MRI to quantify the level of ECRB tendon injury. Just injecting the tendon with steroid to ease the pain without this vital information can cause further tendon damage if the tendon is severely degenerative. If an MRI does show that the level of tendon tearing and degeneration and symptoms are moderate to severe, surgery is recommended to debride the sclerotic ECRB, which is unlikely to heal on its own, and then to repair the tendon. Because this site in the elbow has a very poor blood supply and is therefore slow to heal, Dr. Viola will often use PRP (platelet rich plasma, see below) in conjunction with debridement and repair to further improve the healing response. After this quick procedure, patients are allowed full range of motion and advised to slowly ramp up their level of activity and strengthening over the next few weeks, as pain allows them to. No splinting is required.
If the level of tendon tearing is mild to moderate, as shown on MRI, a PRP injection without surgery is often appropriate to help the tendon heal faster on its own. Introduction of PRP, from your own blood, into the damaged ECRB tendon induces platelets to release concentrated healing proteins and growth factors. The ECRB attachment site at the elbow has a poor blood supply, so the PRP helps initiate a regenerative healing response at the cellular level. After the injection, the arms is sore, but patients are allowed full range of motion and advised to slowly increase their arm level of activity and strengthening as pain improves.
If the MRI shows mild injury to the ECRB, a steroid injection into the tendon attachment can help relieve the symptoms of pain. Although they are potent anti-inflammatory medications, steroids slow healing and can cause tendon rupture. (This is why Dr. Viola will usually not inject patients without an MRI first.)
Modification of daily activities such as not reaching forward and lifting and lighter gripping is recommended to limit the aggravating factors causing further tendon pain.
Physical or Occupational Therapy Hand Therapy can provide stretching and strengthening exercises and education about activity modification and body mechanics. Massage, ultrasound or heat treatments can be pain relieving.
Over the counter pain relievers such as NSAIDs and Acetaminophen can help relieve the pain of the aggravated elbow and wrist. However, NSAIDs are NOT recommended after PRP injections and surgery because they can counteract the body’s mechanism of healing after these procedures.