Lateral Epicondylitis 

The Basics

  • Lateral epicondylitis is an overuse injury that results in chronic inflammation at the origin of the common extensor tendon. This is the bony prominence at the outside of the elbow.

  • The finger and wrist tendons attach to the muscles of the forearm. These muscles become a common tendon group that attaches to the outer bony prominence on the elbow (lateral epicondyle).

  • Patients will complain of pain with gripping, pain with resisted wrist extension, and weakness of grip. They will often complain of pain with trivial activities such as lifting a coffee cup. The degree of pain is related to the amount of inflammation and not the severity of tissue damage.

  • Tennis Elbow is often caused by repetitive wrist extension and gripping movement that results in inflammation and often small tears of the tendon. It is common in laborers who use heavy tools. It is the most common cause of elbow pain and many consider it a “ right of passage for middle age”. It is common in amateur tennis players with a poor or mechanically unsound backhand (this does not mean you are not an incredible tennis player , you just need some backhand work). On occasion it can result from a direct blow to the lateral elbow.

  • Patients will have pain with palpation of the lateral epicondyle and pain with finger or wrist extension against resistance.

  • X-Rays are not required because they will not show the tendon or the injury. An X-Ray may show calcification (calcium deposits) which are a sign of chronic tendinitis. An MRI is not required although it may show inflammation or a tear in the tendon, but this will not change the treatment plan. Ultrasound shows the injury as well but is not required.

Treatment

  • 98% of patients will recover with non operative treatment. The key is patience to allow the body to heal itself. The acute inflammation is useful to start the healing response but chronic inflammation results in prolonged pain. Rest or activity modification is important to avoid the repetitive motion that caused the injury. A counterforce brace is often useful to treat this condition. This is a strap that goes on the forearm muscles to reduce the force on the lateral epicondyle and help the tendon heal. Icing 1-2 times a day directly on the lateral epicondyle will help reduce the chronic inflammation. Anti inflammatory medicines/supplements can be helpful to reduce chronic inflammation and pain.

  • Physical Therapy can be helpful but it is a fine line between stretching and modalities to decrease chronic inflammation and further aggravating the tendon.

  • An injection often takes away the pain in 3-4 days. It does not heal the injury but it decreases the inflammation and can give you pain relief while the tendon heals. If you continue to do the repetitive motion that caused the injury the pain will likely return. After an injection it is important to wear a counterforce strap, to ice your elbow daily ( like a baseball pitcher ices their elbow whether they feel good or not ), and modify activities. You can get up to three injections. If you get an injection you should be cautious. If you continue all your aggravating activities you are increasing the chance you will need surgery.

  • 1) Iontophoresis/phonophoresis- is a treatment done by the therapist to decrease inflammation.

    2) Acupuncture- may be of benefit to promote healing

    3) Plasma Rich Protein or Stem Cell injections- PRP is your own blood spun down to the plasma and injected into the area to promote healing. Stem Cells are from another source and injected. Both should help in theory because they contain significant healing factors with no harm. However, these treatments are costly and insurance does not cover them. The cost is significant which could be frustrating if it does not work. This is often the first line of treatment for professional athletes. They do not want a cortisone injection and return to play because they could make the injury worse. Prolonged rest or surgery could result in missing a substantial part of the season. In this case PRP or stem cells is a reasonable alternative. I have had good success with these injections but it is anecdotal evidence without a large enough group for a case controlled study.

  • Surgery is considered after failure of conservative treatment for 6-12 months. A small incision is made over the lateral epicondyle and the abnormal tendon is debrided or repaired. Often the bone is debrided to cause a bleeding surface that promotes healing.

    Additional Considerations:
    1) Anesthesia- The surgery is outpatient and requires sedation and a local numbing injection. Many patients will require a pre op workup from their PCP, they will need to abstain from eating or drinking the night before surgery , and they will need a ride home from surgery.

    2) Recovery- bandages and an ace wrap will be placed around the elbow with an arm sling for comfort. You can move your fingers and elbow right away. The sutures come out 2 weeks later. I recommend no lifting ( nothing heavier than a pencil ) and no forceful gripping for 3-6 months. These activities can injure the healing tendon and result in continued symptoms.

    3) Results- The vast majority of patients who follow the post operative instructions make a full recovery

    4) Revision Surgery- revision surgery usually involves detaching the entire tendon , removing the outside of the bone , and reattaching the tendon to the bone. This is followed by further lifting and activity precautions

Prevention

Whether you are a laborer or an athlete you need to focus on proper form to prevent injury. Once you are injured you need to rest or modify your activities to prevent a chronic injury. Do not fight through the pain in hope it will go away. Patients with Chronic inflammation issues are more likely to be injured from minor activities, they will take longer to heal , and are more likely to require surgery. Patients are not considered for surgery for 6-12 months. By this time the acute inflammation which is beneficial for healing has been replaced by chronic inflammation which is not helpful. Lateral epicondylitis like all diseases of chronic inflammation can be improved with proper nutrition, fitness, sleep, and stress reduction.