Epicondylitis

Introduction

Repetitive movements of the arms can cause damage to tendons which results in elbow pain.  Tendons are bands that connect muscles to the bone. Overuse of the elbow during sports, occupations, or activities of daily living, can injure tendons which leads to pain and degeneration When a tendon is injured it is called tendinitis. The elbow also has bony prominences called the medial (inside) and lateral (outside) epicondyle. Certain tendons attach on these epicondyles and when the tendons become damaged, it is called epicondylitis. Commonly, lateral epicondylitis is termed “tennis elbow” and medial epicondylitis is called “golfer’s elbow.” However, a patient can develop these conditions from a variety of sports or work-related activities that heavily use the muscles or the forearm and wrist. 

Clinical Presentation

Patients start to experience elbow pain that may radiate up or down the arm. This can start abruptly or gradually worsen over time. A patient may experience muscle weakness of the forearm. Additionally, activities that involve arm strength may be difficult to complete. Tennis players most commonly experience the difficulties with their backhand stroke. 

Pathophysiology

Epicondylitis is less of an acute inflammatory condition and more of a chronic tendinosis. Tendinosis refers to the break down or tear of a tendon. In lateral epicondylitis, the tendon of the extensor carpi radialis brevis muscle is most commonly involved. For medial epicondylitis, the tendon of pronator teres and flexor carpi radialis muscles are most commonly involved. 

Mechanism of injury 

Athletes and people in occupations that involve repetitive movements, specifically eccentric muscle movements of the elbow, most commonly develop epicondylitis. Eccentric contraction means the muscle and tendon are being lengthened while bearing weight. 

Diagnosis

The diagnosis of Epicondylitis is made clinically by a provider based on a patient’s symptoms and physical exam. X-rays or other Imaging is not usually necessary. However, if pain is persistent, imaging may be considered. 

Treatment 

Most people respond well to a combination of the treatment options described below. It may take 6-12 weeks for the pain to resolve.

  • Pain relief: 
    • Acetaminophen (Tylenol) or Ibuprofen can be taken on an as needed basis. 
    • Applying ice or heat to the effected area may also reduce pain.
  • Arm brace: 
    • Later epicondylitis (tennis elbow): A strap or elbow brace can be worn while participating in activities that worsen symptoms or use a lot of arm movement. The brace applies pressure to the muscles of the forearm which reduces the pressure on the affected tendon. This may need to be worn for up to 6 weeks for full resolution of symptoms. 
  • Flexibility exercises: These stretches should promote a good stretch; no pain should be experienced
    • Lateral epicondylitis (tennis elbow):
      • Forearm extensor stretch: Hold your affected arm straight in front of you with your fingers pointing to the ground and palm facing towards you. With your unaffected hand, press down on the back of the hand of the injured arm, bending the wrist even more. Hold this position for 30 seconds. Repeat up to 3 times. 
  • Medial epicondylitis (golfer’s elbow):
      • Hold your affected arm straight in front of you with your fingers pointing to the ground and palm facing away from you. Place your palm against the wall and apply gentle pressure for 30 seconds at a time. Repeat up to 3 times. 
  • Formal Physical Therapy
    • Can be helpful for rehabilitating and strengthening the tendons and reducing pain.

Prevention

  • To keep the elbow healthy, proper strengthening of the shoulder and arm muscles is recommended. 
  • Avoid overuse of the elbow by taking frequent breaks from repetitive hand/wrist motions. 
  • For golfers or tennis players, apply grip tape or increasing the size of the grip may aid in symptom prevention. 
  • Tennis players can also practice proper stroke mechanics. With stroke modifications, up to 90% of symptoms are resolved within 6 months. Proper mechanics involve more force generation from the hips/pelvis and less from the wrist.

References: 

MendMeShop. “Cutting Edge Tennis Elbow Treatments.” Tennis Elbow and Golfers Elbow Injury Information and Treatments, http://www.aidmytenniselbow.com/.

By Kaci Rood and Jon Minor