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epicondylitis, elbow tendinitis, lateral epicondylitis, tennis elbow

What is epicondylitis and what are the most effective ways to treat it?

Elbow tendinitis is a common disorder among physically active individuals that have a good prognosis but may require three to six months to resolve even with optimal management (1). Lateral epicondylitis or ‘tennis elbow’ is the pain and discomfort associated with ‘inflammation’ at the extensor muscle group origin at the lateral humeral condyle insertion, principally in the extensor carpi radialis brevis (ECRB) tendon. Medial epicondylitis or ‘golfer’s elbow’ is less common but tends to be more difficult to treat. The affected area is at the interface between the pronator teres and flexor carpi radialis origin at the medial humeral condyle.

Aetiology

Epicondylitis will remain a problem to treat until we have a better understanding of the nature of this degenerative condition (2). In the case of lateral epicondylitis it is known that insufficient healing occurs after the initial insult, leaving the extensor origin vulnerable to secondary injury. Recent research suggests that potential hypovascular zones might be located at the under surface of the ECRB tendon causing degeneration and partial tears(3).

Why are athletes susceptible to epicondylitis?

The elbow is subjected to enormous valgus stresses during throwing which renders the overhead-throwing athlete at considerable risk of elbow injury(4). Lateral epicondylitis can be the result of overuse technique in racket sports. It occurs in over 50% of athletes using overhead arm motions due to excessive use of the wrist extensor musculature(5). Medial epicondylitis is believed to result from the tremendous valgus stresses that occur during the acceleration phase of pitching(6) and from overuse of the flexor-pronator musculature.

Physical findings

Lateral epicondylitis is characterised by pain and local tenderness over the lateral epicondyle of the elbow. It is exacerbated by resisted wrist extension and tends to be worse when the elbow is extended. Medial epicondylitis is characterised by pain and tenderness at the flexor-pronator tendinous origin. Careful evaluation is important to differentiate medial epicondylitis from other causes of medial elbow pain such as ulnar collateral ligament instability, the diagnosis and surgical treatment of which is currently very popular(6). A diagnosis of epicondylitis can usually be made having taken a careful history from the patient and then performing a methodical examination. There should be no need for ultrasound(7) or magnetic resonance imaging(8) to confirm the diagnosis.

Non-operative treatment

Over 40 different treatment methods for lateral epicondylitis have been reported in the literature. Unfortunately, research has found that all these methods have been inconsistently effective (9). The most popular methods used include rest, non-steroidal anti-inflammatory agents (10), a counterforce brace/strap orthotic (11) and corticosteroid injections(9, 12, 13, 14). It is usually a good idea to engage in a prolonged course of non-operative treatment (nine to 12 months) because the majority of patients will get better. Equipment modifications such as a more flexible racket, larger racket head or larger grip, may also be helpful.

Corticosteroid injections

This is one of the most popular methods used with a high success rate(9). Analysis of the literature, however, tends to suggest that they help in the short rather than the long-term(12). Patients who achieve pain control after only one cortisone injection tend to successfully avoid surgery 88% of the time, whereas those requiring multiple injections avoid surgery only 44% of the time(13). These results question whether we are simply observing the natural outcome of the condition rather than the true effect of the steroid injection. In a recently published randomised study on lateral epicondylitis, the effectiveness of injecting steroid alone was compared with injecting local anaesthetic alone. No statistical difference was found between the two groups even though we know that local anaesthetic has no long-term effect(14). The researchers suggested that it may be the actual method of injecting itself rather than what is injected that helps relieve symptoms. They advocate a ‘peppering’ technique whereby after the needle is inserted into the tender area, multiple small injections are performed by withdrawing, redirecting and reinserting the needle without emerging from the skin.

Low-intensity laser irradiation

This was fashionable as a treatment modality for epicondylitis in the late 1990s. Some found that it substantially reduced symptoms and improved quality of life(15); others found it to be ineffective(16).

Lithotripsy shock wave therapy

This is currently in vogue as a treatment modality. It appears to be safe and have no device-related, systemic or local complications(17). Early published results of its effectiveness are encouraging(17, 18). The roles of acupuncture(19) and ultrasound therapy(20) are questionable and warrant further investigation.

Operative treatment

Non-operative management is still the most common treatment but those who are disabled when this fails can expect improvement after surgery (2). Surgery is only required in less than 10% of cases(1). Surgical options for lateral epicondylitis include the release of the common extensor origin from the lateral epicondyle and/or debridement of the pathological granulation tissue. In medial epicondylitis, debridement of the medial epicondyle and reattachment of the flexor-pronator group can be undertaken in recalcitrant cases. Some surgeons have had success by releasing ECRB from its origin arthroscopically (21) for lateral epicondylitis.

In summary

Epicondylitis is a frequently reported condition common in athletes. Although symptoms tend to resolve with non-operative management, 10% of cases can be persistent.

A wide range of treatment options exist; lithotripsy is currently fashionable. Literature searches indicate that few trials have been conducted with variable outcome measures and limited long-term results. Subsequently, due to the heterogeneity of the data, pooling of the data is not possible and no definitive conclusions can be drawn with regards to the effectiveness of different treatment modalities.

Alex Watson

References

  1. Current Opinion in Rheumatology, Vol 11 (2), pp138-143, 1999
  2. Hand Clinics, Vol 16 (3), pp505-508, 2000
  3. Clinical Orthopaedics & Related Research, Vol 398, pp239-244, 2002
  4. Journal of the American Academy of Orthopaedic Surgeons, Vol 9 (2), pp99-113, 2001
  5. Sports Medicine, Vol 26 (3), pp193-205, 1998
  6. Clinics in Sports Medicine, Vol 20 (3), pp541-548
  7. American Journal of Roenterology, Vol 176 (3), pp777-782, 2001
  8. Acta Radiologica, Vol 42 (5), pp434-440, 2001
  9. Sports Medicine, Vol 28 (5), pp375-380, 1999
  10. Clinical Journal of Sports Medicine, Vol 8 (2), pp78-81, 1998
  11. British Journal of General Practice, Vol 51 (472), pp924-929, 2001
  12. Lancet, Vol 359 (9307), pp657-662, 2002
  13. American Journal of Orthopaedics, Vol 30 (8), pp642-646, 2001
  14. Clinical Orthopaedics & Related Research, Vol 398, pp127-130, 2002
  15. Journal of Clinical Laser Medicine & Surgery, Vol 17 (1), pp29-33, 1999
  16. Archives of Physical Medicine & Rehabilitation, Vol 81 (11), pp1504-1510, 2000
  17. Clinical Orthopaedics & Related Research, Vol 387, pp60-67, 2001
  18. Archives of Physical Medicine & Rehabilitation, Vol 82 (5), pp578-582, 2001
  19. Rheumatology, Vol 41 (2), pp205-209, 2002
  20. Pain, Vol 81 (3), pp257-271, 1999
  21. Arthroscopy, Vol 17 (6), pp582-587, 2001

epicondylitis, elbow tendinitis, lateral epicondylitis, tennis elbow