Tennis elbow
Tennis elbow – Tennis elbow is a tendinopathy of the common extensor origin of the lateral elbow ( John Orchard BMJ 2011 ). First described by Runge et al in 1873 when it was called ” writers cramp “
Tennis elbow is very common Peaks age 35-55 Dominant arm involved in majority of ( ~ 75 % ) cases Equal gender incidence Prevalence 1-3 % ( higher in manual workers ) Tennis players make only 10 % of tennis elbow cases but 50 % of tennis players develop elbow pain and tennis elbow is responsible for 75 % of those Occurs more frequently in non-athletes Most common cause of persistent elbow pain in general practice
Etiology multifactorial Overuse injury of extensor carpi radialis brevis insertion at the lateral epicondyle of humerus Several contributory factors as ○ force ○ repetition ( forearm and elbow ) ○ posture Repetitive overuse –> microtear –> initiates a degenerative process Tendon adaptation –> granulation tissue formation , fibrosis and eventual tendinosis No evidence of acute or chronic inflammation ie not a true inflammatory process Tendons predisposed to injury due to (a) limited vascular supply (b) subject to repetitive tension forces (c) wrap around a convex surface
Risk factors- age 40-60 yrs Previous hx of epicondylitis repetitive activities ( occupational or recreational ) eg tennis , golf , rowing , baseball , kayaking construction work , assembly line work , use of vibratory tools , playing piano , plumbing , painting poor mechanics during activities smoking ( current and previous ) inadequate physical conditioning rotator cuff pathology De Quervains disease Carpal tunnel syndrome Oral corticosteroid therapy
diagnosis is clinical based on history and examination – Pain -severity , onset , duration Exacerbating causes ask about h/o injury or ↑↑ ed level of activity usually insidious onset with no precipitating event Social and occupational history Impact of illness eg ○ difficulty with raising cup ○ shaking hands ○ shaving ○ lifting bags with an extended elbow Patient reports ○ pain at lateral aspect of elbow pt can point to an areas 1.5 cm distal to the lateral epicondyle ○ decreased grip strength ( due to pain ) ○ tenderness at the lateral epicondyle
examination-R/O red flags Elicit typical features as ○ localised point tenderness over and / or distal to the lateral epicondyle and along common extensor tendon ○ pain associated with resisted wrist extension with the elbow extended ○ pain associated with resisted middle finger extension with the elbow extended ○ pain on wrist flexion with the elbow extended ○ weakened grip Elbow joint movements -active and passive usually preserved Consider checking neck/shoulder for referred pain Diagnosis can be verified by US or MRI Consider nerve conduction study if nerve dysfunction suspected Consider blood tests if inflammatory arthritis suspected Plain radiographs usually normal
red flags-h/o trauma joint swelling/redness systemic symptoms rapidly increasing mass
differential;l-Humeral fracture Radial head fracture Osteoarthritis Radial tunnel syndrome Primary ligamentous instability Cubital tunnel syndrome Osteochondritis dissecans of the capitellum Rheumatoid arthritis or septic arthritis Referred pain- from cervical spine Olecranon bursitis
Aim is to provide pain relief and restore physical function and maintain ability to work Non operative measures successful in > 80 % Treatment strategies can involve ○ activity modification ○ rest ○ NSAIDS ○ splint ○ physiotherapy ○ steroid inj ( used widely ) ○ acupuncture Advice patient to d/w OT if work related Offer topical NSAID ( first line CKS ) Offer information and advice leaflet. spints and orthotics , extracorporeal shock wave therapy , atologous injection , corticosteroid injection , platelet rich plasma, physiotherapy, surgery
summary-Usually a self limiting disease Symptoms are usually mild and prognosis is excellent Resolves in 80-90 % of people by 1-2 yrs ( conservatively ) Several modalities of treatment have been tried No universal treatment protocol No treatment has been shown to be superior to others Main complication is continued pain – other complications may be due to the interventions used to relieve pain
referral-Diagnostic uncertainty Severe functional limitation Refractory /severe pain Symptoms persist despite 6-12 months of management in primary care
LINKS and RESOURCES
Exercise for tennis elbow Arthritis Research UK leaflet – https://www.csp.org.uk/system/files/6_tennis_elbow.pdf
A useful page from NHS York Teaching Hospital- also has several other MSK sections https://www.yourphysio.org.uk/condition-directory/lateral-epicondylitis-tennis-elbow1/
BUPA has a very informative page for patients suffering from tennis elbow patients can also book a private physio session https://www.bupa.co.uk/health-information/muscles-bones-joints/tennis-elbow
NICE has produced guidance on Extracorporeal shockwave therapy for refractory tennis elbow https://www.nice.org.uk/guidance/ipg313/resources/extracorporeal-shockwave-therapy-for-refractory-tennis-elbow-pdf-1899867390150085
Another guidance from NICE on autologous blood injection for tendinopathy https://www.nice.org.uk/guidance/ipg438
Patient UK guidance for patients on Tennis elbow- a useful decision aid may come handy https://patient.info/bones-joints-muscles/tendinopathy-and-tenosynovitis-tendinosis/tennis-elbow
Patients may ask about arthroscopy for tennis elbow ( ie surgical option ) a useful generic explanation can be found on OrthoInfo website https://orthoinfo.aaos.org/en/treatment/elbow-arthroscopy/
Shoulderdoc – has a similar section for patients explaining the procedure https://www.shoulderdoc.co.uk/article/635
References
- Tennis elbow BMJ 2009 ;339 :b3180
- BMJ Best Practice Epicondylitis https://bestpractice.bmj.com/topics/en-gb/978
- Clinical guideline to standardise the management of Tennis Elbow Cheshire and Wirral Partnership NHS Foundation Trust
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Lateral and medial non-articular elbow pain Ward Koot Bertram The Denise Eygendaal ELBOW| VOLUME 30, ISSUE 4, P336-345, AUGUST 01, 2016
- Risk factors in lateral epicondylitis ( tennis elbow ) : a case-control study A G Titchener et al Volume : 38 issue : 2 , page(s) : 159-164 ( Abstract )
- Elbow pain : a guide to assessment and management in primary care Br J Gen Pract . 2015 Nov ; 65 ( 640 ) : 610-612
- Tennis elbow : A Review IOSR Journal of dental and Medical Sciences ( IOSR-JDMS ) Volume 17 , Issue 6 Ver .3 ( June 2018 ) ,PP 85-88
- Tennis elbow : associated psychological factors J Shoulder Elbow Surg ( 2018 ) 27, 387-392 Gani NU, Khan HA, Kamal Y, Farooq M, Jeelani H, Shah AB.
- Long term results in refractory tennis elbow using autologous blood. Orthop Rev (Pavia). 2014;6(4):5473. Published 2014 Nov 19. doi:10.4081/or.2014.5473
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Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All Journal of Orthopaedic & Sports Physical Therapy Published Online:October 31, 2015Volume45Issue11Pages938-949 https://www.jospt.org/doi/10.2519/jospt.2015.5841