Lateral epicondylitis, also known as tennis elbow, is one of the most common adult ailments seen in the offices of orthopedic surgeons. Approximately 1-3% of adults will experience lateral elbow pain at one time or another in a given year. For the most part, the discomfort is mild and transient, and care is not sought. However, in some patients, the discomfort is enough that it will affect their daily activities and possibly their work. These patients require more aggressive care. Both nonsurgical and surgical treatments are available, depending on its duration and severity, as well as, the needs of the patient.
The typical patient with tennis elbow presents with a history of repetitive use of the injured arm, especially with the use of heavy tools. The onset of the pain is often gradual although occasionally, the patient will have an acute injury where sudden strain is applied to the arm which causes lateral elbow pain. Because this is a common problem, often beginning with very mild symptoms and typically it gets better with time, there is usually a delay between the onset of symptoms and the patient’s presentation to a physician’s office.
In order to understand tennis elbow, it is important to understand its source. There are four muscles which extend the wrist and the four tendons from these muscles all attach onto the lateral epicondyle of the elbow. This is a small bump that can be felt on the outside of the elbow. Trauma, resulting from injury or overuse, causes an injury to the deepest of the four tendons, resulting in pain. Thus, epicondylitis is a misnomer, because “itis” implies inflammation. Although there can be some inflammation associated with the injury and healing process, it is the damage to the tendon itself which is the source of the problem.
Typically, patients will describe a sharp pain, sometimes burning in character, on the outside of the elbow. It is typically worse with activity and often there will be some sense of weakness about the hand and wrist with difficulty holding objects because of pain at the elbow. On physical exam, classically, the patient will have discomfort just distal to the epicondyle over the extensor tendons and the pain will be worsened when the physician provides resistance against the patient while the patient tries to extend his fingers or wrist.
Usually, basic first aid such as ice, anti-inflammatories, and avoidance of the activities which cause the pain, will relieve the symptoms. Patients need to be made aware, that the pain can last for quite some time, and it is not unusual to have symptoms for up to a year or longer. Once the initial, more severe pain can be diminished, modalities can be introduced which will allow the patient to return to activity. Some discomfort might still be present, and there might be some acute exacerbations of the discomfort, but in general the trend towards improvement can be expected. Importantly, patients can often return to work at this time although they are not yet pain-free.
The three most common treatments used to supplement anti-inflammatory medications are physical therapy, bracing, and steroid injections. Physical therapy will usually include gentle stretching and strengthening exercises. Although this problem occurs with use, controlled exercise can stimulate healing of the damaged area. Bracing includes a wrist splint which brings the wrist up into extension, thus relaxing the extensor muscles and taking tension off the extensor insertion. Elbow wraps take tension off the tendon, are easily tolerated, and are available at almost any drugstore. Steroid injection probably has no long-term benefits however, in the short-term it can relieve pain. This gives the patient some relief and also allows them to participate more actively in therapy and perhaps to return to work more quickly.
Finally, there are surgical procedures available to treat tennis elbow. These are relatively simple outpatient procedures. Because tennis elbow typically gets better over time, the decision to perform surgery is usually based on the patient’s level of discomfort, failure to respond to other measures, or the need for immediate relief due to disability and inability to work. There is a trend towards more immediate surgery as results seemed to be good and will cut down the overall recovery time for some patients; however, it is difficult to recommend surgery as the primary treatment in most cases for a problem that usually gets better anyways.
Tennis elbow is a very common and treatable problem. The duration of symptoms and the fact that these symptoms often interfere with employment are what can make a typically nuisance-type problem into a major disrupting factor in a person’s life. In the end the outcomes are usually quite good but the fact that it takes a long time to recover can be very frustrating. Patience is probably as important as any medical intervention.
William Vranos, MD, is a board-certified orthopaedic surgeon with BMH Orthopaedics & Sports Medicine. He can be reached at 802-251-8611.