UNC SPORTS MEDICINE FAMILY MEDICINE SPORTS MEDICINE Lateral Epicondylitis What is lateral epicondylitis? Lateral epicondylitis, or tennis elbow, affects 1-3% of Americans each year. The epicondyles are the two bumps on the inside (medial) and outside (lateral) part of the elbow. They form the end of the long bone in the upper arm, called the humerus. Epicondylitis occurs from partial or complete tears of the tendons of the forearm, most commonly the extensor carpi radialis brevis. These tears initially cause pain and inflammation. Continued use of the wrist and no treatment causes chronic degenerative inflammation, which leads to edema, persistent inflammation, pain, and scarring of the damaged tendon fibers. Anatomy Muscles that extend the wrist (bend towards the back of the hand) are attached to the lateral epicondyle by tendons. These muscles include extensor carpi radialis brevis, extensor carpi radialis longus, and extensor digitorum. The breakdown, and subsequent pain, from lateral epicondylitis usually occurs along these tendons, about 1-2 cm from the lateral epicondyle. Extensor carpi radialis longus Humerus Extensor carpi radialis brevis Ulna Extensor digitorum Extensor digiti minimi Radius Extensor carpi ulnaris Causes Lateral epicondylitis usually occurs because of overuse or repetitive motion of the extensor muscles of the wrist. This can occur because of: - Poor conditioning of the muscles in the upper arm and shoulder, causing an over reliance on the extensor muscles. Improper technique or positioning with athletic equipment. - Improper equipment – weight, grip size, or even string tension with rackets. Risk factors The strongest risk factor for lateral epicondylitis is age. There is no difference in incidence between women and men. 75% of cases occur in the dominant extremity. Symptoms - Gradually increasing pain on the outside (lateral) aspect of the elbow Worse pain with activities that involve extension of the wrist, e.g. backhand tennis stroke, repetitive use of a screwdriver, or lifting heavy objects In more severe cases, pain can occur with such simple activities as holding a coffee cup or turning a door knob Pain can occasionally radiate down outside (lateral) aspect of the arm Diagnosis The diagnosis of lateral epicondylitis is usually made by a doctor based on typical signs and symptoms in conjunction with a physical exam. Imaging modalities such as x-rays are not needed for diagnosis, but are often used to rule out other possible diagnoses. Physical Exam - Tenderness about 1-2 cm away from the lateral epicondyle, at the tendons for the wrist extensor muscles. Pain with resisted wrist extension when the elbow is extended. Pain when lifting an object such as chair with the palm down. Range of motion and sensation are usually not affected. There is rarely visible redness or swelling. Imaging - Two simple x-rays, one viewing the elbow from the front-to-back perspective and one viewing the elbow from the side, are used to rule out other causes of elbow pain such as osteoarthritis, fractures, etc. While an MRI can be used to diagnosis lateral epicondylitis, it is most often unnecessary and the results do not correlate to prognosis. What are other possible causes of my pain? - Fracture of the radial head (one of the forearm bones) Osteoarthritis of the elbow Osteochondral loose body Synovitis of the elbow (inflammation of the elbow joint capsule) Triceps tendonitis Cubital tunnel syndrome Radial tunnel syndrome Cervical radiculopathy (Nerve pain that radiates from the neck) Posterior interosseous nerve compression syndrome (Compression of a forearm nerve) Treatment - The most important aspect of treatment for lateral epicondylitis is modifying or ceasing inciting activities. For patients with severe disease, such modifications may have to be permanent. The goal of treatment is to relieve pain, resolve the inflammation and strengthen the effected muscle. - Forearm strengthening and stretching exercises are crucial for long term improvement. Some people will require short-term physical therapy. The identification and rectification of improper techniques or equipment are critical. Anti-inflammatory medicines, such as non-steroidal anti-inflammatory drugs (ibuprofen, naproxen) and antiinflammatory creams, may be helpful for many patients. Elbow straps that are worn just below the elbow during inciting activities may lead to some relief. In severe, persistent cases, a corticosteroid injection can be given in the area of maximum discomfort. However, no more than three of these injections should be given. PRP injection (Platelet Rich Plasma) is also an option. Please see information on Sports Medicine website. In the most severe of cases surgery may be considered if no other treatments have worked; however, more than 95% of patients with lateral epicondylitis do not require surgery. Prognosis Among all patients who underwent treatment, either conservative or surgical, 90% reported complete resolution of symptoms and were able to return to their prior level of activity. Return to Play Once a patient is able to complete rapid repetitive motion exercises without pain, the can return to normal activity. They must gradually increase resistance or workload to lessen chance of re-injury. Complete return to play usually occurs by 16 weeks after treatment commences. Resources “Medial and lateral epicondylitis.” Essentials of Musuloskeletal Care. Ed. Letha Yurko Griffin, MD, PhD. Rosemount, IL: American Academy of Orthopedic Surgeons, 2005. pp. 261-266. Owens, Brett MD, Wolf, Moriatis MD, Murphy, Kevin MD. “Lateral Epicondylitis.” From eMedicine. http://emedicine.medscape.com/article/1231903-overview Physical Therapy Specific Physical Therapy exercises and stretches are outlined below. In addition to these activities, certain treatment modalities have proved helpful in treating this condition. Friction massage, manipulation, phonophoresis and iontophoresis can be administered by a physical therapist to control symptoms and promote healing. The most important aspect of recovering from lateral epicondylitis is to stop all activities that cause symptoms. Cross friction massage and ice massage at the area of maximal tenderness can help you to become symptom free more quickly. Cross friction massage means to rub the tender area of your arm circumferentially. Massaging this area with ice may also be helpful. Once symptom free, your physical therapist may recommend exercises that will strengthen the muscles in your forearm. Extend the wrist as shown. Initially begin with no weight, and if pain free, increase in 1 lb. increments to a maximum of 5 lb. Perform 3 sets of 25 repetitions, 5 to 7 days a week for 3 to 4 weeks. Flex the wrist as shown. Initially begin with no weight, and if pain free, increase in 1 lb. increments to a maximum of 5 lb. Perform 3 sets of 25 repetitions, 5 to 7 days a week for 3 to 4 weeks. For supination exercises, begin with the hand in a fist with the thumb pointed up, and rotate the arm 90° as shown so that the palm is up. Initially begin with no weight, and if pain free, increase in 1 lb. increments to a maximum of 5 lb. Perform 3 sets of 25 repetitions, 5 to 7 days a week for 3 to 4 weeks. For pronation exercises, begin with the hand in a fist with the thumb pointed up, and rotate the arm 90° as shown so that the palm is down. Initially begin with no weight, and if pain free, increase in 1 lb. increments to a maximum of 5 lb. Perform 3 sets of 25 repetitions, 5 to 7 days a week for 3 to 4 weeks. Developed by Mark Sakr DO, Andrew Ditto MD, Harry Stafford MD. 2/2010