Do you ever wonder what causes pain in your elbow?
- Posted on June 27, 2011
-
Who gets Tennis Elbow?
Tennis elbow, or lateral epicondylitis is a common elbow problem affecting four out of every 1,000 adults. The tern 'tennis elbow' came into use because it affects nearly half of all tennis players at one time or another, however, tennis players account for less than 5 percent of the total reported cases. The average duration of an episode of epicondylitis if from 6 to 24 months, making it one of the more stubborn conditions to treat and correct.
What is Tennis Elbow?
By definition it is an inflammation or injury of the tissues that attach to the lateral epicondyle including primarily the wrist extensors and supinator tendons. Eventually there may be subperiosteal hemorrhage, calcification or spur formation on the lateral epicondyle. In tennis players it is caused by a combination of forceful grasping, wrist extension and supination during a backhand motion, weak shoulder and wrist muscles, using a tennis racket that is too short or too tightly strung, hitting the ball off center or hitting heavy, wet tennis balls. It can be caused by a variety of other repetitive activities that involve gripping and wrist extension or supination such as hammering, painting, lifting with the palm down or operating various hand tools repetitively. Poor posture of decreased proximal muscle strength can lead to overuse of wrist extension or supination during activity. These muscles are smaller and weaker than more proximal structures and fatigue quickly with repetitive use. In a few cases the cause is a traumatic contusion. Normally the body is able to heal repetitive traumas or microscopic tears to the tendon tissues, however it is theorized that with continued use, the tendons finally give up on trying to heal and a condition develops called angiofibroblastic degeneration. This is a condition in which tissues continually tear, fail to heal, hemorrhaging occurs and there is development of rough, granulated tissue with calcium deposits. Blood flow is decreased or constricted, and collagen leaks out from surrounding tissue, causing inflammation. The pressure of the inflammation can compress the radial nerve and further decrease blood flow. Much of the conservative treatment measures are aimed at increasing blood flow and reactivating the healing process.
Symptoms
The symptoms of lateral epicondylitis include primarily pain localized to the lateral elbow and forearm and pain, which worsens with gripping or grasping and turning palm up. A few patients lose full elbow extension and full wrist motion. It is diagnosed primarily with physical examination. There is palpable tenderness in the lateral elbow and sometimes tightness and tenderness in the wrist extensors or supinators. Pain increases with resisted wrist extension and/or supination. There is often pain and weakness of grip strength especially when the elbow is extended. If no tenderness is present, referred pain from the cervical spine or shoulder should be suspected. Most x-rays are normal, but calcification is visible in 20 percent of cases, therefore films should be taken to rule out any intra-articular conditions. Radial tunnel syndrome can occur separately or in conjunction with tennis elbow involving compression of the radial nerve at the radial tunnel, with tenderness more anterior and distal to the epicondyle.
Conservative Treatment
Conservative treatment is very effective, with an average of 5 percent of cases requiring surgical intervention. Theories and methods for conservative management vary greatly. Ideally, the activity that is causing the repetitive trauma is discontinued temporarily or modified to allow the tissues to rest and repair. This may include the use of tennis elbow strap, which works to compress the tendons against the bone just distal to the normal insertion and distal to the pain or order to create a false insertion to the muscle and thereby giving the injured portion of the tendon a chance to rest. The strap should be used only during necessary activity and removed or loosened at rest to allow adequate blood flow. Wrist braces are often also prescribed to prevent wrist extension or retrain motion without excessive wrist extension. Preferably, movement retraining is utilized along with proximal muscle strengthening to improve posture and positioning as well as movement patterns during activity. This component is essential not only in treatment of symptoms, but also in prevention of recurrence of symptoms and is often neglected.
Treating the symptoms
Symptoms are treated with a variety of modalities or methods that seem to be focused on either reducing inflammation directly or increasing blood flow to the area to speed the natural healing process and thereby reduce inflammation. Direct anti-inflammatory treatments include ice, anti-inflammatory medications, iontophoresis or corticosteroid injections. Several studies suggest better results with injections early in the healing phase, but no significant differences long-term (at 6 months) from other conservative methods. The major risk of steroidal injection is internal rotation rupture of the tissue. This is most common in athletes who have multiple injections and do not restrict impact-loading activities for 7-14 days after injection. All patients who receive an injection should be cautioned against heavy or resistive activities for 2 weeks, There is also a risk of skin depigmentation because in incision site is so close to the pigmented layer of skin. Other potential but less common complications are: allergic reaction, infection, abscess formation, tissue necrosis, uterine bleeding and posterior subcapsular cataracts. Therapeutic methods of increasing blood flow include: deep soft tissue massage, electrical stimulation, ultrasound and heat. Exercise is also important in increasing blood flow and decreasing edema via muscle pumping. It is important and challenging to achieve a balance between movements or exercise that is pain free and has sufficient rest of the tissue for healing. Stretching exercises are an important part of the rehabilitation and treatment process to restore full length of any tightened or shortened tissues. Strengthening exercises are initiated after the acute phase of treatment has been completed, and symptoms are under control.
Surgical Treatment
When all conservative treatment fails, surgical intervention may be necessary. Surgical techniques vary but usually involve removal of the diseased and degenerated tissue around the outside of the elbow to stimulate blood supply and may also involve release of a portion or all of the origin of the affected extensor muscles. In some cases, some bone may be removed from the lateral epicondyle. There is predictable postoperative discomfort, which gradually subsides and resolves by three to six months post-operative. Most patients achieve complete or near-complete pain relief and full mobility. Strength recovery takes longer but is usually attained. Less than 3 percent of all surgical patients for tennis elbow have no improvement. The 85 percent return to full activity including rigorous sports. Surgery is usually uncomplicated although there may be occasional complications associated with anesthesia.
Regardless of the treatment intervention, education for prevention of recurrence is essential. Movement re-education and proximal muscle strengthening along with modification of techniques or equipment may be needed.
Categories