Tennis Elbow (Lateral Epicondylitis) Treatment Options
Tennis elbow is a condition that is a combination of chronic exhaustion and strain in the tendons and muscles, during which the body has difficulty completing the healing and repair process. These muscles and tendons lift the wrist, hand, and fingers and are located on the back of the forearm. Tendinitis is associated with hot, sharp pain at the attachment point of the tendon to the humerus bone. However, an aching pain that spreads from the elbow to the hand and wrist may indicate a more muscular cause of tennis elbow. The classic tennis elbow condition earned its name because tennis often causes it. However, in today’s world it is more commonly caused by the non-neutral postures associated with computer usage and possibly would be better nicknamed “computer elbow.”
Pain associated with tennis elbow occurs most commonly at the teno-osseous origin of the common extension tendon at the lateral elbow area. The tendon arises from the anterior facet of the lateral epicondyle, which is approximately the size of the pinkie finger nail. This facet, a tendon attachment site, faces anterior-laterally. In spite of a fair amount of scientific studies regarding tennis elbow, this malady is still a fairly mysterious medical condition.
Although tennis elbow is widely regarded as tendinitis, it has been increasingly clear to experts that there is no such thing as “tendinitis” that continues beyond approximately two weeks from the onset of pain. Persistent use of anti-inflammatory medication is not only ineffective, but delays or stops the healing process which is driven by the body’s inflammatory response to heal overuse injury and strain conditions. This understanding helps explain why the long-standing recipe of icing and ibuprofen is ineffective for long term treatment and resolution of tennis elbow.
Many physicians believe that micro tears in the tendon that attaches the extensor carpi radialis brevis muscle to the lateral epicondyle of the humerus, is the active cause of tennis elbow pain. These micro tears in the tendon lead to a hyper vascular phenomenon resulting in the associated persistent discomfort and dysfunction. The pain is usually worse with strong gripping with the elbow in an extended position, as in a tennis back hand stroke motion. This problem can occur in any racquet sport as well as golf and other activities that require repetitive gripping and grasping motions.
The classic tennis elbow condition earned its name because tennis often causes it. However, in today’s world it is more commonly caused by the non-neutral postures associated with computer usage and possibly would be better nicknamed “computer elbow.”
What Can Be Done Regarding Treatment Options for Tennis Elbow?
Rest is your first line of defense for this condition. Not resting or modifying your activity because you are not inclined to take the problem seriously is usually the set-up for a persistent, worsening issue. A week of resting the affected arm(s), as much as possible, is often enough to make a significant difference.
- Physical Therapy: Self-directed or Therapist Designed
Several physical therapy strategies may decrease healing time and improve function. These may include physical techniques such as stretching and mobilizing. Contrast hydrotherapy and self-massage friction massage, may also be employed with noted improvements. Icing is often utilized if the condition is determined to be primarily a tendinitis –this strategy is debatable as the healing process is impaired by decreasing the inflammatory process. Healing in musculoskeletal issues is mediated by inflammation. Strategies which are focused on suppressing inflammation may impair the healing process.
- Ergonomic Modifications
Maintaining neutral postures for the wrist, elbow, and shoulder are all important to decrease impairments for healing tennis elbow. As far as keyboard use is concerned-keep the keyboard as flat as possible. If the back of the keyboard is elevated, the wrists are raised upward into extension, causing all of the muscles of the forearm to stay in contraction. Avoid this by using a gel pad to lift the heel of the hand.
The type of mouse used with computer operation plays a fairly minor factor in repetitive strain injuries of the wrist and elbow. Generally, a good quality mouse is highly recommended and a wireless mouse is most valuable. The slightest tension of a mouse cord folding or snagging, results in the operator failing to move the mouse in a less stressful, comfortable manner. It is not that the mouse is necessarily stuck in a bad position, but that the computer user is not free to move it to a better one. By contrast, a wireless mouse is surprisingly liberating and if you are getting uncomfortable using the mouse in one position, you may more easily adjust according to your comfort level.
- Injection Techniques
In an article from Reuters Health (“Injections for Tennis Elbow: Some Work, Some Don’t”) a systematic review of injection therapies concludes the following:
- Tennis elbow affects 1-3% of the population and peaks between the ages of 45-54. Injection therapies have included glucocorticoids, platelet-rich plasma (PRP), autologous blood, prolotherapy, hyaluronic acid, botulinum toxin, polidocanol, and glycosaminoglycan polysulfide.
- In an effort to determine which injection therapies work best, Dr. Robin Christensen from Copenhagen University Hospital in Frederiksberg, Denmark, and colleagues, conducted a systematic review of 17 randomized controlled trials in 1,381 patients. They considered only two outcomes: change in pain intensity, and adverse events (including the number of adverse events leading to withdrawal from treatment).
- Autologous blood, PRP, prolotherapy, and hyaluronic acid were all significantly more effective than placebo, but only prolotherapy was significantly better than placebo after excluding results from trials with high or unclear bias. “Further high-quality trials are needed and should have an adequate sample size, valid inclusion criteria, including confirmation of the diagnosis with imaging, and valid and reliable patient relevant outcome measures” (“Injections for Tennis Elbow: Some Work, Some Don’t”).
- Surgery for Tennis Elbow
It is not difficult to find studies that make surgery for tennis elbow seem like an excellent choice. The problem is that these surgical treatment studies did NOT compare surgery to placebo treatment-a common problem with surgical research.
There is one unpublished study comparing real surgery with fake surgery, done in 2012, by Dr. Martin Kroslak. It was a fairly small pilot study, but the results did not prove that the surgical choice was at all effective. Eleven patients were treated with the standard Nirschl surgical technique and 11 received a sham operation: a skin incision was made exposing the ECRB tendon. Both groups improved equally: “The only difference observed between the two groups was that patients who underwent the Nirschl procedure had significantly more pain with activity at 2 weeks.” Kroslak concludes: “There is no benefit to be gained from the gold standard tennis elbow surgery in the management of chronic lateral epicondylitis. In fact, the Nirschl procedure may increase the morbidity of the condition in the immediate post-operative period.
Tennis elbow pain can be debilitating but there are many treatment options. With the assistance of musculoskeletal ultrasound to be used for diagnoses, it has permitted options for effective regenerative treatments such as prolotherapy and PRP. If you have tennis elbow and you would like to discuss your options, give us a call to schedule an appointment.
“Injections for Tennis Elbow: Some Work, Some Don’t.” Reuters Health Information 27 September 2012: Web.