Eric Pifel, M.D. & Mindy
The Orthopedic Institute of Wisconsin
Lateral epicondylitis is commonly referred to as "tennis elbow” and affects 1-3% of the general population and 15% of workers in at risk industries. Tennis elbow, as the name implies, is often caused by the force of the tennis racket hitting balls in the backhand position. The forearm muscles, which attach to the outside of the elbow, may become sore from excessive strain. Tendons that connect these forearm muscles to the lateral bones of the elbow can roll over the end of the elbow and become damaged when making a backhand stroke in tennis. Specifically, tennis elbow can occur with improper backhand stroke, weak shoulder and wrist muscles, using an excessively tightly strung or short tennis racket, hitting the ball off center on the racket, or hitting heavy, wet balls. However, lateral epicondylitis is not limited to tennis players alone. It can be caused by a variety of sports and occupational activities such as painting with a brush or roller, operating a chain saw, or frequent use of other hand tools on a continuous basis.
The pain associated with tennis elbow is typically well localized and radiates into the upper arm or down to the forearm. The pain may increase down to the wrist, even at rest, if the person continues the activity that causes the condition. It is aggravated by lifting, repetitious use of the forearm and wrist, and shaking hands. Pain may cause weakness of the forearm. Symptoms of epicondylitis may occur suddenly or can develop gradually over time. Once they appear, symptoms are often persistent, although pain may spontaneously resolve. Symptoms occur most frequently in the dominant arm.
The diagnosis of tennis elbow usually can be made based upon a history of pain over the lateral epicondyle and on a physical examination. The physical examination findings may include local tenderness directly over the lateral epicondyle, pain aggravated by resisted wrist extension, pain aggravated by strong gripping or decreased grip strength. There is usually normal elbow range of motion and visual swelling is uncommon. Sometimes, an anesthetic-injection test is performed to confirm the diagnosis. In this test, an anesthetic is injected into the affected area. Epicondylitis is confirmed if the pain is temporarily relieved. In some cases, an x-ray of the elbow is necessary.
The goals of treatment are to allow the healing of forearm muscles and tendons, to reduce secondary inflammation, and to restore forearm muscle strength. Treatment of lateral epicondylitis in the acute period consists of activity restriction, pain relief, and immobilization. Movements involving the inflamed elbow such as lifting, hammering, repetitious wrist motion, and fine hand work should be eliminated to facilitate healing and avoid possible further injury. If tasks at work absolutely require such repetitive movements, then these actions should be avoided outside the workplace. Ice applied to the affected epicondyle for 15 to 20 minutes every four to six hours often results in pain relief. In patients who continue to have pain, a nonsteroidal antiinflammatory drug may be helpful. Many people find that immobilization for three to four weeks of the affected wrist and forearm reduces symptoms. Additionally, studies illustrate the effectiveness of corticosteroid injections within the first 6 weeks. Physical therapy has also been found to be effective after the acute period. Although rarely indicated, surgery, or lateral epicondylar debridement, may be considered in patients with refractory disease in whom symptoms have persisted for one year or longer.
Finally, preventive measures can be taken to prevent injury or recurrence of injury. A healthy elbow requires a healthy shoulder and wrist joint, and strong biceps and triceps to decrease the load on the smaller forearm muscles. Measures that avoid overuse and strain in the elbow and/or forearm include: