Tennis elbow

Lateral epicondylitis is a self-limiting disease that usually responds to conservative treatment. By Dr Harry Brown.

Tennis elbow, also known as lateral epicondylitis, is an overuse injury of the extensor forearm tendons that commonly affects patients over the age of 40. It is found equally in both sexes.

Only about 5 per cent of patients with tennis elbow are tennis players and there are many other activities associated with the condition. However, it is a term that is commonly used among doctors and health professionals.

Loading on the forearm
Lateral epicondylitis involves the wrist extensor and supinator mechanism on the lateral epicondyle. Medial epicondylitis (golfer's elbow) is less common than lateral epicondylitis.

Both syndromes have been associated with occupations such as manual labour that involve physical loading on the forearms, especially when repetitive movement is involved. In cases of both medial and lateral epicondylitis, the dominant upper limb is frequently affected.

Although the condition is known as epicondylitis, it is not thought to be the result of an inflammatory process. The pathogenesis of the condition is not fully understood, but small tears to the common extensor tendon may lead to degeneration of the tendon, triggering fibroblastic and vascular proliferation. It should be thought of as a soft tissue problem.

Pain
A diagnosis of tennis elbow is usually clinically based, taking into account the patient history and the findings on clinical examination. The commonest presenting symptom is pain around the lateral elbow.

This is sometimes associated with an activity that involves extension or supination of the wrist. Overuse of the extensor carpi radialis brevis is thought to be involved in the pathogenesis of the condition.

The pain usually comes on slowly. Gripping and shaking hands can become painful without the patient experiencing any reduction in the range of movement in the elbow. The pain can radiate in the direction of the extensor apparatus. There is often localised tenderness over the lateral epicondyle.

Further investigations are not needed except to exclude an alternative diagnosis (see below). X-rays are usually normal.

Management
Treatments for tennis elbow aim to reduce symptoms such as pain, improve function and minimise the impact of the condition on activities of daily living, without producing significant side-effects.

There are a number of management strategies for tennis elbow, and no single treatment strategy is clearly superior. Many interventions lack a strong evidence base.

Self-limiting
Tennis elbow is a self-limiting condition. The majority of patients recover fully within a year, although an episode can last for up to two years. Most patients will improve with conservative treatment.

Avoidance of activities that worsen the symptoms is recommended. However, this is not always feasible depending on the patient's job.

Patients should be given information and reassurance about the condition. Some patients are relieved to hear their tennis elbow is not arthritis and that it will eventually get better.

Patients should be informed that there are a number of treatment options, one of which is simply observing and seeing how the elbow progresses. For some this is an acceptable course.

Another option is to restrict any activity which makes the symptoms worse. Complete rest, however, is not advised as it can slow down recovery.

Steroid injections
Simple analgesia with paracetamol, topical or oral NSAID medication may be effective. Steroid injections are the best known treatment for tennis elbow.

These can provide a short-term improvement in symptoms, but do not have any effect over the long-term.

In addition, after a few months of treatment they may cease to provide even short-term symptom relief.

Physiotherapy is also helpful, although it can be more expensive than treatment with steroid injections.

Other interventions that are sometimes used are orthotic devices, acupuncture, botulinum toxin injections, autologous blood injections and laser therapy.

However, the evidence for the effectiveness of some of these interventions is inconclusive.

Surgery
For resistant or long-standing cases, there is the option of surgery.

However, this is only appropriate for a minority of patients. There are a number of different surgical approaches and the procedures can be performed arthroscopically or through traditional open routes.

Many patients will be satisfied with analgesia and an explanation of their condition, ideally accompanied by written literature to take away with them.

Dr Brown is a GP in Leeds

Differential diagnoses

  • C6-C7 cervical nerve root compression.
  • Arthritis.
  • Ulnar neuropathy.
  • Fracture of the lateral epicondyle.
  • Entrapment of the posterior interosseous nerve.

References

  • Assendelft W, Green S, Buchbinder R et al. Clinical review: extracts from concise clinical evidence, tennis elbow. BMJ 2003; 327: 329.
  • Smidt N, van der Windt D. Tennis elbow in primary care BMJ 2006; 333: 927-8.
  • Johnson G, Cadwallader K, Scheffel S. Treatment of lateral epicondylitis. Am Fam Physician 2007; 76: 843-8.
  • Wilson J, Best T. Common overuse tendon problems: a review and recommendations for treatment. Am Fam Physician 2005; 72: 811-8.

Resources

Patient information websites

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