Pictorial case study: Pain in the elbow

Tennis elbow can follow overuse, particularly in somebody who overstresses the tendon by unaccustomed activity

Tennis elbow: usually a self-limiting condition

Mr M is 45 years old and has a sedentary occupation. He had taken time off to redecorate his home, but after a few days up a ladder, paintbrush in hand, started to feel pain over the lateral side of his right elbow. The pain worsened as he painted until it extended and radiated down the back of his forearm. He was forced to give up on the task and see his GP.

Diagnosis and management
The patient's history, and findings on examination of tenderness over the lateral epicondyle and reproduction of the pain on extension of the wrist and fingers against resistance, led the GP to make a diagnosis of tennis elbow (lateral epicondylitis). Full movement at the elbow joint suggested there was no joint pathology. If necessary, X-ray can exclude joint pathology and MRI can confirm the diagnosis.

Tennis elbow is thought to be a degenerative process at the insertion of the extensor carpi radialis brevis tendon on the lateral side of the elbow that is used on gripping and cocking back the wrist. It follows overuse, particularly in someone who overstresses the tendon by unaccustomed activity. It most commonly occurs between the ages of 40 and 50 years.

Treatment involves stopping the activity to allow the condition to settle, followed by graded strengthening exercises. An elbow strap or wrist splint can be helpful. Analgesics and NSAIDs help to ease the pain, but cortisone injections are no longer recommended.

A trial with injection of platelet-rich plasma was linked to an improved cure rate two years after treatment.1 Hyaluronan gel injection has been found to help the pain. Botulinum toxin A injection could be considered where surgery is being considered, but has the disadvantage of loss of extension of the third and fourth fingers for some months. Release of the extensor/flexor origin is occasionally indicated as an operation.

Tennis elbow normally resolves within 12 months, so surgery should be reserved for those who fail to respond to conservative management.

Possible differential diagnoses

  • Medial epicondylitis (golfer's elbow)
  • Cervical spondylosis or a disc problem with referred pain from the neck
  • Fibromyalgia

Differential diagnosis
Medial epicondylitis (golfer's elbow)

  • Similar degenerative process in the tendon as tennis elbow but affects insertion of flexor-pronator muscle, flexor carpi radialis at medial epicondyle
  • Frequently associated with golfing, throwing sports, archery and weight-lifting
  • Most common between the ages of 40 and 50 years
  • On examination, pain and tenderness over the medial epicondyle with pain radiating into the forearm
  • Aggravated by rotation of arm, grasping/opening jars
  • May be associated with ulnar neuropathy with tingling, and weakness in fourth and fifth fingers
  • Investigations are usually unnecessary but may consider CRP blood test for inflammation, X-ray, MRI and nerve conduction studies in cases with neuropathy
  • Treatment involves rest and avoidance of the painful movements, with gradual introduction of rehabilitation exercises
  • The use of cortisone injections into the area is still disputed, but if this is done, care should be taken to avoid the ulnar nerve – better results are found after a year of physiotherapy and a 'wait and see' policy
  • Surgery is reserved for severe persistent problems
  • Usually a self-limiting condition that settles within approximately a year

Contributed by Dr Jean Watkins, retired GP in Hampshire Reference

1. Orchard J, Kountouris A. The management of tennis elbow. BMJ 2011; 342: d2687.

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Item Code: MINT/PPR-12008

Date of Preparation: May 2012


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