Tennis elbow (lateral epicondylitis) is a term used to describe pain and tenderness over the lateral epicondyle. It is exacerbated by resisted extension of the middle finger and also by extension of the wrist.
Lateral epicondylitis is seven times more common than its medial equivalent (golfer’s elbow). Many cases resolve with time.
The prevalence has been estimated at 1-3%. The peak age interval is 40 to 50 years, and in this group the figure increases to 19%. Men and women are affected equally.
A sample of tissue from the lateral epicondylitis would not show signs of inflammation. Instead the histological picture is angiofibroblastic hyperplasia and is believed to occur in a tendon that has been damaged by repetitive microtrauma. There is a possible association with the use of fluoroquinolone antibiotics, although this is controversial.
The diagnosis of lateral epicondylitis is usually based on the history and examination. However, about two-thirds of patients will demonstrate an altered signal around the lateral epicondyle on MRI scanning.
Laser Doppler flowmetry has been used to investigate the blood supply in this region. It has been suggested that reduced blood flow and anaerobic metabolism within the extensor carpi radialis brevis may contribute to the pain of lateral epicondylitis.
The main differential is radial tunnel syndrome. Patients who carry out repetitive manual tasks seem to be at risk of both conditions with the junction between the two difficult to define. Radial tunnel syndrome is caused by compression of a branch of the radial nerve (the posterior interosseous nerve or PIN) within the muscles of the forearm and presents with pain in the upper dorsal forearm. It is not associated with such extreme local tenderness over the lateral epicondyle as tennis elbow.
Radial tunnel syndrome is associated with pain on resisted supination and resisted extension of the middle finger.
Decompression of the PIN has been effective in relieving pain in this region and it has been suggested that around 30% of cases of tennis elbow are in fact suffering from PIN entrapment.
Over 40 treatments have been described for tennis elbow and many of these are in routine use.
Local steroid injections
The injection of corticosteroid with local anaesthetic is the mainstay of treatment for this condition.
Oral NSAIDs are usually offered, and topical NSAIDs are also used by some patients. Neither has a strong evidence base.
Various exercise regimens have been proposed for the treatment for lateral epicondylitis. However, again these do not have a strong evidence base.
A lateral epicondylar brace or elbow clamp is a popular treatment. Little evidence exists to support this treatment.
Wrist extension splints
The functional position of the hand is one of slight extension pronation and since active muscle tone is required to achieve this, any kind of activity using the hand may become painful in lateral epicondylitis. For this reason, some workers have attempted to use wrist extension splints to hold the wrist in extension.
The local application of ice has been a standard remedy for musculoskeletal aches and pains.
Extracorporeal shock wave treatment (ECSWT)
In a prospective randomised, placebo controlled trial extracorporeal shock wave therapy was shown to be a safe and effective treatment for lateral epicondylitis.1 Similarly ECSWT was at least as effective as percutaneous tenotomy.2However, as with the other therapies for this condition, other authors have struggled to reproduce these results.
Botulinum toxin has been used for the treatment for lateral epicondylitis. The belief is that the period of temporary paralysis induced by the botulinum toxin injection will allow time for the soft tissue pathology to recover. Some patients develop transient finger weakness.
One study reported good results using lasers as a treatment for lateral epicondylitis.3 Studies of this kind generally use a similar coloured light source as a sham treatment for the placebo group.
A literature review relating to acupuncture for lateral epicondylitis concluded that it is effective for short-term relief.4
Surgery usually reduces the pain of sports-related injuries, in part because most people stop playing sport while recovering from surgery.
Open surgical technique
Day-case surgery can be performed for lateral epicondylitis. A 1-2cm incision is made of the lateral epicondyle and the extensor tendons are released from the bone. This has a high percentage success rate, although it is not easy to explain the mechanism.
It is not inconceivable that several of the procedures proposed for lateral epicondylitis are in fact denervating the local soft tissues and/or indirectly decompressing the PIN.
Arthroscopic surgery has been attempted with mixed results. This approach clearly requires specialist instruments and skills.
Surgical lengthening of the ECRB tendon
A lengthening of the ECRB tendon at the level of the wrist is another possible treatment. About half of patients recovered, although one study also noted a similar response to decompression of the PIN.
When interpreting research papers on this condition, it is important to remember just how different the various cohorts are. Most patients entering a study using surgical treatment have already failed to respond to other treatments such as watch-and-wait, steroid injections or physiotherapy.
My personal recommendations for treatment would be to try steroid injection, epicondylar clamps and physiotherapy, then if pain persists for more than a year, offer surgery.
- Mr Cutts is consultant orthopaedic surgeon at the James Paget Hospital, Norfolk
- Pettrone F, McCall B. Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis.J Bone Joint Surg Am 2005; 87(6): 1297-304.
- Radwan Y, El Sobhi G, Badawy W, Reda A, Khalid S. Resistant tennis elbow: shock-wave therapy versus percutaneous tenotomy. Int Ortho 2008; 32(5): 671-7.
- Tumilty S, Munn J, McDonough S et al. Low level laser treatment of tendinopathy: a systematic review with meta-analysis. Photomed Laser Surg 2010; 28(1): 3-16.
- Trinh K, Phillips S, Ho E, Damsma K. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology (Oxford) 2004; 43(9): 1085-90.