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Tennis elbow

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For other uses, see Tennis Elbow (video game).
Tennis elbow
Other namesLateral epicondylitis, lateral elbow tendinopathy[1]
Left elbow-joint. (Lateral epicondyle visible at center.)
SpecialtyOrthopedics, sports medicine
SymptomsPainful and tender outer part of the elbow[1]
Usual onsetGradual[2]
DurationLess than 1 to 2 years[3]
CausesMiddle age (ages 35-60).
Diagnostic methodSymptoms and physical examination
Differential diagnosisOsteoarthritis
TreatmentNothing is proved to alter the natural course of the disease. Exercises, braces, ice or heat, and medications may be palliative.

Tennis elbow, also known as lateral epicondylitis or enthesopathy of the extensor carpi radialis origin, is an enthesopathy (attachment point disease) of the origin of the extensor carpi radialis brevis on the lateral epicondyle.[1][4] Those with tennis elbow often report pain and tenderness over the bony prominence of the lateral epicondyle, which serves as the common origin of the forearm and hand’s long extensor tendons. Symptoms range from mild tenderness to severe, persistent pain.[1][5][6] The pain may also extend into the back of the forearm.[2] Onset of symptoms is generally gradual, although they can seem sudden and be misinterpreted as an injury.[7][2][8]

Tennis elbow is generally considered idiopathic, with the exact cause and pathogenesis still unknown, though it is thought to involve tendinosis, a degenerative process of the local tendon.[9][10]

It is often stated that the condition is caused by excessive use of the muscles of the back of the forearm, but this is not supported by experimental evidence and is a common misinterpretation or unhelpful thought about symptoms.[11][2][12] It may be associated with work or sports, classically racquet sports (including paddle sports), but most people with the condition are not exposed to these activities.[1][2][13] The diagnosis is based on the symptoms and examination. Medical imaging is not particularly useful.[2][10] Signs consistent with the diagnosis include pain when a subject tries to bend back the wrist against resistance.[1]

The natural history of untreated enthesopathy is resolution over a period of 1–2 years.[14] Palliative (symptoms alleviating) treatment may include pain medications such as NSAIDS or acetaminophen (paracetamol), a wrist brace, or a strap over the upper forearm.[1][2] The role of corticosteroid injections as a form of treatment is still debated.[15] Recent evidence suggests that corticosteroid injections may delay symptom resolution.[16]

Signs and symptoms

[edit]

Patients typically experience pain or burning around the outer part of the elbow (lateral epicondyle of the humerus), which can radiate down the forearm and sometimes up to the upper arm. The pain is often triggered or worsened by activities that involve resisted wrist extension, such as gripping objects.[17][18] Pain intensity varies from mild to severe and can be intermittent or constant, significantly impacting daily life. Patients also commonly report grip weakness and difficulty lifting.[19]

Terminology

[edit]

The term "tennis elbow" is widely used (although informal), but the condition should be understood as not limited to tennis players.[20][21] Historically, the medical term "lateral epicondylitis" was most commonly used for the condition, but "itis" implies inflammation and the condition is not inflammatory.[2][20][21][22][23]

Since histological findings reveal noninflammatory tissue, the terms "lateral elbow tendinopathy" and "tendinosis" are suggested.[24][25] In 2019, a group of international experts suggested that "lateral elbow tendinopathy" was the most appropriate terminology.[26] But a disease of an attachment point (or enthesia) is most accurately referred to as an "enthesopathy."[27]

Causes

[edit]
Location of tennis elbow

The exact cause of lateral epicondylitis remains unclear. However, it is often linked to repetitive microtrauma resulting from excessive gripping, wrist extension, radial deviation, and/or forearm supination.[28][29]

Traditionally, people have speculated that tennis elbow is a type of repetitive strain injury resulting from tendon overuse and failed healing of the tendon, but there is no evidence of injury or repair on histopathology, and misinterpretation of painful activities as a source of damage is common.[30]

Example of repetitive movement that may cause tennis elbow

Pathophysiology

[edit]

The extensor carpi radialis brevis is the most commonly affected muscle in lateral epicondylitis (LE), along with other extensor carpal muscles. Due to its unique origin, the ECRB tendon is prone to abrasion during elbow movements, leading to repetitive microtrauma.

Lateral epicondylitis was Initially considered an inflammatory process, however there is no evidence of inflammation or repair.[23] Therefore, the disorder is more appropriately referred to as tendinosis or tendinopopathy.[24] Tendinosis, a degenerative condition with fibroblasts, abnormal collagen, and increased blood vessels. Repetitive stress causes microtears, scar tissue formation, and biomechanical changes, worsening symptoms over time.

Clinical evalulation

[edit]

Physical examination

[edit]

Diagnosis is based on symptoms and clinical signs that are discrete and characteristic. For example, the extension of the elbow and flexion of the wrist causes outer elbow pain. The physical examination usually reveals marked tenderness at the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (extensor carpi radialis brevis origin).[31] Pain may worsen with resisted wrist extension, middle finger extension, and forearm supination with an extended elbow, although normal elbow movement is often maintained, even in severe cases.[18]

Cozen's test

[edit]

Cozen's test is a physical examination performed to evaluate for tennis elbow involving pain with resisted wrist extension.[32] The test is said to be positive if a resisted wrist extension triggers pain to the lateral aspect of the elbow owing to stress placed upon the tendon of the extensor carpi radialis brevis muscle.[33] The test is performed with extended elbow. NOTE: With elbow flexed the extensor carpi radialis longus is in a shortened position as its origin is the lateral supracondylar ridge of the humerus. To rule out the ECRB (extensor carpi radialis brevis), repeat the test with the elbow in full extension.

Medical imaging

[edit]

Medical imaging is not necessary or helpful.[34]

Radiographs (X-rays) may demonstrate calcification where the extensor muscles attach to the lateral epicondyle.[31] Medical ultrasonography and magnetic resonance imaging (MRI) can demonstrate the pathology, but are not helpful for diagnosis and do not influence treatment.[35][36]

Longitudinal sonogram of the lateral elbow displays thickening and heterogeneity of the common extensor tendon that is consistent with tendinosis, as the ultrasound reveals calcifications, intrasubstance tears, and marked irregularity of the lateral epicondyle. Although the term “epicondylitis” is frequently used to describe this disorder, most histopathologic findings of studies have displayed no evidence of an acute, or a chronic inflammatory process. Histologic studies have demonstrated that this condition is the result of tendon degeneration, which replaces normal tissue with a disorganized arrangement of collagen. Colour Doppler ultrasound reveals structural tendon changes, with vascularity and hypo-echoic areas that correspond to the areas of pain in the extensor origin.[37]

Table of Clinical classification of lateral epicondylitis phases.[38]

Phase Description of pain changes at differnet phases
I Mild pain after activity, usually recovers within 24 hours
II Mild pain more than 48 hours after activity, no pain during activity, can be relieved with warm-up exercises, and recovers within 72 hours
III Mild pain before and during activity, no significant negative impact on the activities, and can be partially relieved with warm-up exercises
IV Mild pain accompanies the activities of daily living and has negative impact on the performance of activities
V Harmful pain unrelated to activities, great negative impact on the performance of activities but does not prevent the activities of daily life. Need complete rest to control the pain
VI Persistent pain despite complete rest and can prevent the activities of daily life
VII Consistent pain at rest, aggravated after activities, and disturbed sleep

Treatment

[edit]

Despite advances in the treatment of LE, there is still a lack of established standards. It is generally self-limiting, and most cases require no treatment, with up to 80% cases recovering within one year.[39] Patients with prolonged symptoms may require further conservative or surgical treatments. Palliative (symptoms alleviating) treatment may include pain medications such as NSAIDS or acetaminophen (paracetamol), a wrist brace, or a strap over the upper forearm.[1][40]

Exercises

[edit]

Stretching and isometric strengthening are the most common recommended exercises. 

The muscle is stretched with the elbow straight and the wrist passively flexed. 

Isometric strengthening can be done by pushing the top of the hand up against the undersurface of a table and holding the wrist straight.[41]

Orthotic devices

[edit]
Counterforce orthosis reduces the elongation within the musculotendinous fibers
Wrist extensor orthosis reduces the overloading strain at the lesion area

Orthosis is a device externally used on the limb to improve the function or reduce the pain. Orthotics may be useful in tennis elbow; however, long-term effects are unknown.[42] There are two main types of orthoses prescribed for this problem: counterforce elbow orthoses and wrist extension orthoses. Counterforce orthosis has a circumferential structure surrounding the arm. This orthosis usually has a strap which applies a binding force over the origin of the wrist extensors. The applied force by orthosis reduces the elongation within the musculotendinous fibers. Wrist extensor orthosis maintains the wrist in the slight extension.

Speculative treatments

[edit]

Other approaches that are not experimentally tested include eccentric exercise using a rubber bar, joint manipulation directed at the elbow and wrist, spinal manipulation directed at the cervical and thoracic spinal regions, low level laser therapy, and extracorporeal shockwave therapy.[43][44][45][46][47]

Medication

[edit]

Although anti-inflammatories are a commonly prescribed treatment for tennis elbow, the evidence for their effect is usually anecdotal with only limited studies showing a benefit.[48] A systematic review found that topical non-steroidal anti-inflammatory drugs (NSAIDs) may improve pain in the short term (up to 4 weeks) but was unable to draw firm conclusions due to methodological issues.[49] Evidence for oral NSAIDs is mixed.[49]

Evidence is poor for long term improvement from injections of any type, whether corticosteroids, botulinum toxin, prolotherapy, or other substances.[50] Corticosteroid injection may be effective in the short term;[51] however, they are of little benefit after a year, compared to a wait-and-see approach.[52] A randomized control trial comparing the effect of corticosteroid injection, physiotherapy, or a combination of corticosteroid injection and physiotherapy found that patients treated with corticosteroid injection versus placebo had lower complete recovery or improvement at 1 year (Relative risk 0.86). Patients that received corticosteroid injection also had a higher recurrence rate at 1 year versus placebo (54% versus 12%, relative risk 0.23).[53] Complications from repeated steroid injections include skin problems such as hypopigmentation and fat atrophy leading to indentation of the skin around the injection site.[51] Steroid injections appear to be more effective than shock wave therapy.[54] Botulinum toxin type A to paralyze the forearm extensor muscles in those with chronic tennis elbow that has not improved with conservative measures may be viable.[55]

Surgery

[edit]

Surgery is an option.[56][57][58] Surgical methods include:[59]

Surgical techniques for lateral epicondylitis can be done by open surgery, percutaneous surgery, or arthroscopic surgery, with no high-quality evidence that any particular type is better or worse than another.[60][57] Side effects include infection, damage to nerves, and inability to straighten the arm.[61] A review of the evidence related to surgery found that published studies were of low quality and did not show that surgery was any more effective than other treatments.[60] A subsequent research trial showed that surgery was no more effective than sham surgery, where patients only received a skin incision, although the trial was limited by a small number of patients.[62]

Epidemiology

[edit]

Enthesopathy of the ECRB origin

[edit]

Evidence from imaging studies suggests that about 1 in 5 humans have detectable enthesopathy of the extensor carpi radialis brevis origin in their lifetime.[63] Symptoms likely vary and are self-limited. The signal changes on MRI seem permanent. There is no evidence that specific occupations or activities are associated with enthesopathy.[64]

Symptoms of lateral epicondylitis

[edit]

Symptoms suggestive of lateral epicondylitis are present in about 1% of the adult population and are most common between ages 40 and 60.[64] The prevalence varies somewhat between studies, likely as a result of varied diagnostic criteria and limited reliability between different observers.[64] The data regarding symptoms of lateral epicondylitis in relation to occupations and sports are inconsistent and inconclusive.[64] The shortcomings of the evidence that addresses the relationship between symptoms and occupation/sport include: variation in diagnostic criteria, limited reliability of diagnosis, confounding association of psychosocial factors, selection bias due to a high non-response rate, and the fact that exposures are usually by subjective patient reports and symptomatic patients might receive greater exposure.

History

[edit]

German physician F. Runge[65] is usually credited for the first description of the condition, calling it as "writer's cramp" (Schreibekrampf) in 1873.[66] Later, it was called as "washer women's elbow".[67] British surgeon Henry Morris published an article in The Lancet describing "lawn tennis arm" in 1883.[68][65] The popular term "tennis elbow" first appeared the same year in a paper by H. P. Major, described as "lawn-tennis elbow".[69][70]

See also

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References

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