Tennis Elbow

Does this patient have tennis elbow?

Tennis elbow, or lateral epicondylitis, is a tendinopathy of the origin of the common extensor tendons of the elbow. Specifically, the extensor carpi radialis brevis (ERCB) is commonly involved.

Presentation

It commonly affects patients in their 30-50’s.
Patients usually do NOT have a history of trauma.
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Despite its name, most patients do not play tennis.
They present with complaints of pain on the lateral part of their elbow. This is exacerbated when they attempt to lift things in front of them, such as a briefcase or a cup of coffee.

Physical exam

Tenderness to palpation over the lateral epicondyle is the hallmark of the diagnosis. Care must be taken to ensure that the pain is not more distal over the wrist extensor muscles themselves for this could represent radial tunnel syndrome.
With the elbow in extension, patients will have pain with resisted wrist extension and passive wrist flexion.
Range of motion (ROM) should also be assessed for elbow flexion, extension, and forearm supination and pronation. Limitations in range of motion may suggest an underlying fracture – and not tennis elbow.

Differential diagnosis

Radial tunnel syndrome – pain will be more distal over the wrist extensor muscle bellies. May also be associated with parasthesias one the back of the forearm.
Fractures – associated with trauma. Limited ROM on exam. Radial head fractures can mimic tennis elbow in terms of the location of the pain. However, radial head fractures will often have limited pronation and supination, and will have an X-ray consistent with a fracture.
Lateral ulnar lateral collateral ligament (LUCL) Injuries – The LUCL originates adjacent to the extensor tendon origins and an injury to this ligament may mimic tennis elbow. Patients with LUCL injuries usually have a history of elbow dislocation, or subluxation. They may also feel a clicking with forearm rotation. Patients with LUCL injuries will have pain and the sensation of instability when the elbow is extended, and the forearm is supinated.
Physeal (i.e., growth plate) Injuries – in the skeletally immature patient, fractures through the bone or growth plate are more common that tendon injuries and should be ruled out. Referral to a pediatric orthopaedic surgeon should be considered when treating skeletally immature patients with elbow pain.
Cartilage Lesions – throwers and gymnasts in particular are prone to cartilage lesions of the radio-capitellar joint. X-rays are often diagnostic, though an MRI may be the only way to make the diagnosis.
Bone lesions – tumors and infections are very rare causes of lateral elbow pain. Most can be identified on X-rays.

What tests to perform?

Radiographs

X-rays are usually negative in patients with tennis elbow.
However, office X-rays are commonly obtained to rule out other pathology, such as a fracture, dislocation or bone lesion.
Occasionally, calcification can be seen adjacent to the lateral epicondyle in chronic cases.

Advanced imaging

Usually not needed in the early stages.
If symptoms persist with non-operative treatment, consider magnetic resonance imaging (MRI) to assess extent of tendon involvement, and to determine if the tendon is torn.
MRI can also rule out concomitant pathology.
If patients are unable to have an MRI, then an ultrasound can be performed though this will not show intra-articular pathology as well.

How should patients with tennis elbow be managed?

First-line treatment

Rest, physical therapy, anti-inflammatories, tennis elbow brace, ergometric improvements in work space

Patients should try to avoid painful activities to allow the tendons to rest.
A prescription for physical therapy should include directions for stretching and eccentric training of the extensor tendons around the elbow. Eccentric training is when the muscle is contracting as it is being elongated (i.e., a “negative” repetition).
Prescribers should also write “modalities prn” so that the therapist can use ultrasound and iontophoresis with a steroid cream that can be used at the therapist’s discretion. Iontophoresis involves rubbing a steroid cream on the skin, then placing electrodes over it that drive the steroids into the tendon using a mild electrical charge. This is not painful for the patient, and is more mild than a steroid injection.
Duration is 6 weeks.
NSAIDs should also be prescribed as long as there are no contraindications.
Patients can be directed to purchase a tennis elbow brace that is available at most pharmacies.
Workplace modifications should be suggested such that patients limits the amount of wrist extension that is necessary to perform their job.

Second-line treatment

Steroid injection

If there is no improvement with first-line treatment, then patients are offered a steroid injection.
Preferred injection consists of dexamethasone 4mg (1cc), 0.25% marcaine (1cc), 1% lidocaine (1cc) – for a total mixture of 3cc.
Injection is placed at the site of maximal tenderness. Care is taken to place the injection around the tendon, and not directly into it. This is done by placing needle into tendon and pushing down plunger. Resistance should be felt. The needle is then backed out until there is minimal resistance on the plunger, and then the contents of the injection is delivered.
After the injection, patients are counseled to rest the elbow for 1 week, then to begin physical therapy again.

Last-line treatment

Surgery

If patients are still having symptoms after 6 months of non-operative treatment including physical therapy, bracing, anti-inflammatories, and injections, then surgery can be entertained.
There are several surgical techniques, but the principle of each is debridement of the pathologic tendon.

Controversies in treatment

Platelet-rich plasma (PRP)

There is some evidence that PRP may be beneficial for tennis elbow. However, this procedure is typically not covered by insurers since it is still considered experimental.

Other treatments options

Shock-wave therapy, prolotherapy, deep friction massage, botulin toxin, and ultrasound have all been described in the literature as treatments for tennis elbow. However, there is insufficient evidence to support their use.
Acupuncture has also been described, and the literature would suggest that it is useful for short-term pain relief.

What happens to patients with tennis elbow?

Most patients will respond to non-operative treatment and have a full recovery.

How to utilize team care?

Specialty consultations: an orthopaedic surgeon should be consulted if the patient has no resolution of symptoms after 6 months of non-operative treatment as outlined above.
Physical therapists (PT) or occupational therapists (OT): PT or OT can both treat this condition. Their role is crucial to treatment.

Are there clinical practice guidelines to inform decision making?

NSAIDs, physical therapy, acupuncture, and steroid injections are more helpful than placebo for short-term therapy (6 weeks). They produce no difference in long-term outcomes of up to 52 weeks (strength of recommendation: A, randomized-control trials).
There is insufficient evidence to support the use of shock-wave therapy, prolotherapy, ultrasound, deep friction massage and bolutin toxin (strength of recommendation: B, multiple systematic reviews).
Surgery may be useful if non-operative treatment is ineffective after 6 months (strength of recommendation: C, case series and expert opinion).

What is the evidence?

Gosens, T, Peerbooms, JC, van Laar, W, den Oudsten, BL. “Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up”. Am J Sports Med. vol. 39. 2011. pp. 1200-8.

Green, S, Buchbinder, R, Barnsley, L. “Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults”. Cochrane Database Syst Rev. 2001. pp. CD003686

Smidt, N, van der Windt, DA, Assandelft, WJ. “Corticosteroid injections for lateral epicondylitis: a systematic review”. Pain. vol. 96. 2002. pp. 23-40.

Smidt, N, Assendelft, WJ, Arola, H. “Effectiveness of physiotherapy for lateral epicondylitis: a systematic review”. Ann Med. vol. 35. 2003. pp. 51-62.

Thornton, SJ, Rogers, JR, Prickett, WD, Dunn, WR, Allen, AA, Hannafin, JA. “Treatment of recalcitrant lateral epicondylitis with suture anchor repair”. Am J Sports Med. vol. 33. 2005. pp. 1558-64.

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