Causes and Treatment of Lateral Epicondylitis

Lateral Epicondylitis Definition of the Injury Lateral epicondylitis is a condition where the muscle at the elbow experiences minor tears (microtrauma) mainly as a result of repetitive stress on the muscle. The annual incidence of this condition ranges from 1% to 3% among the general population.

Lateral epicondylitis is more prevalent among persons aged 35 to 54 years and has an incidence of 4 -7 cases in 1000 patients (Lebrun, 2008). Some of the activities that may result into such trauma include: using heavy hand-held tools, undesirable throwing mechanics, and overuse of the elbow especially in tennis backhand with overuse of one hand common in racquet sports. This is one of the reasons why lateral epicondylitis is commonly known as tennis elbow. This is however a misleading term since it has been found out that only 5% to 10% of lateral epicondylitis patients plays tennis at all (Renfree, 2007). The condition is also prevalent among mechanics, house cleaners and gardeners.

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Mechanism of Injury Lateral epicondylitis occurs when repetitive microtrauma does not repair completely leading to chronic tendinosis. Lateral epicondylitis is an inflammatory lesion that principally affects the extensor carpi radialis brevis (ECRB) muscle. However, degeneration occurs at the lateral epicondyle of the humerus origin due to overuse of the muscles. Sometimes it is possible to have the involvement of the extensor carpi radialis longus as well as the extensor digitorium communis (EDC) involved (Weiss & Weiss, 2008). It is important to note that since lateral epicondylitis is a condition that affects the tendinosis located at the origin of common wrist extensors (on the lateral epicondyle), the ECRB, the EDC, the extensor digiti minimi as well as the extensor carpi ulnaris are also closely involved (Evans, 2010). Despite being termed as epicondylitis, which implies an inflammation, inflammation is rarely seen.

Signs of the Injury Some of the clinical signs that are observed in lateral epicondylitis cases include localized tenderness at the ECRB’s attachment to the epicondyle of the humerus. Upon asking the patient to perform wrist supination against resistance combined with elbow extension, the symptoms are triggered. The patient also provokes the symptoms by attempting to lift a chair from the top (Owens, Wolf & Murphy, 2009). A spur may be evident at the lateral epicondyle in some patients while other patients have the common extensor tendon calcified as revealed by magnetic resonance images.

Symptoms of the Injury A patient who presents with lateral epicondylitis usually complains of pain at the distal part of lateral epicondyle. In some instances, the patient cites pain upon proximal

or distal radiation. Moving the wrist, for instance when gripping on something, or overall movement of the hand for instance when shaking hands or carrying something such as a briefcase by the hand results into pain. There are some instances when the patient may present with swelling (Weiss & Weiss, 2008). The lateral elbow pain beings gradually following rigorous activity with severity of pain increasing as the activity increases. The symptoms usually persist for six months to two years (Lebrun, 2008) with most patients experiencing waning of the symptoms within one year.

Treatment & Rehabilitation Lateral epicondylitis usually resolves by itself over a period of one year in about 80 percent of the patients. Active treatment is usually taken as a treatment approach with less than 10 percent of the cases calling for surgical intervention. Some of the nonoperative means of managing lateral epicondylitis include treating the pain using nonsteroidal anti-inflammatory drugs (NSAIDs). Applying ice on the injured elbow also relieves pain with avoidance of activities that lead to such pain also being helpful. In the initial stages of lateral epicondylitis, the patient can be treated with corticosteroid injections. The injury can also be rehabilitated through occupational or physical therapy where stretching and strengthening of the elbow muscles is enhanced. To ensure that palmar wrist flexion as well as severe tension on extensor tendons does not occur, the patient is advised to do wrist bracing at night and strapping during the day. Currently, investigations are underway on the efficiency of platelet-rich plasma tendon injection as well as botulinum toxin muscle injection (Evans, 2010).

Surgical management of lateral epicondylitis occurs in less than ten percent of the cases where open surgical techniques, percutaneous or arthroscopic techniques may be applied with minimal exposures being emphasized. Open release is usually recommended for patients who present with typical signs and symptoms of the condition as well as patients who have recurrent symptoms. Open surgery is also recommended for patients who present with posterolateral rotatory instability to give room for ligament reconstruction. Arthroscopic surgery is amenable to patients who present with signs of intraarticular lesions. Arthroscopic procedures have become a preferred surgical intervention as they allow for joint evaluation to locate synovial folds as well as allowing for ECRB debridation in pathologic cases (Parsons & Hausman, 2009). Incase of elbow joint instability, pinning is advisable (Weiss & Weiss, 2008).

Injury Prevention Lateral epicondylitis can be avoided if repetitive stress on the extensor muscles of the elbow is avoided. One of the ways to avoid this injury is to put counter-force brace just below the elbow. It is advisable for athletes to use proper techniques during sports and having the right size and weight of racquet. Work-related injury can be avoided by avoiding lifting weights that are more than twenty kilograms more than ten times in a day (Owens, Wolf & Murphy, 2009).

References Lebrun, C. M. (2008). "What are the best diagnostic criteria for lateral epicondylitis", In Wright, J. G. (ed). Evidence-based orthopaedics: the best answers to clinical questions. Elsevier Health Sciences. ISBN 1416044442, 9781416044444 Evans, P. J. (2010). "Open and arthroscopic treatment of lateral epicondylitis." In, Hunt, T. R. (ed). Operative techniques in hand, wrist, and forearm surgery. Lippincott Williams & Wilkins. ISBN 1451102550, 9781451102550 Owens, B. D., Wolf, J. M. and Murphy, K. P. (2009). Lateral epicondylitis. eMedicine.

Retrieved 12 Nov. 2010 from http://emedicine.medscape.com/article/1231903overview Parsons, B. O. and Hausman, M. R. (2009). “Minimally invasive approaches for lateral epicondylitis.” In, Scuderi, G. R. and Tria, A. J. (eds). Minimally invasive surgery in orthopedics. Springer. ISBN 0387766073, 9780387766072 Renfree, K. J. (2007). "Lateral epicondylitis, in adult reconstruction." In, Berry, D. J., Steinmann, S. P. and Tornetta, P. (eds). Adult reconstruction. Lippincott Williams & Wilkins. ISBN 0781796385, 9780781796385 Weiss, L. D. and Weiss, J. M. (2008). "Epicondylitis." In, Frontera, W. R., Silver, J. K. and Rizzo, T. D. (eds). Essentials of physical medicine and rehabilitation: musculoskeletal. Elsevier Health Sciences. ISBN 1416040072, 9781416040071