Tennis Elbow

Tennis elbow is a condition where the outer part of the elbow becomes painful and tender. It's a condition that is commonly associated with playing tennis, though the injury can happen to almost anybody.[1]

The condition is more formally known as lateral epicondylitis ("inflammation to the outside elbow bone")[2], lateral epicondylosis, or simply lateral elbow pain.

According to the best available scientific evidence[citation needed], tennis elbow is an idiopathic, self-limiting, enthesopathy of middle age. As with many other hand and arm conditions[citation needed], speculative etiologies such as overuse, tennis, etc. have very limited scientific support.

It can occur at any age above the teens. It typically occurs between the ages of 35 and 60, resolves in about one year, and never returns. It is rarely seen over age 70.

The condition was first described in 1883.[3].
Symptoms
Pain on the outer part of elbow (lateral epicondyle).
Point tenderness over the lateral epicondyle--a prominent part of the bone on the outside of the elbow.
Gripping and movements of the wrist hurt, especially wrist extension and lifting movements.
Activities that uses the muscles that extend the wrist (e.g. pouring a pitcher or gallon of milk, lifting with the palm down) are characteristically painful.
Morning stiffness.

Etiology
The strongest risk factor for lateral epicondylosis is age. The peak incidence is between 30 to 60 years of age. No difference in incidence between men and women or association between tennis elbow and the dominant hand has been demonstrated.

The pathophysiology of lateral epicondylosis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the extensor carpi radialis brevis muscle are identified in surgical pathology specimens.[4] It is unclear if the pathology is affected by prior injection of corticosteroid.

Among tennis players, it is believed to be caused by the "repetitive nature of hitting thousands and thousands of tennis balls" which lead to tiny tears in the forearm tendon attachment at the elbow.[2]

The following speculative rationale is offered by proponents[who?] of an overuse theory of etiology: The extensor carpi radialis brevis has a small origin and does transmit large forces through its tendon during repetitive grasping. It has also been implicated as being vulnerable during shearing stresses during all movements of the forearm.

While it is commonly stated that lateral epicondlyosis is caused by repetitive microtrauma/overuse, this is a speculative etiological theory with limited scientific support that is likely overstated.[4] Other speculative risk factors for lateral epicondylosis include taking up tennis later in life, unaccustomed strenuous activity, decreased reaction times and speed and repetitive eccentric muscle contractions (controlled lengthening of a muscle group).
Exams and tests
The diagnosis is made by clinical signs and symptoms, which are usually both discrete and characteristic. There should be point tenderness over the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (ECRB origin). There should also be pain with passive wrist flexion and also with resisted wrist extension (Cozen test), both tested with the elbow extendend.[5]

Radiographs may show some bone in the degenerative extensor carpi radialis muscle origin over the lateral epicondyle.

MRI typically shows fluid in the ECRB origin. There may also be a defect in this tissue. The use of the word "tear" to refer to this defect can be misleading. The word "tear" implies injury and the need for repair--both of which are probably inaccurate and inappropriate for this degenerative enthesopathy.
Treatment
In general the evidence base for intervention measures is poor.[6]

Non-specific palliative treatments include:

Non-steroidal anti-inflammatory drugs (NSAIDs): ibuprofen, naproxen or aspirin
Heat or ice
A counter-force brace or "tennis elbow strap" to reduce strain at the elbow epicondyle, to limit pain provocation and to protect against further damage.
Rest is the tennis player's treatment of choice when the pain first appears; the rest allows the tiny tears in the tendon attachment to heal.[2] Tennis players treat more serious cases with ice[7], anti-inflammatory drugs, soft tissue massage, stretching exercises, and ultrasound therapy.[8]

Other treatments with limited scientific support include:

Local injection of cortisone and a numbing medicine
Using a splint to keep the forearm and elbow still for two to three weeks
Heat therapy
Physical therapy
Occupational therapy, primarily for stretching and strengthening of the wrist extensor musculature.
Pulsed ultrasound to break up scar tissue, promote healing, and increase blood flow in the area
Extra-corporeal shock wave therapy (lithotriptor)
Botulinum toxin
Blood injection (possibly augmented by plateletpheresis)
Sclerotherapy
Accupuncture
Trigger Point Therapy
Platelet-rich plasma[9]
There are clinical trials addressing many of these proposed curative treatments, but the quality of these trial is generally poor.[10]

One study has alleged that electrical stimulation combined with acupuncture is beneficial but evaluation studies are inconclusive

Cortisone injections
In four clinical trials comparing corticosteroid injection to placebo (lidocaine) injection that show no effect of the steroids.[12] Complications from repeated steroid injections include skin problems such as hypopigmentation and fat atrophy.


[edit] Laser therapy
Laser Therapy has also been used. The approach was spun off of research on how light affects cells. The findings, that light stimulates and accelerates normal healing, sparked the creation of several devices. The dosage often determines the extent of the success with this treatment, so it is generally recommended that experienced clinicians apply the therapy with a device that can be 'customized.' Professional athletes have used the therapy and it has gained attention in the media lately, on shows like the Canadian health program "Balance" on CTV. However, studies evaluating the efficacy of laser therapy for tennis elbow are currently contradictory.
Exercises and stretches
There are several recommendations regarding prevention, treatment, and avoidance of recurrence that are largely speculative including:

Stretches and progressive strengthening exercises to prevent re-irritation of the tendon[13];
Progressive strengthening involving use of weights or elastic theraband to increase pain free grip strength and forearm strength;
Racquet sport players also are commonly advised to strengthen their shoulder rotator cuff, scapulothoracic and abdominal muscles by Physiotherapists to help reduce any overcompensation in the wrist extensors during gross shoulder and arm movements;
Soft Tissue Release or simply Massage can help reduce the muscular tightness and reduce the tension on the tendons; and
Strapping of the forearm can help realign the muscle fibers and redistribute the load.
There is little evidence to support the value of these interventions for prevention, treatment, or avoidance of recurrence of lateral epicondylosis.[4]