Epicondylitis

Lateral and Medial Epicondylitis: "Tennis Elbow" and "Golfer's Elbow"

What is Epicondylitis?

Epicondylitis is the term used to describe pain that occurs most commonly over the lateral aspect of the elbow, and less commonly over the medial aspect of the elbow, with various athletic and work activities.

The lateral and medial epicondyles of the distal humerus are the bony prominences of the lateral and medial aspects of the elbow respectively. Epicondylitis refers to painful inflammation of the tendon structures that arise from the lateral or medial epicondyle. It is an overuse injury resulting from repetitive stresses to the musculotendinous structures involved in a particular activity. These activities can range from racquet sports or golf, which are the most common culprits, to work activities such as carpentry, word processing, or any other job requiring repetitive motions of the wrist or hand.

What Causes Epicondylitis?

Lateral Epicondylitis, also commonly referred to as tennis elbow, develops as a result of repetitive contraction of the wrist extensor muscles that arise from the lateral epicondyle. In tennis, this is usually a result of the backhand stroke, but in non-athletic activities, it can also be caused by repetitive motion such as typing.

In Medial Epicondylitis, or golfer's elbow, the pain develops as a result of repetitive contraction of the wrist and finger flexor muscles that arise from the medial epicondyle.

In both conditions, several factors may lead to the development of symptoms. The most common cause is overuse, that is performing an activity repeatedly, without allowing adequate rest for the muscles involved. Often, the muscles may be weak, or poorly conditioned, and as a result, they are unable to withstand the stress of the activity. Patients may demonstrate poor technique during a particular sport leading to excess strain of the muscles used. Improper equipment, such as incorrect grip size or string tension for racquet sports or lack of ergonomic equipment for word processing can also lead to problems.

What are the Symptoms?

Patients with Lateral Epicondylitis will complain of aching pain around the lateral epicondyle, with sharp pain during lifting in pronation. The patient may complain of weak-ness of the forearm musculature with difficulty lifting, carrying or gripping objects. The pain will occasionally radiate down towards the wrist. Patients also may experience slight stiffness when trying to fully extend the elbow. It is rare for patients to experience any tingling or numbness of the fingers.

The symptoms of Medial Epicondylitis are similar to those of Lateral Epicondylitis, but are localized to the medial aspect of the elbow. Symptoms are worsened by activities requiring flexion of the wrist or fingers.

Findings on Physical Exam

With Lateral Epicondylitis, the patient will have tenderness over the lateral epicondyle and increased pain at this point as the examiner resists the patient's effort to extend the wrist or supinate the forearm with the elbow in the extended position. There also may be some tenderness in the extensor muscles, distal to their origin from the epicondyle.

With Medial Epicondylitis, the tenderness will be over the medial epicondyle and the patient will experience increased pain with resisted wrist flexion and wrist pronation. In patients with Medial Epicondylitis, it is important to palpate the ulnar nerve posterior to the medial epicondyle, for any tenderness that may be contributing to the patient's symptoms.

Diagnostic Studies

For the initial evaluation and treatment of Epicondylitis! no diagnostic tests are necessary. A patient can be treated based on the symptoms and the clinical exam. Elbow x-rays are not indicated during the first stage of treatment.

Treatment

The first step in the treatment of Epicondylitis is rest. Modify or avoid the activity that caused the symptoms, "if it hurts, don't do it." The activity should be avoided until the symptoms have resolved and the patient has had a chance to rehabilitate the affected structures.

Physical therapy interventions form the mainstay of treatment for Epicondylitis. In the early stages of treatment, apply ice to the affected area for 15 to 20 minutes two to three times a day. Also, apply ice after exercising the forearm.

Refer the patient to a physical therapist for instructions on exercises to be performed at home. These consist primarily of stretching the flexor and extensor muscles of the forearm, wrist and hand. In addition to stretching, strengthen-ing the muscles through proper exercise is paramount to restoring normal function of the injured tissues.

Anti-inflammatory medication is indicated to help relieve the inflammation and pain associated with Epicondylitis. For patients with severe or resistant symptoms, or contra-indications to anti-inflammatory medication, a steroid injection in the involved area can provide expeditious relief.

A tennis elbow strap and occasionally a cock-up wrist splint can provide support to the affected muscle tendon units, allowing relative rest while permitting continued use of the involved extremity. Initially, the strap and splint can be worn at all times discarding the splint after the acute symptoms have resolved. Subsequently, the strap can be worn during vigorous activities to prevent re-injury.

Most patients will improve with the described interventions, but a small percentage have persistent symptoms that require further treatment In those situations, outpatient physical therapy treatments may be beneficial. The physical therapist can supervise the exercises previously discussed, as well as employ modalities to facilitate recovery. Ultrasound treatments, iontophoresis (using electrical current to deliver steroid cream through the tissues) and friction massage often effectively relieve recalcitrant symptoms.

In a few patients, all of the previously described treatments may provide only temporary relief of pain. Surgery may be necessary to alleviate symptoms. Surgery involves debriding degenerated tissue from the origin of the wrist extensor muscles in patients suffering from Lateral Epicondylitis, or the wrist flexor muscles in patients afflicted with Medial Epicondylitis. These are outpatient procedures that take 5 to 12 weeks of recovery

In properly selected patients, the success rate of surgery approaches 80 percent, with the success rate lower in patients who are receiving worker's compensation.

Clinical Features

• Pain over the lateral or medial epicondyle
• Pain upon lifting
• Tenderness over the medial or lateral epicondyle

Treatment

• Rest
• Anti-inflammatory medication
• Physical therapy
• Steroid injection
• Surgery as a last resort