Lateral epicondylitis or tennis elbow is an inflammation that arises from repetitive movements of the elbow. The condition affects the tendons that join the extensor and flexor muscles of the wrist to the lateral epicondyle of the humerus bone. Tennis elbow is characterized by tenderness and pain along the outside of the elbow that shoots down the arm and is exacerbated whenever the wrist is used. While sometimes the onset of tennis elbow can be sudden, more frequently, symptoms develop gradually over some period of time.
Lateral epicondylitis is a malady found most commonly among those who are engaging in work or recreational activities that involve swinging the arm again and again while gripping something tightly as is the case when a tennis player yields a tennis racket. The International Tennis Federation notes that fully half of all professional tennis players will suffer symptoms associated with lateral epicondylitis at some point during the course of their careers.
Tennis elbow symptoms aren’t restricted to tennis players alone, however. The condition affects other athletes like golfers, bowlers, and baseball players, too, as well as workers like landscapers, housecleaners, carpenters and assembly line employees. In fact, according to the National Institutes of Health, 1 percent to 3 percent of the total population will experience lateral epicondylitis symptoms at some point in their lives.
The syndrome affects more men than women. Though it can affect individuals of any age, it’s most commonly found in people between the ages of 30 and 50. Most people who develop lateral epicondylitis will do so on their dominant side, meaning right-handed people tend to develop the condition in their right elbow while left-handed people tend to develop the condition in their left elbow.
When you repeatedly contract and extend your forearm, you’re putting stress on the tendons that join the forearm muscles to the bone. Over time, micro-ruptures and abrasions occur in the stressed tissues, and this leads to the formation of fibrosis and granulation tissue as the ruptures heal. As the condition progresses, the affected tendon may attach more weakly to the lateral epicondyle, which places additional stress on tissues farther from the anchor site.
Research shows that micro-ruptures occur through three sets of circumstances:
• Over-use
Any repetitive activity that involves moving one’s arm while gripping or grasping places stresses on tendon attachments that can result in lateral epicondylitis.
• Trauma
Less frequently, a sudden jerking motion that involves great force or a direct blow to the elbow can result in an inflammatory response that sparks the development of lateral epicondylitis.
• Heredity
Genetically linked mesenchymal disorders that affect connective tissues can also cause tennis elbow symptoms. In the case of these individuals, micro-ruptures will occur in other sites throughout the body as well such as the shoulders, feet, and Achilles’ tendons. Tennis elbow in these individuals is also likely to be bilateral.
With lateral epicondylitis, simple movements such as shaking hands, turning door knobs or washing dishes can become excruciatingly uncomfortable. The pain associated with lateral epicondylitis tends to be experienced as waves of discomfort that radiate from the outside of the elbow down the forearm and into the area around the wrist. Individuals with lateral epicondylitis will typically begin experiencing symptoms 18 to 24 hours after the overuse injury occurred.
Along with discomfort, many people will also experience weakness in the affected hand. You may also find it exceedingly difficult to straighten out the affected arm fully. Tennis elbow can interfere with the activities of daily life in a major way because symptoms often persist for months even with treatment.
There are also certain circumstances in which it’s important to seek medical attention right away if you’re feeling pain in your arm. Pains that shoot down your left arm are one of the classic symptoms of a heart attack, so you will need to have that diagnosis ruled out or confirmed as soon as possible even if you suspect the discomfort is associated with lateral epicondylitis.
The definitive physical examination that physicians perform to confirm a diagnosis of tennis elbow is called Cozen’s Test. Your physician will first take a thorough medical history, paying particular attention to behaviors that might put you at risk for developing repetitive stress injuries.
You will then be asked to extend your affected arm out in front of you with your wrist pointing upward and your hand in a closed fist. Your physician will try to push your arm toward the floor and instruct you to resist. If the pain in your upper forearm and elbow area increase, then you have lateral epicondylitis.
Tennis elbow will resolve on its own with rest in many cases. It’s a painful condition, however, so people affected by it frequently seek medical attention to help them control the discomfort since it is often impractical to limit the use of the affected arm.
Treatments for lateral epicondylitis aim to control discomfort, reduce any associated inflammation, restore range of motion and promote healing. In the majority of cases, these goals can be accomplished through medical treatments. Additionally, preventative therapies may be offered that will teach you ways to decrease stress to the affected elbow when you move your arms so that the injury will not reoccur.
• Braces
A forearm brace may be able to reduce stress on affected tissues. It’s important, however, to go on using your arm because immobilization for any length of time will decrease the blood supply to your arm, which can hamper healing and may lead to muscle atrophy and increased weakness.
• Physical therapy
Physiotherapeutic exercises used in conjunction with lateral epicondylitis are designed to strengthen and stretch the extensor, flexor, deviator, pronator and supinator muscles of the wrist. Deep tissue massage can also be useful in breaking up knots of granulated tissue deep within the connective tissues around the elbow.
• Corticosteroid injections
If immobilization and oral non-steroidal anti-inflammatory medications are ineffective at controlling discomfort, your doctor may inject cortisone or another corticosteroid into the affected joint. While corticosteroids have been shown to have some benefit in reducing acute pain in the short run, the reoccurrence of pain may take place in as short a period of time as six weeks after an injection. Corticosteroid injections should never be administered to patients who are suffering from an infection, and no patient should ever receive more than three injections over the course of a single year.
• Other injections
Some patients have found relief from their tennis elbow symptoms through the injection of platelet-rich plasma and Botox-type drugs. Acupuncture have also yielded positive results in some instances.
• Ultrasonic tenotomy
Ultrasonic tenotomy is a type of surgical procedure in which a needle is placed through the skin and into the granulated scar tissue in the tendon. Ultrasonic energy is then applied to the area to liquefy the damaged tissue, which can then be suctioned out through the needle.
and a faulty diagnosis can make treatment a total waste of time.
Failure to accurately diagnose a condition in its early stages can lead
to chronic problems and sometimes devastating results.
Diagnostic musculoskeletal sonography (MSUS) provides the perfect tool for the rehab practitioner. Yet many doctors and physical therapists have no experience with MSUS, are unaware of its advantages, and have no idea how to use it as a diagnostic tool.
Below is a prime example of how ultrasound can take the guesswork out of diagnosis.Successful Treatment
A bad physical therapy experience is one of the primary causes of unnecessary surgery.
We have equipped our clinic with the latest research-grade technology to arrive at objective and accurate diagnoses, and to objectively measure our patients’ progress.
Most importantly, we are the only facility in the US where structural medical diagnosis is reflected in functional treatment, and vice versa.
In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.
Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.
The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.
Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup
Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)
Complete tear of rectus femoris
with large hematoma (blood)
Separation of muscle ends due to tear elicited
on dynamic sonography examination
