Evolving Treatment Options for Tennis Elbow

Tennis elbow, also known as lateral epicondylitis has been around for hundreds of years. It was first linked with lawn tennis back in the 1800s. Since that time, our knowledge and understanding of the condition has slowly developed. This article presents a summary of the latest information on lateral epicondylitis.

Overexertion, repetitive motion and the use of heavy tools are the most common risk factors. The condition can develop without any of these risk factors.

Local microtrauma of the extensor carpi radialis brevis (ECRB) tendon can cause acute inflammation in the early stages of tennis elbow. If the area doesn't heal, the condition can become chronic.

Recently, it was discovered that chronic epicondylitis is not an inflammatory condition at all. Degeneration and scarring called fibrosis occur. These changes are observed at the site of the ECRB insertion. This is along the outside of the elbow. The fibrosis and disordered collagen fibers are the result of repeated attempts to heal microinjury from overuse.

Painful symptoms persist because there are nerve endings in the connective tissue around the ECRB. Pain is generated by excitatory chemicals in the tissue around the ECRB. Scientists think this finding explains why steroid injections help even when there is no sign of acute inflammation.

Efforts to diagnose the problem can be very difficult. The physician relies on the patient's history, a physical exam, and imaging studies. It is important to rule out other conditions such as bone fractures, shoulder problems, or true elbow joint lesions.

Treatment begins with a nonoperative approach. Fostering healing in the acute phase is important. Inflammation is controlled with medication, rest, and ice or other cold compresses. Rest or at least a reduced force or load on the tendon is essential during the acute phase.

Forearm bands and wrist splints may be recommended. Physical therapy may include stretching, strengthening, and eccentric muscle training (EMT). Eccentric muscle contractions occur when the ECRB is in its shortest, fully contracted position and slowly lengthens. This occurs as the wrist moves from an extended position toward neutral and then into a flexed position.

If conservative care is not successful, there is an intermediate step before surgery is considered. Injections, shock wave therapy, and laser light therapy may be helpful. Injections include steroids or botulinum toxin (BOTOX). Botox is a nerve blocker that partially paralyzes the ECRB. Without constant tension on the tendon, healing can take place.

And finally, if all else fails, surgery is a possibility. Surgical options include open or arthroscopic débridement, release or repair of the ECRB, and nerve decompression. Débridement is the term used to describe removing extra tissue and cleansing the area.

The authors describe each surgical technique and the expected postop care. Potential complications are also included for each operation. The results of surgical treatment for lateral epicondylitis reported by numerous studies are good to excellent. Arthroscopic and open approaches yield similar results. When the ECRB is released, recovery is faster if it's done arthroscopically.

Not everyone is helped by conservative or operative care. In up to 20 per cent of patients, symptoms persist despite all efforts to cure the problem. More studies are needed to focus on finding effective ways to treat patients with lateral epicondylitis.

References: Ryan P. Calfee, MD, et al. Management of Lateral Epicondylitis: Current Concepts. In Journal of the America Academy of Orthopaedic Surgeons. January 2008. Vol. 16. No. 1. Pp. 19-29.