What's Going on With Chronic Tennis Elbow?

Lateral epicondylitis, commonly known as tennis elbow, is not limited to tennis players. Any activities that repeatedly stress the same forearm muscles can cause symptoms of tennis elbow. For example, painting with a brush or roller, running a chain saw, and using many types of hand tools. Reaching across the computer keyboard to use the mouse is one of the more common causes of this problem today.

Symptoms that last more than the expected time for healing can result in chronic epicondylitis. It’s not completely clear what is happening in the healing process of chronic tennis elbow. Finding out if there is bone involvement might be helpful in planning the best treatment program. In this study, bone scintigraphy is investigated as a possible diagnostic tool for chronic epicondylitis.

Bone scintigraphy looks at the distribution of blood flow and active bone. It helps show blood flow to and through the bone and shows places throughout the skeletal system where the bone is actively metabolizing. A radioactive dye (99mTc-HDP) is injected into the blood stream. Areas of high bone metabolism show a larger bone uptake of the dye. A three-phase bone scintigraphy test shows blood flow, blood pooling, and bone metabolism.

The advantage of bone scintigraphy is that changes in bone metabolism show up on the bone scan before structural changes would appear on an X-ray. Conditions such as fractures, infections, tumors, and arthritis can be recognized with a bone scan long before they can be seen with plain radiographs.

In the case of epicondylitis, bone scintigraphy can show whether or not there is a reparative process started. The test results don't explain what is causing the problem. They just show the specific areas of bone where local bone responses are occurring.

Patients included in this study had failed to respond to conservative care including cast immobilization, oral and topical medications, heat or electrical stimulation, and steroid injections.

Everyone was seen by a physician who took a detailed medical history and completed a physical exam. Height, weight, health status, pain assessment, arm and grip strength, and motion were measured and recorded. Special tests for epicondylitis were performed to confirm the diagnosis.

Patients were asked to answer questions about their pain, how the pain affected regular activities, and time spent in leisure or recreational activities. Many other types of information were also gathered such as past elbow injuries, treatment tried so far, tobacco use, and work history/sick leave. One of the goals of the study was to see if pain intensity (or any of these other factors) correlated with the results of the bone scintigraphy in any way.

The study did not show any difference in scintigraphy results among patients based on pain intensity or duration. Men had higher uptake values than women suggesting faster and better healing responses. The longer the symptoms were present, the lower the scintigraphy rating (indicating poor healing). Patients who had steroid injections into the elbow were also more likely to have a poor bone healing response.

Patients with higher bone uptake on the scintigraphy had greater strength, less functional loss, and better ability to return to work. Patients with abnormal blood flow, blood pooled in the area, and low bone uptake of 99mTc-HDP had the worst results with poor recovery and more relapses.

The authors suggest that although bone scintigraph is not routinely ordered, it has a place in the diagnosis of chronic epicondylitis. It does not replace standard X-rays and medical examination. But it offers additional information about the underlying healing or inflammatory process present. This type of advanced imaging shows when there is a healing response in the bone tissue and may help guide patients in making treatment, rehab, and return-to-work decisions.

References: Tuomo T. Pienimäki, MD, PhD, et al. Three-Phase Bone Scintigraphy in Chronic Epicondylitis. In Archives of Physical Medicine and Rehabilitation. November 2008. Vol. 89. No. 11. Pp. 2180-2184.