Tennis Elbow Remains a Difficult Problem

Despite over 100 years of study and treatment, lateral epicondylitis, otherwise known as "tennis elbow" remains a difficult problem to treat. Recent research has shown us that partial tears of the extensor carpi radialis brevis (ECRB) tendon just don't heal right. But the reason for this remains unknown. After the acute injury, repetitive microtrauma results in an area of fibrosis (scarring) rather than inflammation. Finding ways to successfully treat this problem is a challenge health care providers face every day.

To help primary care physicians, orthopedic surgeons, sports medicine physicians, and physical therapists, two orthopedic surgeons from the University of Virginia took the time to research the problem of lateral epicondylitis. They provide us with updated information on this condition starting with the pathology and pathophysiology as it is currently understood. A review of the diagnosis includes clinical presentation, clinical tests, and diagnostic imaging. And finally, there is a discussion of treatment (both conservative and surgical).

The idea that lateral epicondylitis isn't really an "-itis" (inflammatory) condition at all has been made clear by microscopic studies of the affected tissue. The lack of blood supply to the area (called hypovascular zones) is a key feature of this problem.

Although the radial recurrent artery normally provides blood to the extensor carpi radialis brevis (ECRB), in patients with lateral epicondylitis, there are two areas with decreased blood supply. These two hypovascular zones are located: 1) where the ECRB tendon attaches to the bone and 2) just a little bit (two to three centimeters or about half-an-inch) below the tendon-to-bone attachment.

How does the examiner know for sure the problem is lateral epicondylitis? Caucasian women between the ages of 35 and 50 are affected most often. But those kinds of demographics aren't enough to make a diagnosis. The clinical presentation is another helpful clue. Pain along the outside of the elbow that goes down the forearm is a telltale sign. There may be tenderness right over the bone. Pain with gripping or lifting is common. And painful symptoms are brought on or increased when the examiner resists the movement of wrist extension.

This collection of symptoms usually directs the physician to consider ordering some imaging studies. X-rays are often ordered but research shows that in the case of lateral epicondylitis, they aren't really needed or helpful unless the patient fails to improve with conservative (nonoperative) care. MRIs can be more useful but they are also more expensive. An MRI may show areas of tendon thickening, avulsion of the tendon (pulls away from the bone), and severity of damage.

What do the experts have to say about treatment? Well, everyone agrees that conservative care should be first and foremost. But what that should be remains a point of debate and controversy. There are many choices available from the wait-and-see approach, to the use of antiinflammatory medications, steroid or platelet-rich plasma injections, shock-wave therapy, physical therapy, and splinting.

And even within each of those treatment choices, there remains considerable uncertainty about what works best. Stretching, strengthening, soft tissue mobilization, deep friction massage, and electrical stimulation all seem to have some benefit. But is there some way to combine two or more of these approaches for the best results? And if so, which two (or three -- or more) work together to produce optimal outcomes? These are questions current research has not been able to answer just yet.

We do know that in up to 90 per cent of all cases, conservative care has the intended effect. Patients report decreased pain, improved strength, and pain free return of full function of hand, wrist, and forearm. It may take up to a full year to get those kinds of results but most patients agree it is worth the time and effort.

For those few people who do not get the hoped for improvements, surgery is a final option. Here again, there are several choices and no real evidence that one approach works better than another. The surgeon may remove the diseased portion of the extensor carpi radialis brevis (ECRB) tendon, perform a tendon repair, or surgically release the tendon.

(through the skin) release has a good track record with decreased pain, improved strength, and return-to-work for many patients. The downside of this surgical approach is that the surgeon is unable to look inside the joint for any other damage or injury that might be part of the problem.

In conclusion, the authors say the current evidence isn't strong enough to support one treatment over another for lateral epicondylitis except to say: start with conservative care, give it a full year, then re-evaluate. If there hasn't been enough progress made, then consider surgery as the next available option. There is a need for continued, ongoing study and research to clear up treatment decisions and find the ideal approach that yields the best results.

References: Namory D. Bagayoko, MD, and Stephen F. Brockmeier, MD. Current Controversies in the Management of Lateral Epicondylitis. In Current Orthopaedic Practice. September/October 2012. Vol. 23. No. 5. Pp. 480-485.