Lateral Epicondylitis- definition, causes, symptoms, diagnosis, test, treatments, surgery, exercises, recovery time

Can lateral epicondylitis be caused by trauma?

Early history of lateral epicondylitis

Lateral epicondylitis ‘tennis elbow’ is one of the commonest lesions of the arm. The first description was made by Runge in 1873. Years after, the condition was described by Morris in 1882. There followed considerable correspondence concerning the condition by Dr. Major considering the pathology to lie in the annular ligament ‘discussed later’ around the head of the radius and the triceps muscle. Winkworth disagreed with Morris and Major, proposing that it was nerve entrapment that caused the pain. With this disagreement as to the pathology and with the debate over the correct method of treatment did the arguments begin, and tennis elbow became disproportionately represented in the English, the German and, to a lesser extent, the French literature. Recently, tennis elbow has become a topic of importance to medical professionals and people who suffer the illness, and numerous medical research papers have been published debating the pathology and the effectiveness of various treatment modalities.

Lateral epicondylitis medical terminology

A condition in which the outer part of the elbow becomes sore and tender at the lateral epicondyle. The lateral epicondyle is the small outer lower bony eminence of the humerus bone, which is tuberculated and curved forward to give attachment to a number of tendons and ligaments.

The medical term ‘lateral epicondylitis’ literally means inflammation of the lateral epicondyle. However, this is considered a misnomer because the microscopic evaluation of the condition reveals degeneration of fibrous tissues, new blood vessels formation, and collagen disarray rather than inflammation of the bone.
Lateral epicondalgia is quiet more proper name for the condition referring to pain and tenderness over the lateral epicondyle.
Lateral epicondylitis is the most common overuse syndrome which is associated with excessive wrist extension. Although it is usually referred to as ‘tennis elbow’, the condition is work-related and more common in non-tennis players, and several wrist activities and postures can attribute to its development.

Anatomy of the lateral epicondyle

The upper arm bone ‘humerus’ together with the two bones in the forearm ‘radius and ulna’ make up the elbow joint. The three bony bumps located at the bottom of the humerus are called epicondyles.

Muscles that extend your fingers and wrist are attached to the lateral epicondyle by their tendons.
The tendon usually involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB).

Lateral Epicondylitis: Background, Epidemiology, Functional Anatomy
Lateral Epicondylitis: Background, Epidemiology, Functional Anatomy

The lateral epicondyle gives attachment to the following structures:

  • The lateral collateral ligament complex (LCLC):

The radial collateral ligament, the lateral ulnar collateral ligament, the annular ligament, and the accessory lateral collateral ligament form a group of four ligaments attached to the three bones of the elbow joint to hold it together.

  • Anconeus muscle:

A small muscle that takes its origin from the lateral epicondyle and gives insertion on the posterior surface of the ulna. Although its role in elbow extension is considered trivial in humans, it supports the elbow joint in full extension.

  • Supinator muscle:

A broad muscle in the posterior compartment of the forearm, it originates from the lateral epicondyle and inserts on the upper thirds of the radius. Its main function is to supinate your forearm.

  • Extensor carpi radialis brevis muscle:

It originates from the lateral epicondyle by the common extensor tendon, which gives attachment to four forearm extensor muscles, and gives insertion into the lateral dorsal surface of the base of the third metacarpal bone in the hand. When the muscle is contracted, the wrist is abducted and extended.

  • Extensor digitorum muscle:

The extensor digitorum arises from the lateral epicondyle by the common extensor tendon, and it divides below into four tendons. Upon contraction, the muscle can extend the phalanges, then the wrist, and finally the elbow.

  • Extensor digiti minimi muscle:

The muscle is also attached to the lateral epicondyle by the common extensor tendon. It gives insertion into the fifth digit ‘the little finger’ and also acts to extend the wrist and the little finger as well.

  • Extensor carpi ulnaris muscle:

The last muscle attached to the lateral epicondyle by the common extensor tendon. Its insertion is at the base of the fifth metacarpal bone in the hand. By its contraction the muscle extend the wrist and slightly the elbow joint.
As demonstrated by the anatomy of the muscles arising from the lateral epicondyle, any overuse activity or trauma related to these muscle can participate in the development of lateral epicondylitis. Most typically, the primary pathology is tendinosis ‘damage to a tendon at a cellular level in the form of chronic degeneration’ of the extensor carpi radialis brevis tendon.

Epidemiology ‘frequency of incidence

In the US one to three percent of the population is affected by lateral epicondylitis every year. One study has shown that about one in ten patients with persistent symptoms required surgery at six months. Men and women are affected at nearly equal rates. However, in tennis players, male players are more often affected than female players. Up to 50% of all tennis players develop lateral epicondylitis and the risk is increased by several factors, such as poor swing technique, heavy racket, incorrect grip size, and high string tension. The duration of occupational exposure may influence the incidence of the condition, which most commonly develops between 40 and 50 years of age. The disorder occurs more often in the dominant extremity. Generally, lateral epicondylitis occurs much more frequently than medial epicondylitis ‘golfer’s elbow’.

Lateral epicondylitis at microscopic level

Although the inflammation is present only in the earliest stages of the disease process, a degenerative process is determined to be the main cause of lateral epicondylitis. Precipitated by repetitive wrist extension and forearm pronation, the rate of stretching exceeds the tolerance of the tendon and a micro-tear starts to appear in the origin of extensor carpi radialis brevis ‘ECRB’, and may also extend to involve the origin of extensor carpi ulnaris ‘ECU’. If the insult is sustained, a concentration of fibroblasts, vascular hyperplasia and disorganized collagen, known collectively as angiofibroblastic hyperplasia, can be seen at microscopic level. Continuous pathological changes might cause structural failure to the tendon, such as partial or complete rupture.
Lateral epicondylitis can also be associated with radial tunnel syndrome, a condition in which compressive neuropathy of the posterior interosseous nerve (PIN) results in pain in the forearm and wrist.

Who is at risk to get tennis elbow?

Despite the fact that tennis is the most common sport to cause lateral epicondylitis, a large portion of the population can get affected. The condition is common among laborers who utilize heavy tools, and workers engaged in repetitive gripping or lifting tasks. Moreover other sports like squash, fencing, and weight lifting can predispose injury to the common extensor tendon. In addition, any jobs or hobbies that require repetitive arm movements or gripping, such as carpentry, typing, painting, raking, and knitting, may increase the risk of developing lateral epicondylitis. Musicians, for example pianists and drummers, are also at risk.

Poor general condition leads to fatigue of the core and shoulder muscles, which puts an overemphasis on the extensor muscles of the forearm. Improper training or sport’s technique lead to over stretching of the common extensor tendon and therefor degenerative changes. Scapular dyskinesis, a condition in which there is deviation in the normal resting or active position of the scapula, will lead to a compensatory increased load placed on the wrist extensors of the same side.

To sum up, any activity that requires excessive repetitive wrist and elbow joints movement can precipitate development of lateral epicondylitis.

How does the condition present?

The most often complaint is pain over the bony eminence of the lateral epicondyle that may radiate down the forearm, and occasionally proximally to the arm. The pain is usually triggered and worsen with activity that contracts the common extensor mass. The intensity of the pain increases with resisted wrist extension, and gripping activity. The grip strength may be decreased in some cases. Typically the pain worsen with activity and relieved by rest, and may occur 24 to 72 hours after repeated use of the wrist. Symptoms are of gradual, insidious onset, but the severity could range from intermittent mild to be constant, severe, and affecting all daily activities, or even may occur at night causing a disturbance of sleep. The severity may be aggravated to a level that simple activities like picking up a coffee cup ‘coffee cup sign’ will act as a trigger for the pain. In most cases the patient will pinpoint the pain and tenderness few millimeters below the origin of the extensor carpal radialis brevis muscle.

Doctor’s Examination

Your doctor will put history into consideration for making a diagnosis. This include how the symptoms began, any occupational risks, and sports participation. By inspection alone, it is very unlikely to observe any abnormalities except in patients with longstanding disease and partial or complete rupture of the extensor tendon at its attachment, where there may be a prominence of the bony epicondyle. By palpation, tenderness is found at the site of origin of ECRB. However, the pain is usually more diffuse, surrounds the lateral epicondyle, with a point of tenderness at the bony prominence itself.

Any full range of active or passive movement may produce pain, though in severe cases the pain could be elicited by a limited extension of the elbow or wrist joints. A number of tests have been described to reproduce this pain to help diagnosis of tennis elbow;

  • Mill’s Test: The doctor palpates the patient’s lateral epicondyle with one hand, while pronating the patient’s forearm, fully flexing the wrist, and the elbow extended. Pain elicited in the area of the lateral epicondyle indicates a positive test.
  • Maudsley’s test ’resisted third digit extension’: The doctor resists extension of the middle finger of the hand, while palpating the patient’s lateral epicondyle. A positive test is indicated by pain over the lateral epicondyle. This is owing to selective stress on the ECRB tendon.Maudsley’s test ’resisted third digit extension
  • Cozen’s test ‘resisted wrist extension test’: The patient’s elbow is stabilized in 90 degrees of flexion by the clinician’s one hand, while palpating over the lateral epicondyle. The patient is asked to extend his wrist in this position against manual resistance of the clinician. The test is considered positive if pain is produced or increased in the area of the lateral epicondyle. Resisted wrist extension with the elbow fully extended and in pronation stresses the whole of the common extensor origin and can recreate the pain in mild to moderate cases.cozen’s test (lateral epicondylitis)
  • Chair lift test: The classic test where doctor will ask you to stand with your affected arm straight out in front of you. Bring your thumb, index, middle, and fourth fingers together, and grasp the chair only with these fingers and try to lift it with your arm straight and extended out in front you at least three times. If this action brings pain over the lateral epicondyle the test is positive.

    chair lift test tennis elbow
    chair lift test tennis elbow

Doctors always examine the range of movement of the shoulder, elbow, and wrist on the affected side. This is to exclude any other disorders.

Other conditions similar to tennis elbow

Because the multiple elbow and forearm overuse injuries and syndromes can mimic one another, a thorough history with every patient is of crucial importance. However, slight presentation differences can be distinguished as following:

  • Biceps tendinosis: A condition that produces anterior ‘front’ elbow pain aggravated by flexion or flexion supination. Athletes may often complain of biceps muscle weakness, and they can remember a single distinct movement or change in activity that has caused the pain.
  • Anterior capsule strain: In this condition there is anterior elbow pain similar to that of biceps tendinosis. However, the pain is aggravated by repetitive hyperextension and is not affected by elbow flexion.
  • Pronator syndrome: A compressive neuropathy of the median nerve at the level of the elbow. Patients often complain of pain or paresthesia over the median nerve distribution, and sometimes the pain is located over the anterior proximal forearm.
  • PIN Compression Syndrome: A compressive neuropathy of the posterior interosseous nerve (PIN), which could be associated with lateral epicondylitis. The patient experiences a deep aching pain in the forearm, from the outer elbow to the wrist. Studies have shown that about 5% of patients with tennis elbow will have PIN compression syndrome combined with it.
  • Triceps tendinosis: Patients with this injury complain of pain over the back of their elbows aggravated by resisted elbow extension.
  • Posterior Impingement of Elbow: A condition in which there is pain and tenderness at the back of the elbow, especially when trying to straighten the joint in activities such as throwing, swimming and boxing.
  • Medial epicondylitis or golfer’s elbow: an overuse injury that is quite similar to the more common tennis elbow, though the pain is located on the medial ‘inner’ side of the elbow.
  • Elbow synovial fold syndrome: Patients present with snapping pain or elbow locking during flexion or extension of the joint. The condition is due to the presence of synovial folds ‘also known as synovial fringe or plicae’. Synovial plicae are folds of synovial tissue around the articular surface. These folds are remnants of embryonic septa of the normal articular development, and usually they produce symptoms and pain. The condition is often confused with lateral epicondylitis. However, proper clinical evaluation and imaging diagnosis is essential for appropriate management of patients with query presentations.
  • Cervical radiculopathy: When associated with pain in the elbow and forearm, cervical radiculopathy could also be confused with lateral epicondylitis.

In most cases a diagnosis of lateral epicondylitis can be made clinically. However, where the diagnosis is less clear, further investigations may be required.

How diagnosis of tennis elbow is confirmed?

Hematological tests looking for raised inflammatory and other autoimmune markers may be considered, as an infective cause or an associated inflammatory process might be suspected. However, laboratory studies are still of limited role in the diagnosis of tennis elbow.

Imaging studies are rarely needed initially in evaluation of lateral elbow pain, yet plain elbow radiographs ‘X-rays’ can be helpful to exclude bony pathologies, including osteoarthritis, and osteophytes, which are bony projections associated with degeneration of cartilage at the joint surface. In some severe cases patchy calcification, which means accumulation of calcium salts, in the overlying soft tissue may be seen on plain radiographs at the attachment of the common extensor tendon.

Ultrasound imaging can be useful by identifying structural changes in the affected tendons, including thickening or thinning, hypo-echogenic areas, represented with darker colors, indicating tissue degeneration, tendon tears, calcification, bony irregularity or calcific deposits. Doppler ultrasound is able to detect neovascularization ‘new blood vessels formation’. Musculoskeletal ultrasound has another role in assisting some treatment options to be discussed later.

The absence of these changes represented by ultrasonography and Doppler ultrasound have been shown to rule out the diagnosis of lateral epicondylitis.

Although MRI ‘magnetic resonance imaging’ is not necessary for establishing the diagnosis, increased signal intensity at ECRB tendon origin may be seen in up to 50% of cases. Whereas MRI can demonstrate any intra-articular pathology as well as the presence of degenerative tissue and tears within the tendon, positive findings on MRI have been shown to correlate poorly with patients’ symptoms in one blinded study. The study showed that the length of separation within the ECRB tendon was not related to the severity of symptoms. Another study compared CT ‘computed tomography’ arthrography with MRI to identify capsular tears only on the deep surface of ECRB, using arthroscopic findings as a reference. CT arthrography was more sensitive than MRI in identifying capsular tears; 85% of CT results were correct compared with 64.5% for MRI.How is tennis elbow diagnosed?

Additionally, electromyography sometimes is used to identify muscle weakness. Finally, a local anesthetic block at the common extensor tendon area may lead to temporal symptom resolution and confirmation of the diagnosis.

It is important to remember that the presence of an abnormality on various imaging modalities should not be used as a substitute for clinical judgement. This is because imaging abnormalities do not necessarily correlate with the clinical symptoms, as imaging results may represent incidental asymptomatic findings.

What can you do to help your tennis elbow?

For tennis elbow, there are many treatment options your doctor will consider, but no single modality is 100% effective. The aims of treatment for lateral epicondylitis are to control pain, preserve movement, improve the grip strength, and to return to normal function. Various conservative measures are usually applied before the surgical option.

On the one hand, only watchful waiting combined with rest, avoidance of aggravating activities and modification of behavior usually leads to a remission in symptoms. One study has proven greater improvement in pain from lateral epicondylitis at 52 weeks when employing watchful waiting relative to the use of corticosteroid injections. On the other hand, a study published in November 2006, investigated the efficacy of physiotherapy compared with watchful waiting approach and corticosteroid injections over 52 weeks in tennis elbow, has demonstrated that physiotherapy combining elbow manipulation and exercise has a superior benefit to watchful waiting in the first six weeks, and to corticosteroid injections after six weeks, providing a reasonable alternative to injections in the mid to long term. The significant short term benefits of corticosteroid injection are paradoxically reversed after six weeks, with high recurrence rates, implying that this treatment should be used with caution in the management of tennis elbow. Finally, at 52 weeks, there was not much of a difference in comparing physiotherapy to watchful waiting.

The role of nonsteroidal anti-inflammatory drugs ‘NSAIDS’

Topical NSAIDS such as diclofenac may provide short-term relief. However, when comparing oral naproxen, a nonsteroidal anti-inflammatory drug, to placebo, there was no difference noted for pain reduction in lateral epicondylitis. A review from Cochrane in 2013 assessed the benefits and harms of topical and oral NSAIDs for treating people with lateral elbow pain. Comparisons of 759 participants were looked at, and no direct comparisons between oral and topical NSAIDs were available. The outcomes demonstrated that topical NSAIDs may be beneficial in improving pain for up to 4 weeks. Evidence about the benefits of oral NSAIDs has been conflicting, and oral NSAID use may result in gastrointestinal adverse effects in some people. In the end, there remains limited evidence from which to draw firm conclusions about the benefits or harms of topical or oral NSAIDs, in treating lateral elbow pain.

The role of corticosteroid injections

As depicted before, a study has shown that administering a corticosteroid injection decreased pain in lateral epicondylitis at 6 weeks but not beyond.

Another double-blind randomized controlled trial with 2-year follow-up compared the ongoing positive effect of platelet-rich plasma ‘PRP’ versus corticosteroid injection. Patients treated with PRP had great benefits in terms of the reduction of pain and the function, exceeding the benefits from corticosteroid injection, even after a follow-up of 2 years. However, further follow-up from this trial should take into account possible costs and harms as well as benefits. To sum up, corticosteroid injections are effective in reducing pain in the short term, although the procedure’s effect may be quite disappointing in the long term.

The role of platelet rich plasma ‘PRP’

Another, increasingly popular, therapy is platelet-rich plasma therapy. Platelet rich plasma is human blood that is spun down and separated producing a concentration of platelets above normal values. Platelets are the clotting cells of our blood, but they also have great potential in enhancing the healing of muscles, tendons, and ligaments. Studies suggest that growth factors released by platelets recruit reparative cells that may augment tissue repair, and accelerate soft tissue healing. Platelet Rich Plasma therapy ‘PRP’ is considered a ground breaking treatment option that relieves pain by naturally promoting long lasting healing, but the outcome and sustained results are still highly dependent on the extent of the injury. One hundred forty patients with tennis elbow pain were evaluated in one study. All these patients were initially given a physical therapy protocol and a variety of other non-operative treatments. Twenty of these patients had significant persistent pain, despite these interventions, and they were considering surgery. Fifteen patients of this group, who had failed non-operative treatment, was then given a single percutaneous injection of platelet-rich plasma ‘active group’, whereas five patients were given bupivacaine ‘control group’. Eight weeks after the treatment, the platelet-rich plasma patients noted 60% improvement in their visual analog pain scores versus 16% improvement in control patients. At six months, the patients treated with platelet-rich plasma noted 81% improvement in their visual analog pain scores, and their scores reached 93% reduction in pain, at the final follow up, compared with before the treatment. Overall, PRP is an especially safe treatment option with no risk of allergic reaction. However, PRP is not considered a first line treatment and is usually considered after other more traditional treatments have failed.

The role of elbow counter force brace

Many people might ask about the way tennis elbow strap works. Elbow counter force brace acts by reducing the tension forces on the wrist extensor tendons, and should be applied firmly approximately 10 cm distal to the elbow joint. A counter force brace may decrease pain and increase grip strength at 3 weeks in individuals with tennis elbow.

While some authors believed that there is no firm conclusions to be drawn from the use of such orthotics, one study compared 3 common types of orthoses for their effect on grip strength. Maximum and pain-free grip strength were assessed with the patient wearing an elbow strap orthosis, an elbow sleeve orthosis, and a wrist splint. The use of the elbow strap and sleeve orthoses resulted in an immediate and equivalent increase in pain-free grip strength, whereas the wrist splint provided no immediate improvement in either pain-free or maximum grip strength.What is a counterforce brace?

Radiofrequency thermal lesioning

Recently, ultrasound-guided percutaneous radiofrequency thermal lesioning has been reported to be an effective method. In a study published in August 2011, thirty four patients with symptoms of lateral epicondylitis for more than 6 months, in whom previous interventions had failed, were examined at baseline and then at first, third, and sixth months after the procedure of radiofrequency thermal lesioning. There were significant pain reductions at the first, third, and sixth months of follow up. Grip strength surprisingly improved at third and sixth months of follow up but not significantly at the first month. Only five patients needed a repeat procedure because of unsatisfactory symptom relief, and of these, four reported satisfactory results after the second procedure.

Is autologous blood injection ‘ABI’ effective?

A medical procedure in which the patient’s own blood is injected into an area of the body for promotion of healing process. ABI is most commonly used to treat degeneration of tendons, which may occur in association with small tears, as in tennis elbow. In a study by David Connell, thirty five patients with refractory lateral epicondylitis ‘symptom duration of 13 months’ underwent sonographic evaluation prior to injection with autologous blood. Patients were reviewed, and measures to assess the pain were taken before and after procedure, at 4 weeks, and 6 months. Interestingly, autologous blood injections demonstrated significant improvement in symptoms at 4 weeks and at 6 months.  Autologous blood injections also demonstrated statistical improvements regarding tendon thickness, interstitial cleft formation, and neovascularity.

The role of hyaluronate ‘HA’ injections

Hyaluronic acid, a glycosaminoglycan found in various connective tissue of humans, functions as a tissue lubricant, and is thought to play an important role in modulating the interactions between adjacent tissues. HA injections is a novel approach to the treatment of chronic lateral epicondylitis. Prospective randomized clinical trial in primary care sport medicine was done to determine the efficacy and safety of peri-articular hyaluronic acid injections in chronic lateral epicondylitis. Primary outcomes were improvement of pain at rest and after elbow grip testing. There was also improvement in secondary outcomes of grip strength, patient global satisfaction, and assessment of normal elbow function in the HA group versus the control group.

The role of polidocanol injection

Polidocanol is a vascular sclerosant, used for treatment small varicose veins. Doppler-guided sclerosing polidocanol injections targeting the area with new blood vessels formation, have recently been demonstrated to give promising clinical results in patients with chronic lateral epicondylitis pain. In a pilot study, 11 patients with the diagnosis of tennis elbow in altogether 13 elbows, were included. At 8-month follow-up after the treatment with polidocanol injection, there was a good clinical result in 11 out of 13 elbows. The findings indicated that one treatment with sclerosing polidocanol injections, targeting the area with vascularity in the extensor origin, has a potential to reduce the tendon pain and increase grip strength, in patients with chronic painful tennis elbow.

The role of botulinum toxin ‘BTX’

Botulinum toxin ‘BTX’ is a neurotoxic protein produced by the bacterium clostridium botulinum. The toxin inhibits the release of the neurotransmitter ‘acetylcholine’ from nerve endings at the junction between the nerve axon and the muscle surface, and thus causes flaccid paralysis. Muscles weakened by toxin injection recover from paralysis after several months. In tennis elbow, the toxin is thought to provide temporary paralysis of the painful common extensor origin, thereby allowing a healing response to occur. After all, a double-blind randomized controlled study published in 2017 did not find significant differences between corticosteroid and botulinum toxin injections. In addition, clear adverse effects, such as extra pain, digit paresis, and weakness of finger extension, were evident in many patients.

Modalities of weak proven efficacy

Laser treatment has not been proven to be effective method to relieve symptoms of lateral epicondylitis. Additionally, extracorporeal shock wave therapy ‘ECSWT’ is not well evidence-based. Acupuncture was demonstrated as of some evidence of short-term improvement in pain reduction at 2 to 8 weeks. However, other studies demonstrated insufficient evidence to recommend its use.

Nevertheless, topical agents like nitrates are thought to stimulate collagen synthesis and improve healing of the common extensor tendon. One study demonstrated that application of topical nitrates to be an effective method of treating pain from lateral epicondylitis.

Home remedy for tennis elbow; physiotherapeutic modalities

Physical therapy, including strength training and stretching, have been shown to decrease pain and increase grip strength in patients with lateral epicondylitis. Concentric exercises are contractions that shortens a muscle, while eccentric exercises are contractions that stretch it. Patients should progress from concentric to eccentric exercises, and then stress eccentric exercises when able to tolerate them.

Examples of exercises that could help your tennis elbow:

  • Wrist extensor stretch: Straighten your arm fully. Relax your wrist so that you leave your hand hanging. With your other hand, gently push against the back of your hand so it bends towards you. Feel a stretch along the top of your arm.Are Tennis Elbow Straps Effective?
  • Wrist flexor stretch: Straighten your arm fully. Relax your wrist. Use your other hand to gently pull your fingers upwards towards you. Feel a stretch in your wrist muscles.Wrist flexor stretch
  • Extensor strengthening: This exercise is considered progression of the previous one. Rest your forearm on a table. Hang your wrist and hand off the edge. Hold a light hand weight. Moving only your wrist, raise the weight. Hold for 10 seconds then slowly lower it.
  • Wrist Curls: Rest your forearm on a table with palm facing up. Hang your wrist and hand off the edge. Hold a light hand weight or can of beans. Moving only your wrist, gently raise the weight. Hold for 5 seconds, then gently lower the weight.Wrist Curls
  • Handshake stretch ‘wrist deviation exercise’: Hold the weight with your thumb pointing up, like if you were going to shake someone’s hands. Move the weight up and down slowly. Keep your arm still by resting it on the table and only move your wrist.Handshake stretch
  • Wrist Rotations exercise: Hold the weight in your hand with your thumb pointing up. Turn the wrist inward as far as possible, and hold for 2 seconds. Turn the wrist outward as far as possible, and hold for 2 seconds. Repeat the technique as many times as you can.Wrist Rotations exercise
  • Sock squeeze exercise: Hold a rolled-up sock or a tennis ball. Make a fist around it and squeeze. Hold the squeeze for 5 seconds. Relax and repeat the technique.
  • Bicep curls: Hold a light weight. Secure your injured elbow with your other hand or by sitting in a chair and resting it on your thigh. Slowly curl the weight up towards your chest and down again.

When is surgical intervention indicated?

Surgical intervention can be very effective for refractory cases of lateral epicondylitis. If your symptoms do not respond after 6 to 12 months of nonsurgical treatments, your doctor may recommend surgery. There are two main techniques for the surgery, open and arthroscopic. The main principle is release and debridement of ECRB origin at the lateral epicondyle.

In open surgery, an incision is positioned over the common extensor origin. The ECRB, which is located deep and posterior to the extensor carpi radialis longus muscle, is visualized, and the degenerative tissue is excised. The lateral epicondyle is decorticated and capsule is repaired, if breached. Finally, the common extensor tendon is closed side to side. In arthroscopic technique, advantages include visualization and ability to address an intra-articular pathology. The lateral capsule is dissected anteriorly, and the ECRB is released from the origin, where muscle tissue begins. The epicondyle is finally decorticated. Surgery is usually performed as an outpatient surgery, and rarely requires an overnight stay at the hospital. The care of the hand in the post-operative period is very important in helping to ensure a good result. Lastly, tennis elbow surgery is considered successful in 80% to 90% of patients. However, it is not uncommon to see a loss of strength.

Recovery time; return to play

There is no magic fix for tennis elbow that can happen overnight. The time required for proper healing depends on the modality of treatment used and the extent of injury. Following surgery, for instance, your arm may be immobilized temporarily with a splint. After the splint is removed, exercises are started to stretch the elbow and restore flexibility. Gradual strengthening exercises are started about 2 months after surgery. With an emphasis on the patient to avoid aggravating activities and techniques, the athlete should be able to perform pain-free range of motion activities. Some treatment options have long-term benefits regarding decreasing the pain and regaining function, while others only favors short-term improvements, as discussed before.

To sum up, lateral epicondylitis, or ’tennis elbow’, is a common condition that generally might be self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment. With early attention and consultation, the condition may be easily controlled. Patients at risk of developing lateral epicondylitis should follow proper techniques for their repetitive daily activities, in addition to home exercises, in order to avoid aggravated symptoms and work or sports limitations.

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Dr. Omar Elashrii
About Dr. Omar Elashrii 4 Articles
I am working as an orthopedic surgeon and part-time medical writer. I graduated from Alexandria university medical school in 2014. After I have finished my internship year, I worked as a family medicine health care unit first doctor for one year. Currently, orthopedic surgery is my field of interest and profession.

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