General
Pain at the outer aspect of the elbow joint is most commonly caused by a “Tennis Elbow” or lateral epicondylitis. In tendon fibres of the common extensor origin (CEO) muscles, an area of swelling, new blood vessel formation and even some local tearing may occur. The muscles involved may include extensors to the wrist, fingers and supinator of the forearm and so resisted movement or stretching of these muscles may aggravate and potentiate this condition. Although it is eventually self limiting and does not lead to any permanent long term disability it can be very persistent and recurs if continually aggravated .
Signs and Symptoms
- pain at the outer side of the elbow,
- worse with gripping or lifting with the forearm in pronation.
- sometimes loss of full elbow extension
- loss of grip strength
- tender just below bony lateral epicondyle
Differential Diagnoses
Other causes of pain over the lateral aspect of the elbow are:
radial tunnel syndrome: the motor branch of the radial nerve or posterior interosseous nerve is compressed usually as it passes between the 2 heads of the supinator muscle. Tenderness is usually 3-4 cms down the forearm from the bony lump.
radiocapitellar arthritis: The pain is usually more posterior and with rotation of forearm.
posterolateral impingement: tissue is caught between the head of radius and capitellum especially with the elbow in extension and forearm rotation.
Pathomechanics
An episode of trauma may cause an acute tear, or repetitive activity may cause failing (microtears) of the tendinous insertion of the muscles. This area attempts to heal with fibrous or scar tissue which contracts as it matures, and so is shorter than the surrounding tendon/muscle fibres. This is retorn with further stressing. A vicous cycle is set up of tear - scarring - contracture - retearing etc. and so treatment must aim to break this cycle.
Treatment Options
- pain relief.
- avoidance of reinjuring (rest).
- anti-inflammatory medication if tolerated.
- cortisone injection into the area of pathology, maybe under guidance of ultrasound.
- thin tennis elbow band. This causes a pressure rise in the muscles beneath, so the healing fibres at the origin are spared the stress with action of the distal muscles.
- stretching of CEO muscles. Of course the patient must release the band first!
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In the early stages only the first 3 measures would be needed but if the patient doesn’t respond then I would suggest combining the other 3 as follows:
Inject under ultrasound (U/S) preferably with the needle releasing some fibres, and while the local anaesthetic is still working institute immediate stretching of CEO by physio. This tears the scar tissue; the steroid will work after 36 hours to minimise the scar tissue reforming and the patient is instucted to stretch the CEO hourly during the waking hours for the next 6 weeks. Thus while healing occurs the scar is not allowed to contract shorter than the surrounding muscle/tendon fibres, so will not tear later (recurrence). A programme of “Stretch and Rest”
 The specific stretching must be
- extend the elbow
- pronate the forearm, and finally
- flex the wrist
The patient must feel the tightness at the lateral epicondyle with each stretch.
Consider this as you would a hamstring tear - ice and stretch regularly!
Resistant cases - treatment
- shockwave therapy. This has been used over the last 8 years and in my experience, has about 50% success rate. Some patients find it very uncomfortable and do not complete their full course (usually 3 treatments).
- surgery. As this is a self limiting condition and will usually respond to the earlier measures especially if the patients are sensible and alter their activities, rarely is surgery necessary.
Surgery
An initial arthroscopic examination often shows some patchy synovitis between the head of radius and coronoid process anteriorly. At the back of the joint there is often an enlarged posterior fat pad and a firm fringe of tissue extending from this, around the lateral aspect of the joint between the head of radius and the capitellum towards the front. This sometime wears a groove on the lateral aspect of the head or radius.
Arthoscopically I remove the synovitis, fat pad and lateral fringe.
A small lateral incision is used to expose the CEO, the area of greyish vascular tissue is removed from the tendinous origin, the periosteum under the pathological tissue is diathermied (denervated), and the superficial wound closed.
Post operative
A bandage is applied with elbow in flexion, for 10 days with early finger and hand exercises.
Stretching of the CEO muscles begins under physio supervision after 10 days for a period of 6 weeks, followed by strengthening of those same muscles.
Summary
- most patients can be managed by simple advice and local physical therapy, “stretch and rest”
- only resistant cases need injection and or shockwave therapy
- only after the above methods have failed, does the patient need to consider referral to a surgeon for interventional surgery.
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