Tennis Elbow (Lateral Epicondylitis)

Lateral epicondylitis (LE), commonly known as “tennis elbow,” is a condition that causes pain and inflammation in the outer part of the elbow. It stems from repetitive motions and overuse of the forearm muscles and tendons. Microtears and an immature reparative response result in gradual deterioration and pain.1 Tennis elbow may result from repetitive movements such as gripping, wrist extension, radial deviation, and forearm supination.

Tennis elbow involves tendonitis or tendinosis of the lateral epicondyle region of the humerus, affecting the common extensor tendon. Despite its relatively high prevalence, there is still no effective gold standard treatment for tennis elbow.3

History and Epidemiology  

There is ongoing academic and clinical debate regarding the prevalence of tennis elbow. Some research shows the annual incidence in the US remained stable overall between 2007 and 2014, with incidence and surgical intervention for tennis elbow increasing in those older than 65.4

Other studies of tennis elbow have found that the age- and sex-adjusted annual incidence of tennis elbow decreased significantly over time from 4.5 per 1000 people in 2000 to 2.4 per 1000 in 2012, while those opting for surgery within two years tripled over the study period from 1.1% to 3.2%.5 However, the authors cautioned that this decrease may have been attributable to evolving diagnostic criteria.

Other researchers place the annual incidence of tennis elbow between 1% and 3% in the general American population.6 The lower range of this prevalence estimate translates into approximately 3,383,000 people who are burdened by pain and limited mobility associated with tennis elbow. This condition warrants further investigation to standardize diagnosis and explore effective treatment options. 

Tennis Elbow Diagnosis & Presentation

The diagnosis of tennis elbow is made by identifying localized discomfort at the origin of the extensor carpi radialis brevis with tenderness presenting over the lateral epicondyle approximately 5 mm distally and anterior to the midpoint of the condyle. Exacerbation of pain is caused by resisted wrist dorsiflexion and forearm supination in addition to grasping objects.7 Patients may also present a loss of grip strength and complain of pain during daily activities including grasping objects, turning door knobs, and shaking hands.Tenderness is typically found upon palpation at the site of insertion of the extensor retinaculum tendon, and, not uncommonly, this tenderness is centered around the lateral epicondyle of the humerus with a focal point at the bony prominence.8

Advanced tennis elbow may manifest as a bony palpable prominence over the lateral epicondyle. Additionally, skin atrophy and detachment from the common extensor origin may be observed as a result of regular corticosteroid injections or long-standing disease.9

There are a number of lateral epicondyle tests used to diagnose tennis elbow. Cozen’s test is a useful diagnostic tool in which the elbow is flexed at 90 degrees with the forearm in pronation and the patient is asked to perform active extension of the wrist against resistance imposed by an examiner. The test confirms a tennis elbow diagnosis in the case that the patient reports pain in the lateral epicondyle and at the origin of the extensor musculature of the wrist and finger.10

Other useful diagnostic tests that may be used to confirm tennis elbow include the Mill’s test, in which full pronation and complete flexion of the wrist and finger prevents full elbow extension or resistance at the elbow and pain at the epicondyle, and the Maudsley’s test, in which pain at the lateral epicondyle is caused by resisted extension of the middle finger with the elbow fully extended and the forearm pronated.11

Differential Diagnosis

A number of other conditions are similar to tennis elbow, thus examiners must be methodical in ruling out other causes of pain and tenderness. Differential diagnoses include elbow bursitis, cervical radiculopathy, posterolateral elbow plica, posterolateral rotatory instability, triceps tendonitis, and radial nerve entrapment, among others.6 Since tennis elbow may coincide with other anatomical or physiological issues, a thorough exam is warranted. It is recommended that clinicians conduct examinations sequentially, beginning with the cervical spine before proceeding to the entire upper limb and concluding with the shoulder.12

Imaging may be used to rule out other conditions. Radiographic imaging may be used to rule out arthritis or epicondyle calcifications related to articulation or malformation of the involved bones. However, recent systematic reviews of tennis elbow radiographs have suggested that it is rare for radiographic films to alter management of the condition.13, 14

Magnetic resonance imaging (MRI) is typically the best tool for clinicians to accurately diagnose tennis elbow and simultaneously rule out other pathologies.15 Moreover,MRIs can aid assessment of similar conditions, such as synovial folds, and offer opportunities to assess lateral collateral ligaments.12

Ultrasound imaging may also be helpful in ruling out other conditions as well as revealing the extent of tennis elbow pathology. Ultrasound images can reveal the presence of a lateral collateral ligament tear to assess lateral elbow tendinopathy severity and potentially identify patients who may not respond to nonoperative therapy.16

Tennis Elbow Management (Nonpharmocotherapy and Pharmacotherapy)

Because symptoms often resolve without intervention, treatment and care for tennis elbow should start with the most conservative approaches, including17:

  • behavioral modifications
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • straps or braces
  • physical therapy
  • extracorporeal shock wave therapy
  • corticosteroid injection
  • laser therapy

Although NSAIDs are commonly initiated after a diagnosis of tennis elbow, research regarding their efficacy is mixed for oral NSAIDs, and topical NSAIDs have demonstrated low efficacy for long-term relief.18

The injection of a local corticosteroid has favorable short and mid-term results; however, it is not a permanent fix for many patients, especially for those with chronic or recalcitrant tennis elbow.19 When tennis elbow is diagnosed as a chronic condition, or patients are not responding to NSAIDs or local corticosteroid injections, physical therapy is often initiated. Common rehabilitation modalities utilized include8:

  • ultrasound
  • phonophoresis
  • electrical stimulation
  • manipulation
  • soft tissue mobilization
  • neural tension
  • friction massage
  • augmented soft tissue mobilization (ASTM)
  • stretching and strengthening exercises

Research shows that the use of straps and braces may also offer significant relief from pain due to tennis elbow. In particular, elbow counterforce braces that are applied over the proximal forearm may be helpful in reducing strain on the forearm.20, 21

Extracorporeal shock-wave therapy (ESWT), which involves inducing microtrauma to the affected area using repeated shock waves to stimulate neovascularization and healing, has also become popular for treating tendon injuries. There is significant anecdotal evidence that ESWT is efficacious in treating tendonitis and tendinosis; however, multiple controlled studies have yielded mixed results. While several studies have found that ESWT is no more effective than placebo, 22, 23 other studies have concluded that ESTW is effective for people with chronic LEs and argued the need for more robust, definitive studies.24, 25

Alternatively, laser therapy may offer relief for those suffering with chronic LEs,26 though more tightly controlled, robust research is needed.27 Alternative treatments such as platelet-rich plasma injections, acupuncture, and dry needling may be effective.28, 29

Owing to the associated expenses and time required for recovery, surgery is a last resort for people suffering from chronic or recalcitrant tennis elbow. A recent review of tennis elbow surgeries found that most patients recovered fully and were able to regain full function of their forearms.30

Monitoring Side Effects. Adverse Events. Drug-Drug Interactions

NSAIDs should be used as a short- to mid-term approach for pain management in the setting of tennis elbow. However, long-term use of NSAIDs may increase risks for gastrointestinal, renal, and cardiovascular complications.31 Although corticosteroid injections tend to be safe and efficacious in the short-term, prolonged or overuse of corticosteroid injections can also lead to adverse outcomes, including accelerated osteoarthritis progression, subchondral insufficiency fracture, complications of osteonecrosis, and rapid joint destruction with bone loss.32

References

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Author Bio

Gary Loss, a former public education consultant, is a writer with diverse experience in the education, medical, and business sectors.