Tennis Elbow (Lateral Epicondylosis)
Tennis Elbow or Lateral Epicondylosis, is a common cause of lateral elbow pain. It develops due to a combination of overuse and tendon degeneration. It traditionally occurred in tennis players but is common in other sports (e.g. racquet, gym, cricket etc). In middle aged individuals, in whom tendon degeneration occurs with age, it sometimes develops relating to use of keyboards, or repetitive gripping or activities of daily living.
Lateral Epicondylosis usually causes lateral elbow pain with gripping and may lead to secondary weakness in wrist and hand function. If the conditions deteriorate, pain may become continuous, and occasionally leads to pins and needles and reduced elbow movement. The pain can radiate up the arm or down to the wrist and patients do not always realise where the symptoms are coming from.
On examination, the lateral epicondyle and lateral elbow tendons are always tender, and painful wrist provocation with resisted wrist extension and sometimes gripping. The differential diagnosis includes referred pain from the cervical spine, radiocapitellar joint arthritis, biceps insertional tendinopathy and posterior interosseous nerve entrapment (which can coexist with lateral epicondylosis).
Confirmatory tests are sometimes required and include ultrasound or MRI, which show degeneration and thickening of the tendon. These investigations often reveal new blood vessel invasion (an altered healing response) or even intra-substance tendon tears. Xrays may show spurring of the lateral epicondyle bone or calcific tendinopathy.
Treatment is often prolonged and recovery may take longer than 12 months. There is reasonable medical evidence supporting relative rest of provoking activity, altering biomechanical factors, analgesics and a graded strengthening rehabilitation program that usually includes eccentric exercises. Some people receive symptomatic relief from a counterforce brace.
If after 6-12 weeks of treatment the lateral elbow pain persists in spite of appropriate treatments, there are multiple second line therapies which are often used to complement exercise rehabilitation. However, these interventions have less supporting medical evidence of efficacy. They include cortisone injections, which help relieve pain and may permit better compliance with rehabilitation, but are not cure for the underlying disease.
Nitrate patches have level 2 evidence of effectiveness, and are often used as they are inexpensive and safe, but headaches can be a problem in some people. Lithotrypsy or shockwave therapy involves a pneumatic hammer directly peppering the lateral epicondyle tendons. It is often painful at the time and has variable level of evidence in some studies.
Autologous platelet rich plasma (PRP) injections are becoming more popular. They are purported to introduce natural tendon growth factors into the degenerate tendon, but at present medical evidence is lacking. In theory, PRP takes 2-6 weeks to produce some tendon healing, and sometimes a second injection is recommended. Surgery is reserved for cases which have been refractory to other therapies. It not been shown to be universally effective and usually involves debriding the degenerate tissue, even with intrasubstance tears are present. Recovery can sometimes be prolonged.
In summary, at Qsports we recommend activity modification, exercise rehabilitation and a degree of patience. Second line treatments are reserved for those who are not responding and surgery is very rarely required as most cases will recover.