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Tennis elbow, also known as “shooter’s elbow” and “archer’s elbow”, is a condition where the outer part of the elbow becomes sore and tender. The accurate medical term is lateral epicondylalgia. It is a condition that is commonly associated with playing tennis and other racquet sports, though the injury can happen to almost anybody.
The condition is also known as lateral epicondylitis (“inflammation to the outside elbow bone”), a misnomer as histologic studies have shown no inflammatory process. Other descriptions for lateral epicondylalgia are lateral epicondylosis, or simply lateral elbow pain.
Runge is usually credited for the first description in 1873 of the condition. The term tennis elbow was first used in 1883 by Major in his paper “Lawn-tennis elbow”.
The strongest risk factor for lateral epicondylosis is age. The peak incidence is between 30 to 60 years of age. No difference in incidence between men and women or association between tennis elbow and the dominant hand has been demonstrated.
The pathophysiology of lateral epicondylosis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the extensor carpi radialis brevis (ECRB) muscle are identified in surgical pathology specimens. It is unclear if the pathology is affected by prior injection of corticosteroid.
Among tennis players, it is believed to be caused by the “repetitive nature of hitting thousands and thousands of tennis balls” which lead to tiny tears in the forearm tendon attachment at the elbow.
The extensor digiti minimi also has a small origin site medial to the elbow which can be affected by this condition. The muscle involves the extension of the fifth digit and some extension of the wrist allowing for adaption to “snap” or flick the wrist – usually associated with a racquet swing. Most often, the extensor muscles become painful due to tendon breakdown from over-extension. Improper form or movement allows for power in a swing to rotate through and around the wrist – creating a moment on that joint instead of the elbow joint or rotator cuff. This moment causes pressure to build impact forces to act on the tendon causing irritation and inflammation.
The following speculative rationale is offered by proponents of an overuse theory of etiology: The extensor carpi radialis brevis has a small origin and does transmit large forces through its tendon during repetitive grasping. It has also been implicated as being vulnerable during shearing stresses during all movements of the forearm.
While it is commonly stated that lateral epicondlyosis is caused by repetitive microtrauma/overuse, this is a speculative etiological theory with limited scientific support that is likely overstated. Other speculative risk factors for lateral epicondylosis include taking up tennis later in life, unaccustomed strenuous activity, decreased reaction times and speed and repetitive eccentric muscle contractions (controlled lengthening of a muscle group).
The diagnosis is made by clinical signs and symptoms, which are usually both discrete and characteristic. There should be point tenderness over the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (ECRB origin). There should also be pain with passive wrist flexion and also with resisted wrist extension (Cozen’s test), both tested with the elbow extended.
An easy at-home test can be performed to determine whether you have tennis elbow. Stand behind a chair, place your hands on top of the chair back with your palms down, and try to lift the chair up. If this causes pain on the outside of your elbow, the culprit is most likely tennis elbow.
MRI typically shows fluid in the ECRB origin. There may also be a defect in this tissue. The use of the word “tear” to refer to this defect can be misleading. The word “tear” implies injury and the need for repair – both of which are probably inaccurate and inappropriate for this degenerative enthesopathy.
Depending on the severity and number of small tendon injuries that build up, the ECRB may not be able to fully heal. Nirschl defined four stages of lateral epicondylitis, showing the introduction of permanent damage beginning at Stage 2.
The stages are:
In general the evidence base for intervention measures is poor.
Non-specific palliative treatments include:
Rest is the tennis player’s treatment of choice when the pain first appears; the rest allows the tiny tears in the tendon attachment to heal. Tennis players treat more serious cases with ice (although the effectiveness of ice treatment has been challenged in clinical research), anti-inflammatory drugs, soft tissue massage, stretching exercises, and ultrasound therapy.
In recalcitrant cases surgery may be indicated. Many techniques have been described using open, percutaneous or arthroscopic approaches. Most techniques aim to release the strain on the extensor carpi radialis brevis muscle, remove degenerative tissue and promote healing.
Other treatments with limited scientific support include:
There are clinical trials addressing many of these proposed curative treatments, but the quality of these trials is generally poor.
One study has alleged that electrical stimulation combined with acupuncture is beneficial but evaluation studies are inconclusive.
One recent presentation at a scientific meeting described the Tyler Twist Protocol, a physical therapy intervention. Although the study has yet to be published to verify claims made in the newspaper.
In four clinical trials comparing corticosteroid injection to placebo (lidocaine) injection that show no effect of the steroids. Complications from repeated steroid injections include skin problems such as hypopigmentation and fat atrophy.
There are several recommendations regarding prevention, treatment, and avoidance of recurrence that are largely speculative including:
There is little evidence to support the value of these interventions for prevention, treatment, or avoidance of recurrence of lateral epicondylosis.
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