Whether it’s from a sports-related injury or a repetitive motion activity required in some fields of work, lateral epicondylagia/epicondylitis, better known as “tennis elbow,” is a nagging condition that affects from 1-3% of the population. As many are all too familiar with, the pain from tennis elbow is characterized by pain that insidiously intensifies around the outside (lateral) portion of one’s elbow. The pain may be intensified by firmly gripping an object, or even while attempting to shake another individual’s hand. Furthermore, the pain may be reproduced by forcibly moving the wrist during lifting movements, opening cans, holding a coffee cup, brushing one’s teeth, or even at times while opening a door knob. As the condition worsens, the pain may extend from the elbow down the forearm and into the wrist.
So what is tennis elbow? As most are aware, lateral epicondylagia/epicondylitis gets its name because it is often seen in tennis players from repetitive backhand swinging or poor striking techniques (50% of all tennis players will experience this at some point during their careers). This doesn’t mean that it is limited to tennis, though. In fact, less than 5% of all of the “tennis elbow” cases that are seen and treated are due to tennis injuries. As mentioned before, this kind of condition is an overuse condition so any sport or activity in which the forearm is used extensively may result in the same pathology.
Though many people are familiar with the term, a lot of individuals may suffer from this chronic condition and not even know what they have, simply writing it off as a sign of aging or arthritic pain. Simply speaking, lateral epicondylagia/epicondylitis is an overuse injury of the elbow and the tendons of the forearm responsible for wrist movement which originate on that bony prominence that is located on the outside of our elbow called the lateral epicondyle.
Anatomically speaking, the lateral epicondyle is the site in which the wrist extensor muscles share a common origin. These muscles include: supinator, anconeus,extensor carpi ulnaris, extensor digiti minimi, extensor digitorum, and extensor carpi radialis brevis. It is usually the extensor carpi radialis brevis muscle (ECRB) that is causing most of the problems and pain because of it’s relatively small origin for the kind of force that it is able to produce and transmit. Because of the disproportion between the origin site and the muscle forces, it is hypothesized that in repetitive and forceful movements of wrist extension, the tendon may experience degenerative changes that lead to pain and inflammation.
Typically, the condition will resolve on its own and patients will be able to manage their symptoms very conservatively using NSAIDs for pain management and the RICE technique (Rest, Ice, Elevation, and Compression) to help bring down any swelling and facilitate healing. Just like many of the other chronic, overuse injuries, though, tennis elbow may linger around and pose to be resistant to rest and more conservative methods. In these cases, most individuals have been offered cortisone shots, prescribed physical therapy to stretch and strengthen the muscles of the forearm and help patients to learn proper form and ergonomics, and offered forearm braces that are intended to rest the tendons originating on the lateral epicondyle. If the symptoms continue to linger, then the patient is considered for surgery (very seldomly), which involves excising damaged tissue and reattaching muscle back to the proper bony origins.
But how effective are the treatments when compared to non-treatment? This is a question that we always ask when we consider patient management, but that has recently been readdressed in a new study out of Australia that was published in the Journal of the American Medical Association in February.
The study involved 165 individuals experiencing unilateral “tennis elbow” for greater than 6 months duration that were treated at a single, university clinic from 2008 to 2010 with a follow-up visit in 2011. The study was randomized, injection-blinded,and placebo-controlled.
The researchers split the patients up into four groups: Corticosteroid injection (43 patients), placebo injection (41 patients), corticosteroid injection plus physical therapy (40 patients), or placebo injection plus physical therapy (41 patients). They then looked at the 1-year global rating of change scores, which screened for complete recovery or significant improvement and the 1-year recurrence (defined as complete recovery or much improvement at 4 or 8 weeks, but not later).
What they discovered is certainly quite interesting in terms of the way we treat. We have known for several years now that steroid injections seem to offer short-term relief, but are not so effective in the long-term management of chronic pain, but what these researchers found was that Corticosteroid injection resulted in lower complete recovery or improvement at 1 year versus the placebo injection. Furthermore, their results showed that the physical therapy and no physical therapy groups did not differ on 1-year ratings of complete recovery or improvement.
According to their study, they noticed that the 4-week mark displayed an interesting phenomenon in which the patients receiving the placebo injection plus physical therapy began displaying greater complete recovery or improvement scores when compared to the corticosteroid injection and physical therapy group. Furthermore, there was no difference between patients receiving corticosteroids plus physical therapy versus the corticosteroid use alone.
All in all, the study concluded that “Among patients with chronic unilateral lateral epicondylalgia, the use of corticosteroid injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences.”
Before jumping immediately to practice-changing methods of treatment, it would naturally be expected that this study be recreated with a larger patient population and further confirmed by peers. Very seldom does one study offer substantial enough proof to immediately alter treatment modality and philosophy, but it certainly may serve as the catalyst for progress and change.
Such a statement is certainly bold and interesting in the face of our current treatment methods. It poses as a strong reminder that we must continue to examine and reexamine our treatment modalities to ensure that they truly are helping our patients the way we think that they are. Furthermore, it continues to show us just how hard it can be to adequately manage syndromes and conditions of chronic pain and inflammation. Sometimes practices based on sound theory and physiology don’t match up to our expectations and may even produce worse outcomes than no intervention at all. This is the beauty of the human body and the scientific process.
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Bisset L, Paungmali A, Vicenzino B, Beller E. (2005). "A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia.” British Journal of Sports Medicine 39 (7): 411–22
Coombes B, et al (2013). "Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial." JAMA 309: 461-69.
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