Tennis Elbow / Lateral Epicondylitis

Golfer's Elbow / Medial Epicondylitis

What is it?

Irritation of the tendons where they attach at the elbow is called epicondylitis but is most commonly known as tennis elbow or lateral epicondylitis.  This commonly occurs on the outside of the elbow.  Golfer's elbow or medial epicondylitis is a degeneration of the tendon on the inner side of the elbow.  The exact cause of these conditions is not known but it does tend to occur after repetitive use of the muscles around the elbow, hence the names tennis elbow and golfer's elbow.

Tennis elbow involves the extensor carpi radialis brevis tendon on the outside of the elbow and any activity that twists and extends the wrist can lead to tennis elbow. It is common in tennis players but most cases actually occur in people who don't play tennis!

Golfer's elbow can occur after repetitive use of the forearm and wrist muscles and it is not again exclusively limited to golfers.

What are the symptoms?

Pain over the bony prominence over the inner or outside of the elbow.  This pain can extend down the forearm to the wrist and hand.  The pain is made worse by bending the wrist and grasping objects tightly.  There may be discomfort in flexing or extending the wrist also.

Clinical Examination

Usually patients localise the pain very well to the bony prominence over the lateral side or outside of the elbow with tennis elbow.  Pain is usually localised to the medial side or inner side of the elbow with golfer's elbow. 

What investigations are required?

Usually the diagnosis is a clinical diagnosis and in some cases an ultrasound scan or MRI scan may be required to further diagnose the injury.

What are the treatment options?

The treatment options are listed in two main groups; non-operative treatment and operative treatment.

Non-operative treatment:
The main step in treating epicondylitis is to manage the activities that cause the pain, which may be tennis or golf but no exclusively so.  Painkillers can be used to relieve the pain and anti-inflammatory medication should be trialled to alter the course of the disease.

A tennis elbow strap can be worn just below the elbow to limit the stress on the tendons.  Placing an ice bag or performing an ice massage on the area may also be recommended.

Physiotherapy to stretch the tendon and retrain the muscles is important and this is affective in up to 70% of cases.  This is recommended before any operative treatment is considered.  Injections may also be suggested if the condition does not respond to the above treatments.  Steroid injections are most commonly used but generally wear-off after a few weeks or months.  There is some suggestion that whilst steroid injections may provide short-term relief, they make the condition go on for a longer period.

Depending on the doctor's preferences, a referral for a platelet rich plasma injection under ultrasound-guidance may also be offered, as this is considered to be more effective than steroid injections.  However, it can be more expensive and depends on private health fund cover.

Operative treatment:
For very severe cases and those that have failed to improve with injections, surgery may be required.  The surgery is usually performed as a day-case surgery and this is often performed with an open approach with a small incision over the affected bony prominence and debridement of the insertion of the elbow.  The elbow can be moved two days after surgery and the patient will require one week off work.  Full recovery may take up to three months after the surgery.  It is important to prevent tennis elbow from reoccurring by keeping the muscles strong with physiotherapy and exercising after the surgery.  It is important to use proper form when playing tennis or lifting heavy objects.

Possible complications:

Not all cases of tennis elbow or golfer's elbow can be treated effectively by surgery.  A number of patients will go through all of the possible options for treatment and still have ongoing pain. There is no one clear treatment that provides universal relief from this condition, which is a source of frustration for surgeons, physiotherapists and especially patients.



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