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Tennis Elbow (Lateral Epicondylitis)

Tennis elbow or, more appropriately, lateral elbow epicondylalgia is a very common problem in adults over the age of 30. The onset is usually slow and subtle without a clear identifying event to precipitate the onset. Once it develops it doesn't let you forget! It seems that at every turn you bang it into something.

Symptoms

 Usually there is exquisite point tenderness at the most prominent point on the outer elbow. There is frequently pain in the form of a dull ache over a larger area of the outer elbow sometimes radiating all the way to the top of the wrist with lifting. Pain may also radiate up to the shoulder. The person may have perceived pain from wrist to shoulder. Bump the elbow and you'll know it! Grasping objects results in increased pain especially if the elbow is straight when reaching and the palm is facing downwards. It stands to reason that symptoms are lessoned by avoidance of palm down grasp and restricting oneself to grasping objects only a short distance away to avoid elbow extension.

Diagnosis

 Normally the patient complains of tenderness upon squeezing the epicondyle and the extensor muscle just towards the hand. There is rarely any significant tenderness over the posterior interosseous nerve in the radial tunnel. Absence of pain in the outer elbow upon resisting turning the forearm palm upwards with elbow extended or flexed helps to rule out radial tunnel syndrome-a rare diagnosis of exclusion. X-ray is usually normal and CAT scan and MRI are not indicated. Unfortunately the controversial questionable diagnosis of "fibromyalgia" lists outer elbow tenderness as one of its cardinal sites! This often delays correct treatment.

Cause

 Age related degeneration is the most obvious contributing factor. Some element of "over use" is frequently but by no means always identified. In fact, a lot of patients are retirees or couch potatoes involving their non-dominant arm. Evaluation of surgical tissue specimens from involved elbows has proven that there is almost never any inflammation but rather, evidence of degenerating tissue. Thus calling this problem an "itis" which means inflammation is clearly incorrect. Epicondylalgia or pain in the epicondylar area of the elbow is the correct term.

Since this problem usually occurs in the same individual who has or has been treated for carpal or cubital tunnel syndrome- often they are unaware of it when they come in with both- and because the outer elbow is innervated by the radial nerve rather than the median nerve involved in carpal tunnel or the ulnar nerve involved in cubital tunnel, there may be some element of a “peripheral neuropathy” to account for it.  

Comorbidities

(Other conditions occurring at the same time)

 This problem usually occurs in the same person who has been treated for or who has carpal and or cubital tunnel syndrome. There is a suggestion that abnormal function of the radial nerve innervating the outer elbow has a lot to do with the onset of symptoms suggesting some sort of a peripheral neuropathy. In fact at least two prominent surgeons, Emmanuel Kaplan in the 1950's and Wittenberg in the 1980's over have promulgated denervation of the outer elbow as a solution. This has led to the least invasive and fastest recovery, lowest cost solution to the problem as discussed below.

Treatment Options

Nonoperative: It's not unusual for the elbow to hurt for months while slowly improving or becoming better tolerated. There is no general agreement on the best treatment. Though physical therapists think they can help I've not seen a case yet that PT has had lasting benefit.  After all, increased activity is what most patients claim aggravates the symptoms. There is no scientific reason why cortisone injection should help this condition but it frequently gives weeks to months if not permanent relief. Aside from one or two days of increased pain that often follow injection there is minimal risk of any side affect. A snug wrap or tennis elbow band or strap gives some relief but has no affect on actually solving the problem.

Operative

There are three operative choices to consider but only on logical one:

     Percutaneous Lateral Elbow Tenotomy

     Extensor Origin Debridement (Nirschl procedure)

     Arthroscopic Extensor Origin Debridement

The best track record of the three contemporary options is unquestionably held by the tenotomy. Specifically reported on in a large series in 1980 from a surgeon tending a tennis club and subsequently by numerous others (request a brochure with references). It costs less, leaves no visible scar, does not require time off of work, and has minimal risk. It takes 3 to 6 months for a person to reach maximal medical improvement or MMI.

The other two choices are much more expensive and more risky-especially the elbow arthroscopy with three potential nerves to injure (ulnar, radial and median). Recovery from these other options is also much more prolonged requiring weeks rather than hours to days. The Nirschl procedure also leaves a sizeable scar-not something a young woman wants to sport any more than an active self conscious man in his prime.

Results

Results will depend upon patient selection by age, occupation, habits (such as smoking which may prevent healing), side involved and handedness, as well as, the surgeon's skill in supervising non-operative care and applying the operative technique. For the percutaneous tenotomy the good to excellent outcomes can be expected between 80-90% (8 to 9 out of 10 cases). According to the largest reported series by Buford et al 70% are pain free by 3 months with another 20% taking a few more months to reach MMI. In the case of workers comp patients return to work with minor restrictions is usually immediate. 

Elbow arthroscopy to trim away decayed tissue from the inside known as the arthroscopic ECRB (extensor carpi radialis brevis) debridement is very expensive and puts three nerves at risk of injury and, in my opinion, has a poor track record as has been pointed out by Mark Cohen, a highly respected orthopaedist at Rush Medical Center in Chicago citing four studies.  There are about 40% of people treated in this fashion that continue to have pain in their elbow and, as was pointed out by Yoon, et al., in July 2015 Arthroscopy, Volume 31, there is still a substantial percentage treated this way that are frankly dissatisfied, i.e. poor outcome.  In Yoon’s study 18% or 8 of 45 patients were dissatisfied. 

A formal open lateral epicondylectomy is disfiguring, painful and requires a lot of immobilization.  Though the results for achieving the pain relief are ultimately about as good as percutaneous tenotomy, the road to getting there is much rougher and leaves obvious scars.  Time off work necessary also elevates the cost substantially, so it is a much less convenient and potentially disfiguring treatment.  

Factors affecting outcome

 Workers comp patients in my practice recover more slowly but ultimately do quite well; it's just harder to get the average person blaming his job for a problem and at odds with his employer to concede recovery. This is especially true if the injured worker has no job to go back to or hates the position. Self Abuse with smoking and or heavy alcohol consumption can also not be expected to benefit healing.

References

Nebraska Hand and Shoulder Institute, P.C.

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