Tennis elbow

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Tennis elbow is a condition where the outer part of the elbow becomes painful and tender, usually as a result of a specific strain or overuse. Although it is called "tennis elbow", it should be noted that it is not restricted to tennis players. If one hyperextends an elbow in any sport, this may be classified as tennis elbow. Anyone who does a lot of work involving lifting at the elbow or repetitive movements at the wrist is susceptible to tennis elbow. The condition was first described in 1883. . The medical term is lateral epicondylitis.

Etiology
With tennis elbow, extensor carpi radialis brevis tendon of the extensor carpi radialis brevis muscle has been identified as the primary site of pathological change. There have also been pathological changes found at the extensor digitorum communis, longus and ulnaris tendons. 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.

There is no evidence relating mode of onset to pathology although it is generally acknowledged that tennis elbow is caused by repetitive microtrauma/overuse.

Inflammatory changes have been noted in the acute stages of the condition but have been found to be absent if symptoms become chronic (3 months +). This may explain why approaches such as corticosteroid injections have little impact in the chronic stages of the condition.

Although the name suggests otherwise tennis elbow can affect anyone not just racquet sport players although there are numerous studies that have implicated racquet sports as a cause or contributing factor for tennis elbow. The peak incidence is between 34 to 54 years of age. No difference in incidence between men and women or association between tennis elbow and the dominant hand has been demonstrated. A weak association has been found between work and tennis elbow development.

Risk factors for this condition vary from 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).

Symptoms
Differential diagnosis for tennis elbow includes anconeus compartment syndrome, bursitis, cervical radiculopathy, radio-humeral joint dysfunction, hypothyroidism, lateral epicondyle avulsion, musculocutaneus nerve entrapment, non-union of radial neck fracture, osteoarthritis, posterior interosseous syndrome, posterolateral rotatory instability, radial nerve tension, radial tunnel syndrome, rheumatoid arthritis, strained lateral collateral ligaments and snapping plicae syndrome.
 * Pain on the outer part of elbow (lateral epicondyle).
 * Gripping and movements of the wrist hurt, especially wrist extension and lifting movements.
 * Tenderness to touch, and elbow pain on simple actions such as lifting up a cup of coffee or throwing a baseball.
 * Pain usually subsides overnight.
 * If no treatment given, can become chronic and more difficult to eradicate.

Summary of Tennis Elbow and Diagnostic Findings

 * Lateral epicondylitis is also known as tennis elbow
 * Overuse syndrome of the common extensor tendon, predominantly affecting the extensor carpi radialis brevis.
 * Lateral epicondylitis typically occurs in the 4th and 5th decades
 * Equal prevalence in women and men.
 * Term "lateral epicondylitis" is a misnomer because, pathologically, this condition consists of mucoid degeneration with a paucity of acute or chronic inflammatory cells.
 * Diagnosis of lateral epicondylitis requires history and physical examination.
 * Imaging is usually reserved for cases refractory to nonsurgical treatment and for patients in whom the clinician wants to exclude other abnormalities and assess the amount of tendon damage before surgery.

Treatment
Applying heat and ice in combination works extremely well, as ice controls swelling and heat heals and promotes blood flow and also relieves the tightness and pain. http://www.fitlinxx.com/Article.htm?id=365

Although not founded in clinical research, the tennis player's treatment of choice is frequent icing and compression (Cold compression therapy) for inflammation, and taking anti-inflammatory pain-killers, such as ibuprofen. In general the evidence base for intervention measures is poor.

A brace might also be recommended by a doctor to reduce the range of movement in the elbow and thus reduce the use and pain. Also, ergonomic considerations are important to help with the successful relief of lateral elbow pain.

Initial measures
Rest, ice, and compression are the treatments of choice. There are many excellent cold compression therapy products available. Nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce pain, and inflammation.

Exercises and stretches
Stretches and progressive strengthening exercises are essential to prevent re-irritation of the tendon. Progressive strengthening for this condition involves using weights or elastic theraband to increase pain free grip strength and forearm strength. Racquet sport players also are commonly advised to strengthen their shoulder rotator cuff, scapulothoracic and abdominal muscles by Physiotherapists to help reduce any overcompensation in the wrist extensors during gross shoulder and arm movements.

Physiotherapy
With physiotherapy, ultrasound can be used to reduce the inflammation and promote collagen production although the current evidence for its efficacy is inconclusive. Manual therapy (a form of physiotherapy) is an important part of the treatment; and can take the form of elbow joint mobilisations/manipulations and/or extensor muscle tissue mobilisations. Nerve mobilisation can also be helpful if the Physiotherapist finds a positive nerve tension test in their assessment. The most common upper limb nerve found to be sensitive is the radial nerve for this condition. Elbow clasps are also found to give temporary relief of symptoms.

Local steroid injections
Intra-articular glucocorticoid steroid injections can resolve episodes for several months, but there is a risk of later recurrence. Following an injection, the patient normally experiences increased pain over the subsequent day before the steroid starts to settle the condition over the next few days. As with any steroid injection, there is a small risk of local infection and tendon rupture. Most doctors will restrict giving further courses after two injections, as there is less likelihood of effectiveness but increased risk of side-effects.

As opposed to short-term effect , the longterm benefits of local steroid injection are less clearly established.

Surgical intervention
If conservative measures fail, release of the common extensor origin may be helpful.

Indications for operation:

Tennis elbow (lateral epicondylitis) which has not responded to conservative treatment.

Anaesthetic:

General Anaesthetic (Fully asleep) or regional (the arm will be numb) Local anaesthetic will be injected into the wound for post-operative pain relief

Operation type:

Open

Incisions:

A 3cm (1.18") incision over the lateral epicondyle (the tender area).

Procedure:

The common extensor origin is released from the lateral epicondyle and scar tissue removed.

Wound Closure:

A single non-absorbable suture running under the skin will be used to close the wound, paper stitches will be placed over this.

Dressings:

An Elastoplast dressing will be placed over the top of the paper stitches and an elastic support bandage over the top of this.

Immediate aftercare:

You can go home when you feel comfortable.

Alternative treatments
Laser Therapy

The Use of Laser Therapy (Low Power or Low Intensity Laser Therapy) is a currently used treatment. The approach was spun off of research on how light affects cells. The findings, that light stimulates and accelerates normal healing, sparked the creation of several devices. The dosage often determines the extent of the success with this treatment, so it is generally recommended that experienced clinicians apply the therapy with a device that can be 'customized.' Professional athletes have used the therapy, and it has gained attention in the media lately, on shows like the Canadian health program "Balance" on CTV.However studies evaluating the efficacy of laser therapy for tennis elbow are currently contradictory.

Acupuncture has also been proven to be beneficial but evaluation studies are also inconclusive.