Q & A: LATERAL EPICONDYLITIS (TENNIS ELBOW)

by Lorenzo G. Walker, M.D.

Surgery of the Hand and Upper Extremity

QUESTION: I work as a mechanic and my job activities involve taking off old auto mufflers and replacing them with new ones. By the end of the day, I have an achy, burning pain on the outside of my elbow that seems to get worse and worse as I perform my job duties. After work, despite the fact that I treat this with ice and have taken some Advil, it is constantly sore. At times, when I play tennis on the weekend, I find that this activity also aggravates the same spot. What can I do?

ANSWER: Pain about the outside of the elbow is more common in carpenters, secretaries, and people who work on assembly lines than it is in tennis players. Nevertheless, the syndrome of lateral epicondylitis has been given the name "tennis elbow" over time. Lateral epicondylitis is caused by excessive strain on the muscles on the forearm which produce backward movements in the wrist and fingers. All of these muscles originate at a single bony point (see figure). Repetitive trauma secondary to occupational exposure or recreational exposure can cause small tears in these muscles, setting off an inflammatory reaction which results in pain.

The pain of lateral epicondylitis is usually on the outer aspect of the elbow, but can travel down the forearm to the hand, or even up in the shoulder. At times the pain is worse during activities of work or recreation; however, it can also become worse in the evening. All activities that involve wrist and hand motion can make the pain worse. Lateral epicondylitis is most common in the age ranges between 30 and 50 years old. This is a time when aging muscles that are subjected to constant strain can become inflamed more easily. The older you are, the more susceptible you are to the inflammation and the slower the healing process which is required for this area to become less painful may take.

Initial treatment of tennis elbow is rest. Anti-inflammatory medications and tennis elbow braces are both good ways to treat the initial inflammation caused by tennis elbow. These modalities give the small tears in the muscle on the outside of the elbow an opportunity to heal without being placed under further strain. Should these measures not improve the symptoms, cortisone can be injected into the muscle origin. The goal of the steroid is to break the inflammation cycle. Because there is not much room to maneuver, injecting steroid into this muscle origin is more complex than injecting other areas. A superficial injection may cause some discoloration of the skin, or even some loss of subcutaneous fat; however, these complications are extremely rare. After the steroid injection has been given, it is recommended that the affected individual ice the arm to reduce the swelling from the shot. Three hours of elbow icing should take away nearly all the inflammation that the injection has created. The skin should also be allowed to rewarm for 5-10 minutes every half hour. The following day, the elbow also needs to be iced for 20 minutes, twice a day. The steroid injection may take up to 48 hours to start working. Two injections of this type can be given, but a third is discouraged, as three shots is felt to significantly weaken the bone tendon interface.

Once the acute inflammation from lateral epicondylitis has subsided, we recommend a vigorous exercise program. This may again be combined with anti-inflammatory medications. The exercise program can be administered by a hand therapist, but eventually the responsibility is up to the individual, as most of the exercises can be done in the home program. 75% of patients will be relieved of their problem if they follow their exercise program vigorously. Care must be taken that the program only be initiated once the symptoms of acute inflammation have subsided.

Rarely is an operation needed for tennis elbow. Surgery is reserved for those who fail to get better with 6-12 months of conservative therapy. This includes ice, anti-inflammatory medications, injections, tennis elbow bracing, and completion of a rigorous exercise program. The operation for lateral epicondylitis is done on an outpatient basis. The purpose is to relieve the tautness of the muscle origin which causes the pain. The muscle is initially cut away from its bony anchorage, the scar tissue is removed, and the muscle origin is stitched securely into its new position, a bit lower down the forearm. After surgery, immobilization is required for approximately three weeks. Range of motion exercises are initiated between weeks three and six, and resistive exercises are started at six weeks. When muscle strength reaches 95% of the unoperated side, it is felt that the patient is ready to return to the work or sport activity which initially caused the symptoms. Results of the surgery are approximately 75-80% successful in carefully selected patients, making the lateral epicondylar release a very worthwhile procedure.