Epicondylitis

What is Epicondylitis?

Epicondylitis occurs when tendons in the elbow develop microscopic tears and inflammation. The muscles and tendons responsible for flexing and extending the wrist and fingers attach in the elbow region to the upper arm (humerus). The areas of attachment are the round knobs just above the elbow joint (epicondyles). The tendons develop inflammation and, sometimes, microscopic tears. This process is known as epicondylitis, either on the inside (medial) or outside (lateral) of the elbow. It is more commonly known as "tennis elbow" when on the lateral side and "golfers elbow" when found on the medial side. The cause is unknown. Prolonged gripping, such as using a hammer or tennis racket, or in repetitive use of the wrist for lifting as in assembly line work or cashiering may increase the symptoms.

How is it diagnosed?

History: The symptoms of pain, swelling and inability to use the wrist may appear suddenly, but, more often, onset is gradual and progressive. Individuals may relate a change in activity or increase in size and weight of tools being used immediately preceding the pain, but most cases occur without an obvious cause. Pain is localized to the epicondylar region initially, but may progress to involve the muscle mass of the forearm. Questions should also be asked about neck and shoulder injuries.

Physical exam: Two findings are diagnostic: pain localized over either epicondyle or just distal, and increased pain with resisted wrist motion (flexion for medial and extension for lateral epicondylitis). As the condition becomes more chronic, pain and weakness may involve the forearm as well, especially with resisted wrist and finger motion.

Tests: X-rays are done to rule out intraarticular pathology.

How is Epicondylitis treated?

Rest from the aggravating activity, ice packs or massage, anti-inflammatory medication for pain and inflammation, and a supportive band around the forearm would be the initial conservative treatment. The band spreads the force of the muscle contraction over a greater area, thus providing rest to the inflamed tissues. Stretching exercise can be started immediately, and strengthening exercises can be started as the pain subsides.

Local injection of corticosteroid may be used in difficult cases. The injection may not be fully effective for five to seven days and can be repeated about three times. Splints or long arm casts to provide restriction of both the wrist and elbow can be used in individuals who are not responding to other methods of treatment.

Physical therapy modalities may treat the symptoms like pain but do not change the recovery time. Surgery is rarely necessary to repair the tendon tears or clean the inflamed tissue from around the tendon insertion.

Medications

What might complicate it?

Failure to stop the aggravating activity and/or stiffening of the elbow joint would complicate treatment. There may be a one or two day increase in pain after local injections, which is called post-injection flare.

Predicted outcome

Although recovery may be slow and tedious, most individuals will have relief of all symptoms by twelve months from onset. Recurrent episodes later in life are common.

Alternatives

Irritation of the nerves around the elbow including nerve entrapment, fractures, loose bodies, ligament injuries, inflammatory disease, infection, intraarticular diseases, and referred pain could present with a similar history.

Rehabilitation

Physical therapy and/or occupational therapy, three times a week, for a period of four weeks. After that time, transition should be made to a home exercise program.

Appropriate specialists

Physiatrist, orthopedic surgeon, certified hand therapist (occupational and physical therapist), sports medicine specialist, and rheumatologist.

Last updated 28 May 2015