Tennis Elbow
Dr M K Mam
Tennis elbow, also called lateral epicondylitis, is a fairly common problem. It is certainly a common cause of pain on the outside of the elbow. Tennis was the first sport to bring attention to this problem as earlier it was found mostly in tennis players.
However, tennis players aren’t the only people who develop tennis elbow (TE)
It is also found in other sports and professions that involve repetitive movements of the wrist and arm like plumbers, painters, carpenters, bricklayers, gardeners, butchers etc. Computers are certainly an essential part of our life these days and most of us use these whether we are in office or at home. There are reports that TE is one of the problems that is associated with the use of computer- mouse and /or key board for longer hours. That is why it is also called mouse or computer elbow.
Cause: The exact cause of TE is not known. It is an overuse injury and usually follows repetitive stress at the tendinous attachment of common extensor muscle of wrist at outside bony prominence of elbow, i.e. lateral epicondyle. Repetitive wrist extension and forearm rotation movements and stresses due to sports and professional activities may result in a series of tiny tears in the tendinous attachment at lateral epicondyle of the muscles that are responsible for these movements.
Clinical presentation: The patient is usually an active adult complaining of pain on outside of the elbow. Pain often comes insidiously and increases gradually. The pain may radiate down into forearm and wrist. The patient feels pain and weakness on lifting even small things, using computer mouse, shaking the hands, turning a door knob, turning a tap or holding a cup of tea. The patients also complain of weakened hand grip strength. Dominant extremity is more often affected. The elbow usually looks normal. There is localized tenderness, i.e. pain on pressure over front of the outside prominence of elbow. The movements of the elbow and the forearm are normal.
Risk factors: Various factors that may increase the risk of TE include— i) Profession- People having jobs that involve repetitive movements of the wrist and arm like plumbers, painters, carpenters, butchers, gardeners etc. are more likely to develop TE. Again the people involved in handling heavy loads are also at a higher risk of getting TE. Spending long hours at computer, whether you are typing or playing games, does increase the chances of getting TE.
ii) Sports- People involved in racket sports especially where overhead movements are used, are more likely to be affected with TE. Poor technique of the sport certainly increases the chances of TE.
iii) Gender- It somehow affects women more often than men.
Diagnosis: The diagnosis of TE is clinical and is based on history and the findings on physical examination. Imaging is usually not required . X- rays may be done to rule out other causes of pain on the outside of elbow and any local pathology such as arthritis, infection, injury etc. Systemic problems like gout, rheumatoid arthritis etc. can also be ruled out by doing appropriate lab tests. Specialized investigations like MRI is normally not required; however, it is very useful when there is a doubt in diagnosis and we want to rule out any
other pathology.
Prevention: It is very important that a person learns and follows proper technique of the particular sport or profession, especially when it involves weight lifting as poor technique increases the chance for injury including TE. It is also essential that one remains in overall good physical shape. It is good to avoid or modify activities involving any repetitive lifting or pulling of heavy objects. We must strengthen the muscles of the forearm by proper strengthening exercises so as to increase the stability of the elbow joint. Any equipment that is used must certainly be appropriate to the ability, body size, and muscular strength of the individual. People working on computers for long hours just need to relax the shoulder, forearm and wrist. One should get up, stretch, and walk around periodically for five minutes or so at least once an hour.
Treatment: Despite all the advances, there is no true consensus on the most effective treatment of TE, especially for effective long-term outcomes. Good thing is that majority of cases resolve spontaneously within a year or so and the main aim of treatment is to speed up the recovery. Rest to the elbow joint is important. TE braces do help by giving some rest and reducing strain to the forearm muscles. Analgesics and anti¬inflammatory drugs (NSAIDS) help the patient to cope with the pain on a short-term basis. Topical analgesic gels may offer some short term relief. Physical therapy - stretching and strengthening exercises of forearm muscle, and local ultrasonic therapy is useful in many of the patients. It is also important that we avoid or modify the activities which aggravate the pain like lifting, especially heavy weights
Majority of patients respond to an injection of a local anaesthetic and corticosteroids. It certainly provides a good pain relief, but it is for a short term and the recurrences are usual. We may also have local skin problems such as hypo- pigmentation and fat atrophy leading to indentation of the skin around the injection site especially after repeated steroid injections.
Most of the TE patients respond to conservative treatment; however there may be a relapse and /or moderate discomfort in many of the patients. The patients very often need a long period of treatment for recovery and we need to educate the patients accordingly. As such, we must follow an approach of wait and see i.e. watchful wait in most cases. Surgery is considered in a very small percentage of cases that are not responding to a sustained period of conservative treatment for at least for a year or so. Tendinous attachment of the common extensor is released surgically and this can be done by an open method or percutaneously with or without use of an arthroscope (pin hole surgery).
(Dr Mam is the former Vice-Principal, Professor & Head of Orthopaedics, Christian Medical College, Ludhiana and past President, North Zone, Orthopaedics Association)
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Courtesy: March2019, Koshur Samachar