Tennis Elbow

Lateral epicondylalgia: degenerative tendinopathy at the common extensor origin on the lateral epicondyle of the humerus, most commonly involving the extensor carpi radialis brevis. The process is angiofibroblastic degeneration with disorganised collagen and neovascularisation, not a true inflammatory tendinitis.

• Affects 1 to 3% of adults, peaking at 35 to 55 years, equally in men and women. Only a minority of patients are tennis players. Common causes are repetitive wrist extension and gripping (manual work, computer mouse use, carpentry, painting, plumbing, meat processing, and racquet sports with poor backhand technique, heavy racket or tight grip).
• Risk factors: age, repetitive forceful gripping, smoking, obesity, and corticosteroid or fluoroquinolone exposure.
• Natural history: most episodes resolve in 6 to 12 months, and about 80 to 90% recover within a year without surgery, though some have symptoms for 2 years or more.

• Pain over the lateral elbow, radiating to the forearm, worse with gripping, lifting (especially with the palm down), turning a door handle, shaking hands, and wringing out a cloth. Rest pain is mild. Night pain suggests another cause.
• Examination: tenderness at or just distal to the lateral epicondyle (the extensor origin), pain on resisted wrist extension with the elbow extended (Cozen test) or resisted middle finger extension (Maudsley test), pain on passive wrist flexion with the elbow extended and forearm pronated (Mill test), and reduced grip strength, which is worse with the elbow extended. Elbow range of movement is normal.
• Differential diagnosis: radial tunnel syndrome (posterior interosseous nerve compression, tenderness over the radial tunnel 3 to 5 cm distal to the epicondyle, with pain on resisted supination), posterolateral rotatory instability, lateral synovial plica, elbow osteoarthritis, osteochondritis dissecans of the capitellum, cervical radiculopathy (C6 or C7), referred shoulder pain, lateral ligament injury, bursitis, fracture, and neoplasm.
• Red flags: trauma with swelling or locking, night or rest pain, neurological signs, fever, or a history of malignancy.
• Complications: persistent pain, weakness, loss of function and work, tendon tear, and secondary depression.

• Clinical. No tests are needed for typical presentations.
• X-ray of the elbow for persistent pain beyond 3 months, trauma, locking or suspected arthritis (it may show calcification near the epicondyle or osteochondral lesions).
• Ultrasound shows tendon thickening, hypoechoic areas, calcification and neovascularity, and tears. MRI for diagnostic doubt, suspected tear or coexisting pathology.
• Cervical spine examination and nerve conduction studies if radiculopathy or radial tunnel syndrome is suspected.

• Education and activity modification: reduce or modify aggravating activities, avoid repetitive heavy gripping, adjust work ergonomics, use two hands for lifting with the palm up, and check racket grip size, string tension and technique. Complete rest is not advised, and a gradual loading programme is the basis of recovery.
• Analgesia: paracetamol 1 g orally 6 hourly. Topical diclofenac 1% gel 2 to 4 g 3 to 4 times daily for 2 to 4 weeks gives short term relief. Oral NSAIDs (ibuprofen 400 mg 8 hourly with food for up to 1 to 2 weeks) give small short term benefit with no long term gain.
• Exercise therapy (the most effective long term approach), 3 to 4 times weekly for 8 to 12 weeks:
  • Isometric wrist extension holds (45 seconds, 4 to 5 repetitions) for pain relief early.
  • Progressive eccentric and heavy slow resistance strengthening of the wrist extensors (3 sets of 10 to 15), followed by grip, forearm and shoulder strengthening, and stretching.
• Support: a counterforce forearm strap or brace worn during activity (for short term relief), and a wrist splint at night in painful cases.
• Corticosteroid injection: gives faster pain relief in the first 2 to 6 weeks, but is worse than placebo or physiotherapy at 6 to 12 months, with higher recurrence, so it is not first line and should be used sparingly. If used: triamcinolone acetonide 10 to 20 mg (or methylprednisolone acetate 20 mg) with lidocaine 1% 1 to 2 mL, injected around the tender point (not into the tendon), and not more than 1 to 2 injections. Warn about skin atrophy, depigmentation and tendon weakening.
• Other options for persistent disease after 3 to 6 months (evidence mixed or limited):
  • Platelet rich plasma, a single injection of 2 to 3 mL, may improve pain at 6 to 12 months compared with steroid.
  • Extracorporeal shock wave therapy, 3 weekly sessions.
  • Glyceryl trinitrate patch 1.25 mg per 24 hours (a quarter of a 5 mg per 24 hour patch), changed daily for 6 to 24 weeks, with headache as the main side effect.
  • Autologous blood injection, hyaluronic acid, botulinum toxin and prolotherapy have uncertain benefit.
• Surgery, for severe pain and loss of function after 6 to 12 months of well delivered conservative therapy: open, percutaneous or arthroscopic release or debridement of the degenerative extensor carpi radialis brevis origin, with success of about 80 to 90%. Rehabilitation takes 3 to 6 months. Complications include persistent pain, loss of strength, and lateral instability if the ligament is damaged.
• Special groups:
  • Pregnancy: use ergonomic change, brace, paracetamol and physiotherapy. Avoid NSAIDs after 20 weeks and steroid injection unless essential.
  • Diabetes: monitor glucose for 3 to 5 days after injection.
  • Smokers: advise cessation, which improves tendon healing.
  • Elderly: use topical NSAIDs, exercise, and avoid repeated injections.
  • Renal impairment and gastrointestinal disease: avoid oral NSAIDs.
• Follow up: review at 6 weeks and 3 months. Refer to orthopaedics, sports medicine or hand surgery for no improvement by 6 months, diagnostic doubt, or consideration of surgery.