| Tennis | |
|---|---|
| Classification and external resources | |
Left elbow-joint, showing posterior and radial collateral ligaments. (Lateral epicondyle visible at center.) |
|
| ICD-10 | M77.1 |
| ICD-9 | 726.32 |
| DiseasesDB | 12950 |
| eMedicine | orthoped/510 pmr/64 sports/59 |
| MeSH | D013716 |
Lateral epicondylitis or lateral epicondylalgia, also known as tennis elbow, shooter's elbow and archer's elbow, is a condition where the outer part of the elbow becomes sore and tender. It is commonly associated with playing tennis and other racquet sports, though the injury can happen to almost anyone.[1]
Tennis elbow is an overuse injury occurring in the lateral side of the elbow region, but more specifically, occurs at common extensor tendon that originates from the lateral epicondyle. While the common name tennis elbow suggests that people who play tennis may develop this condition, other activities of daily living may also cause it.[2]
Data was collected from 113 patients who had tennis elbow and the main factor between them all was overexertion. Sportspersons as well as those who used the same repetitive motion for many years, especially in their profession, suffered from tennis elbow. It was also common in individuals who performed motions they were unaccustomed to. The data also mentioned that the majority of patients suffered tennis elbow in their right arms.[3]
Other descriptions for tennis elbow are lateral epicondylosis, lateral epicondylalgia, or simply lateral elbow pain.
Lateral epicondylitis is a painful condition at the lateral epicondyle of the humerus. The acute pain that a person might feel occurs as one fully extends the arm. Since the pathogenesis of this condition is still unknown, an appropriate name is still in the works. Despite the term being tennis elbow, tennis players make up a small number of individuals who suffer from this ailment, often found in manual workers, such as builders and waiters. Bowden states that it should be called lateral elbow syndrome.[4]
Runge is usually credited for the first description in 1873 of the condition.[5] The term tennis elbow was first used in 1883 by Major in his paper "Lawn-tennis elbow".[6][7]
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The symptoms associated with tennis elbow are, but are not limited to: radiating pain from the outside of your elbow to your forearm and wrist, pain during extension of wrist, weakness of the forearm, a painful grip while shaking hands or torquing a doorknob, and not being able to hold relatively heavy items in the hand. The pain is similar to the pain of the condition known as Golfer's elbow but the latter occurs at the medial side of the elbow.[2]
During early experiments, it was thought that tennis elbow was primarily caused by overexertion. Studies have shown that trauma such as direct blows to the epicondyle, a sudden forceful pull, or forceful extension have caused more than half of these injuries.[3]
One explanation of how tennis elbow may come about is proposed by Cyriax. The theory states that there are microscopic and macroscopic tears between the common extensor tendon and the periosteum of the lateral humeral epicondyle. An operation conducted in this study showed that 28 out of 39 patients showed tearing at the tendon cuff. Kaplan stated that the radial nerve was significantly involved in tennis elbow. He noted the constriction of the radial nerve by adhesions to the capsule of the radiohumeral joint and the short extensor muscle of the wrist. Evidence found that many differed in how they contracted tennis elbow. Disorders such as calcification of the rotator cuff, bicipital tendinitis, or carpal tunnel syndrome may increase chances of tennis elbow.[3]
The pathophysiology of lateral epicondylitis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the extensor carpi radialis brevis (ECRB) muscle are identified in surgical pathology specimens.[8] It is unclear if the pathology is affected by prior injection of corticosteroid.
Among tennis players, tennis elbow is believed to be caused by the repetitive nature of hitting thousands and thousands of tennis balls which lead to tiny tears in the forearm tendon attachment at the elbow.[9]
The extensor digiti minimi also has a small origin site medial to the elbow which can be affected by this condition. The muscle involves the extension of the little finger and some extension of the wrist allowing for adaption to "snap" or flick the wrist – usually associated with a racquet swing. Most often, the extensor muscles become painful due to tendon breakdown from over-extension. Improper form or movement allows for power in a swing to rotate through and around the wrist – creating a moment on that joint instead of the elbow joint or rotator cuff. This moment causes pressure to build impact forces to act on the tendon causing irritation and inflammation.
The following speculative rationale is offered by proponents of an overuse theory of etiology: 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 shear stress during all movements of the forearm.
While it is commonly stated that lateral epicondylitis is caused by repetitive microtrauma/overuse, this is a speculative etiological theory with limited scientific support that is likely overstated.[8] Other speculative risk factors for lateral epicondylitis include taking up tennis later in life, unaccustomed strenuous activity, decreased mental chronometry and speed and repetitive eccentric contraction of muscle (controlled lengthening of a muscle group).
Another factor of tennis elbow injury is experience and ability. The proportion of players who reported a history of tennis elbow had an increased number of playing years. As for ability, poor technique increases the chance for injury much like any sport. Therefore an individual must learn proper technique for all aspects of their sport. The competitive level of the athlete also affects the incidence of tennis elbow. Class A and B players had a significantly higher rate of tennis elbow occurrence compared to class C and novice players. However, an opposite, but not statistically significant, trend is observed for the recurrence of previous cases, with an increasingly higher rate as ability level decreases.[2]
Other ways to prevent tennis elbow:
To diagnose tennis elbow, the physician performs a battery of tests in which pressure is placed on the affected area while the patient is asked to move the elbow, wrist, and fingers. X-rays are used to confirm and distinguish possibilities of existing causes of pain that are not related to Tennis Elbow, such as fracture or arthritis. Medical ultrasonography and magnetic resonance imaging (MRI) are other valuable tools for diagnosis but are frequently avoided due to the high cost.[2] MRI screening can confirm excess fluid and swelling in the affected region in the elbow, such as the connecting point between the forearm bone and the extensor carpi radialis brevis.
The diagnosis is made by clinical signs and symptoms, which are both discrete and characteristic. With the elbow fully extended, there are points of tenderness over the affected point on the elbow, which is the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (extensor carpi radialis brevis origin). There will also be pain with passive wrist flexion and resistive wrist extension (Cozen's test).[10]
Depending upon the severity and quantity of multiple tendon injuries that are built up, the extensor carpi radialis brevis may not be fully healed by conservative treatment. Nirschl has defined four stages of lateral epicondylitis, showing the introduction of permanent damage beginning at Stage 2.
Evidence for the treatment of lateral epicondylitis is poor.[12] There are clinical trials addressing many of these proposed treatments, but the quality of the trials is poor.[13] In some cases, severity of tennis elbow symptoms mend without any treatment within six to twenty-four months. However, if tennis elbow is left untreated, it can lead to chronic pain that degrades quality of daily living.[2]
There are several recommendations regarding prevention, treatment, and avoidance of recurrence that are largely speculative[8] including stretches and progressive strengthening exercises to prevent re-irritation of the tendon[14] [15] and other exercise measures.
Evidence suggests that joint mobilization with movement directed at the elbow resulted in reduction in pain and improved function.[16] Positive results have been found with manipulative therapy directed at the cervical spine, although data regarding long-term effects were limited.[17] Low level laser therapy administered at specific doses and wavelengths directly to the lateral elbow tendon insertions offers short-term pain relief and less disability in LET, both alone and in conjunction with an exercise regimen.[18]
Topical non-steroidal anti-inflammatory drugs (NSAIDs) to relieve lateral elbow pain in the short term, however there were no improvements found in functional outcomes. Injected NSAIDs were suggested to be better than oral NSAIDs. There was insufficient evidence to recommend or discourage the use of oral NSAIDs.[19]
Corticosteroid injection are effective in the short term[20] however are of little benefit after a year compared to a wait and see approach.[21] Complications from repeated steroid injections include skin problems such as hypopigmentation and fat atrophy leading to indentation of the skin around the injection site.[20]
Botulinum toxin type A to paralyze the common extensor origin chronic tennis elbow that has not improved with conservative measures.[22]
In recalcitrant cases, surgery may be an option.[23]
Response to initial therapy is common, but so are relapse (18% to 50%) and/or prolonged, moderate discomfort (40%).
In tennis players, about 39.7% have reported current or previous problems with their elbow. Less than one quarter (24%) of these athletes under the age of 50 reported that the tennis elbow symptoms were "severe" and "disabling." While 42% over 50 identified severe and disabling symptoms. More women (36%) than men (24%) considered their symptoms to be severe and disabling. Tennis elbow is more prevalent in individuals over 40, where there is about a 4-fold increase among men and 2-fold increase among women. Tennis elbow equally affects both sexes and although men have a marginally higher overall prevalence rate as compared women, this is not consistent within each age group, nor is it a statistically significant difference.[24]
Playing time is one factor in tennis elbow occurrences. However, an increased incidence with increased playing time is statistically significant for only respondents under the age of 40. Individuals over the age of 40 who played over 2 hours, had a 2-fold increase in chance of injury. Those under 40 had a 3.5 times increase compared to those who played less than 2 hours per day.[2]
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