Tennis Elbow?

Tennis elbow, also known as "Shooter's elbow" and "Archer's elbow", is a condition where the outer part of the elbow becomes sore and tender. The accurate medical term is lateral epicondylalgia. It is a condition that is commonly associated with playing tennis and other racket sporsts, though the injury can happen to almost anybody.

The condition is also known as lateral epicondylitis ("inflammation to the outside elbow bone"), a misnomer as histologic studies have shown no inflamatory process. Other descriptions for lateral epicondylalgia are lateral epicondylosis, or simply lateral elbow pain.

Runge is usually credited for the first description in 1873 of the condition. The term tennis elbow was first used in 1883 by Major in his paper Lawn-tennis elbow

Symptoms
Pain on the outer part of elbow.
Point tenderness over the lateral epicondyle – a prominent part of the bone on the outside of the elbow.

Gripping and movements of the wrist hurt, especially wrist extension and lifting movements.
Activities that use the muscles that extend the wrist (e.g. pouring a pitcher or gallon of milk, lifting with the palm down) are characteristically painful.
Morning stiffness.



Etiology
The strongest risk factor for lateral epicondylosis is age. The peak incidence is between 30 to 60 years of age. No difference in incidence between men and women or association between tennis elbow and the dominant hand has been demonstrated.
The pathophysiology of lateral epicondylosis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the extensor carpi radialis brevis muscle are identified in surgical pathology specimens. It is unclear if the pathology is affected by prior injection of corticosteroid.

Among tennis players, it 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.

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 shearing stresses during all movements of the forearm.

While it is commonly stated that lateral epicondlyosis is caused by repetitive microtrauma/overuse, this is a speculative etiological theory with limited scientific support that is likely overstated. Other speculative risk factors for lateral epicondylosis include taking up tennis later in life, unaccustomed strenuous activity, decreased reaction times and speed and repetitive eccentric muscle contractions (controlled lengthening of a muscle group).

Exams and tests
The diagnosis is made by clinical signs and symptoms, which are usually both discrete and characteristic. There should be point tenderness over the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (ECRB origin). There should also be pain with passive wrist flexion and also with resisted wrist extension (Cozen's test), both tested with the elbow extended.

MRI typically shows fluid in the ECRB origin. There may also be a defect in this tissue. The use of the word "tear" to refer to this defect can be misleading. The word "tear" implies injury and the need for repair--both of which are probably inaccurate and inappropriate for this degenerative enthesopathy.

Treatment
In general the evidence base for intervention measures is poor.
Non-specific palliative treatments include:

• Heat or ice
• A counter-force brace or "tennis elbow strap" to reduce strain at the elbow epicondyle, to limit pain provocation and to protect against further damage.

Rest is the tennis player's treatment of choice when the pain first appears; the rest allows the tiny tears in the tendon attachment to heal. Tennis players treat more serious cases with ice (although the effectiveness of ice treatment has been challenged in clinical research ), anti-inflammatory drugs, soft tissue massage, stretching exercises, and ultrasound therapy.

In recalcitrant cases surgery may be indicated. Many techniques have been described using open, percutaneous or arthroscopic approaches. Most techniques aim to release the strain on the extensor carpi radialis brevis (ECRB) muscle, remove degenerative tissue and promote healing.

Other treatments with limited scientific support include:

• Acupuncture
• Blood injection (possibly augmented by plateletpheresis)
• Botulinum toxin
• Extra-corporeal shock wave therapy (lithotriptor)
• Heat therapy
• Immobilization of the forearm and elbow using a splint for two to three weeks
• Local injection of cortisone and a numbing medicine
• Low level laser therapy
• Occupational therapy, primarily for stretching and strengthening of the wrist extensor musculature.
• Physical therapy
• Platelet-rich plasma
• Pulsed ultrasound to break up scar tissue, promote healing, and increase blood flow in the area
• Sclerotherapy
• Trigger point therapy

There are clinical trials addressing many of these proposed curative treatments, but the quality of these trials is generally poor.
One study has alleged that electrical stimulation combined with acupuncture is beneficial but evaluation studies are inconclusive.

One recent presentation at a scientific meeting described the Tyler Twist Protocol, a physical therapy intervention. Although the study has yet to be published to verify claims made in the newspaper.

Cortisone injections
In four clinical trials comparing corticosteroid injection to placebo (lidocaine) injection that show no effect of the steroids. Complications from repeated steroid injections include skin problems such as hypopigmentation and fat atrophy.

Exercises and stretches
There are several recommendations regarding prevention, treatment, and avoidance of recurrence that are largely speculative including:

1. Stretches and progressive strengthening exercises to prevent re-irritation of the tendon
2. Progressive strengthening involving use of weights or elastic theraband to increase pain free grip strength and forearm strength
3. Racquet sport players also are commonly advised to strengthen their shoulder rotator cuff, scapulothoracic and abdominal muscles by Physiotherapists to help reduce any overcompensation in the wrist extensors during gross shoulder and arm movements
4. Soft Tissue Release or simply Massage can help reduce the muscular tightness and reduce the tension on the tendons; and
5. Strapping of the forearm can help realign the muscle fibers and redistribute the load.
6. Use of a racket designed to dampen the effect of ball striking.

There is little evidence to support the value of these interventions for prevention, treatment, or avoidance of recurrence of lateral epicondylosis.

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