Tennis elbow (epicondylitis of the humerus) is a common clinical condition, so what is the proper treatment? Take a look at the key points in this review by Rosenzweig in Techniques in Shoulder & Elbow Surgery.
Tennis elbow (lateral humeral epicondylitis) is a common clinical condition that causes pain in the lateral aspect of the elbow when the patient grips and lifts objects with force. Statistically, epicondylitis occurs in 10-50% of tennis players. However, epicondylitis can also occur in workers who have repeated inappropriate force activities for long periods of time.
It has been found that epicondylitis of the humerus is actually a tendon degeneration of the short extensor carpi radialis (ECRB) or the extensor digitorum communis (EDC) tendon, rather than a result of local inflammation. However, the finding of neuropeptides at the radial short extensor carpi radialis suggests that neuroinflammation may be a cause of the lateral elbow pain that patients experience.
Etiology
The most common cause of tennis elbow is tendon injury caused by repetitive forceful stretching of the forearm extensor muscles, which is particularly likely to occur in patients aged 35-50 years. Young or professional tennis players are at an increased risk of developing tennis elbow due to overuse of the elbow joint. Also, lack of resistance of the skeletal muscular system predisposes to tennis elbow.
Some researchers suggest that tennis elbow may be caused by a failure of repair after tendon injury and local vascular damage. The normal tendon repair can be interrupted by subsequent injury, while the damaged tendon continues to disrupt the tendon repair. professor Cyriax believes that the muscle-bone junction is the most susceptible to injury because the tendon fibers there are relatively unsupplied with blood.
Tennis players are prone to tennis elbow for both intrinsic and extrinsic reasons. The extrinsic cause is the use of too heavy a racket or too small a grip resulting in incorrect forces acting on the extensor digitorum communis tendon. The intrinsic cause is the chronic accumulation of microtrauma to the tissues involved due to excessive use of the wrist joint during the backhand stroke.
Clinical presentation and physical examination
The patient complains of pain in the lateral aspect of the elbow joint, which may radiate to the forearm and may be aggravated by gripping or lifting objects with the affected limb.
Physical examination should include an examination of the cervical spine, as pain due to nerve root compression at C5-C6 or C6-C7 can be misdiagnosed as humeral epicondylitis. The examiner can observe for lateral elbow pain by asking the patient to move the cervical spine and performing the Spurlings test.
Once the cervical spine has been ruled out, a thorough examination of the patient’s shoulder function is required, including a strength test of the shoulder joint to assess the balance of contraction of the shoulder muscles.
The stability of the scapula is important for tennis ball pumping and without a stable point of force for the rotator cuff muscles, shoulder function will be significantly limited. Overuse of the wrist extensors and degenerative tendon degeneration.
Next, the function of the patient’s wrist extensor muscles needs to be examined. lucado et al. found that symptomatic female tennis players had a significantly higher wrist flexion/extension strength ratio than asymptomatic women. It is likely that this muscle strength imbalance in tennis players is associated with the development of tennis elbow, while the development of tennis elbow in non-tennis players may also be associated with muscle imbalance.
Finally, palpation of the lateral epicondyle of the humerus reveals tenderness and pressure pain in the lateral epicondyle and anterior aspect of the forearm. Pain at the lateral epicondyle of the humerus can occur with the elbow joint extended and the forearm rotated anteriorly to extend the wrist joint or with the wrist fully flexed. If pain occurs during forceful fist clenching or restricted extension of the middle finger, degeneration of the radial carpal short extensors also occurs. When pain occurs with limited extension of the radial wrist joint or pressure pain in the humeral epicondyle indicates involvement of the radial long wrist extensor.
In addition, patients often have decreased grip strength due to pain in the lateral humeral epicondyle, a stable and sensitive diagnostic indicator of tennis elbow, so it is also necessary to measure the grip strength of the affected limb with a hand-held grip strength meter.
Neurological considerations
The diagnosis of tennis elbow also requires consideration of symptoms caused by abnormalities in the nerve structures, such as radial nerve entrapment syndrome and posterior interosseous nerve compression, which can cause pain in the lateral elbow joint.
It has been found that 5% of patients with humeral epicondylitis may have radial nerve compression because deep branches of the radial nerve pass behind the Frohse arch along the edge of the posterior rotator muscle fibers. Deep pressure pain at the radial head and limitation of posterior rotation of the forearm indicate radial nerve injury, while pressure pain at the humeral epicondyle and limitation of wrist extension suggest tennis elbow. The posterior interosseous nerve may be compressed at the point of entry into the posterior rotator muscle.
The pain of this type of nerve entrapment sign is more diffuse, whereas in tennis elbow the pain is concentrated in the forearm muscles distal to the lateral epicondyle of the humerus. Limited extension of the middle finger in elbow extension helps to differentiate neurologic disease, but the presence or absence of radial short carpal extensor muscle involvement must be determined.
In addition, the cervical nerve roots need to be evaluated for compression. Localized trigger points or chronic muscle spasm in the neck can also cause tennis elbow patient-like pain. One study suggests that severe chronic cervical nerve compression can result in a negative repeat strength test of the carpal extensors.
Conservative treatment
Nirschl et al. divided conservative treatment into three phases, primarily the acute inflammatory phase, the chronic inflammatory phase, and the muscle strength deficit phase. There are more conservative treatments, ranging from those aimed primarily at symptom relief to etiologic treatment. However, due to individual differences, there is still no uniform standard of treatment.
The first thing that is carried out is health education of the patient and correction of wrong activity patterns. The common conservative treatments for tennis elbow are ultrasound therapy, ultrasound drug penetration therapy, electrical stimulation, iontophoresis, heat therapy and cryotherapy. Manual therapy can also be used to treat tennis elbow, such as moving the affected limb or massage.
In addition, active muscle strength restoration programs such as wrist extensor restoration should be done in conjunction with scapular and rotator cuff muscle group restoration. Some researchers suggest that tennis elbow can be treated by stretching the wrist extensors and forearm muscles, with the wrist joint as if it were supported with the top cocked up, or by stretching with a reverse force.
If nerve root compression is suspected, symptoms of compression can be relieved by moving the joint, cervical traction and manual therapy. Tennis elbow can also be treated with injections of NSAIDs, cortisone, and concentrated platelet plasma.
Sling support
Struijs et al. did not find any pain relief or recovery of grip strength in the treatment of tennis elbow with sling support. Half-loop slings or reaction slings are recommended for the treatment of tennis elbow. The semi-loop sling-assisted wrist orthosis reduced elbow angle and improved electromyography of the radial carpal short extensors when the patient lifted objects.
The force of extension acting on the arm reduces the activity of the radial short extensor carpi radialis and the common extensor tendon when lifting objects in healthy people. When grasping an object the wrist can be made to produce an extension force, when the arm extensors are needed to stabilize the wrist joint.
During the acute phase of tennis elbow, a 30° wrist extension splint is worn for daily activities, and proximal limb functional exercises can be used to treat tennis elbow. In addition, wearing a reaction ring brace during exercise can help reduce discomfort.
Functional Exercises
Muscle strength and flexibility training can be effective in the treatment of tennis elbow, with centrifugal strength training considered the most effective method. It restores strength to the tendon by simulating the production of collagen by mechanoreceptors that help the tendon recover, and also improves the collagen cohort in the tendon and stimulates the formation of collagen cross lines, thereby increasing the tensile strength of the tendon.
Centrifugal strength training begins by immobilizing the forearm with the elbow and wrist in the extended position and making a fist. The patient lowers the affected wrist with the opposite hand and then raises it to the original position. Each set is repeated 5-15 times for a total of 3 sets and is recommended to be done daily.
It is normal to experience mild discomfort during training, but if the pain is severe, stop training immediately. Once the patient can easily complete the exercise, the resistance can be increased by adding gravity or rubber bands (Figure 3).
Another method of centrifugal strength training at the wrist is by tying weights to the end of a rope. The patient completes the centrifugal strength training by controlling the rise and fall of the weights through the handle, with the healthy arm holding the handle during the intervals of repetitive motion (Figure 4).
The studies all showed significant pain relief, but the importance of the training, the weight of the weights, and the duration of the training varied from study to study. Most of the studies noted good results with 10-15 training sessions and a duration of 6-12 weeks.
In addition, studies have found that muscle strength training combined with other treatment options, such as ultrasound, massage or orthopedic therapy, can be effective in relieving pain and restoring function.
Tennis players swing and hit the ball primarily by mobilizing the muscles of the scapula, shoulder and elbow, and injury to any of these areas increases the load on the wrist extensors. Clerks who use computers for long periods of time can also develop tennis elbow due to overuse of the wrist extensor muscles.
Therefore, the authors concluded that the primary treatment options for tennis elbow are pain relief, health education, and exercise of the proximal muscles (the most important part of tennis ball striking). This would include core muscle strength training for rotational function of the shoulder and elbow joints, scapular muscle training, posterior rotation training with elevation of 45° and 90°, and diagonal patterns of D1 and D2 extension and flexion (proprioceptive neuromuscular easing techniques). In addition, both closed-chain and open-chain exercises can be used during the treatment.
Concentration of platelet plasma
If none of the above methods are effective, it is recommended to inject platelet plasma concentrate (PRP), which contains cell growth factors and cytokines that promote proliferation, differentiation and maturation of human cells.
Two recent studies have found that inactivated PRP containing leukocytes can be used as an alternative treatment option to surgery for tennis elbow and have also shown good clinical prognosis.
However, neither of these studies identified a reason why PRP relieves pain in tennis elbow patients, nor did they find changes in tendon structure. The authors of this article suggest that PRP reduces pain symptoms by improving microvascular circulation in the tendon and surrounding muscle tissue.
Surgical treatment
When conservative treatment of tennis elbow fails, surgical options include incisional debridement and repair or simple debridement, percutaneous decompression, and arthroscopic debridement. Regardless of the surgical approach chosen, the principle of surgical treatment is the same: removal of degenerative tissue at the radial short extensor carpi radialis (and the common extensor tendon if involved).
Nirschl et al. followed 130 patients with tennis elbow who underwent incisional debridement for up to 10 years and showed that 97% of patients had significant improvement in symptoms and 93% returned to their preexisting level of motion. Thorton et al. showed good recovery of grip strength after surgery by modifying Nirschl’s surgical technique and fixing the repaired tendon to the lateral epicondyle of the humerus with a suture anchor.
Arthroscopic debridement for tennis elbow can be equally effective and can also address intra-articular lesions, as Szabo et al. found that 44% of patients had a combination of intra-articular lesions. Another advantage of arthroscopic treatment is the short return to work time (11 days on average).
Solheim et al. followed 300 patients with tennis elbow for 3-6 years, and although both groups had a good clinical prognosis, the arthroscopic group had a higher mean shoulder, arm, and hand dysfunction score (Quick DASH), and patients recovered better after surgery. The time to return to work after surgery was shorter in the arthroscopic group.
Excessive debridement can damage the lateral collateral ligaments of the elbow resulting in posterior lateral rotational instability. The lateral collateral ligament can be well protected during arthroscopic debridement by keeping the lateral collateral ligament parallel to the superior half of the radial head. Complications such as heterotopic ossification and paralysis distal to the incision have also been studied.
Surgical technique
The patient is placed supine on the operating table with the affected limb abducted on a special surgical table for the hand and the scapula padded. A tourniquet is placed on the upper arm and a sterile towel is placed. An esmarch tourniquet is applied to expel the blood and then inflate the tourniquet.
A 2-3 cm incision is made on the anterior side of the lateral humeral epicondyle distally, and a plane is visible with the radial carpal long extensor muscle at the anterior border and the common extensor tendon at the posterior border. The radial carpal long extensor muscle is separated anteriorly so that the underlying radial carpal short extensor muscle can be exposed.
Since the degenerative tissue is light gray in color, it is easily distinguished from healthy tendon tissue, so complete excision of the diseased tissue is not difficult. In addition, the scratch test can be used to determine whether the debridement is complete.
A small suture anchor is then inserted into the lateral epicondyle of the humerus to thoroughly flush the surgical area of bone debris to avoid heterotopic ossification. The repaired radial short extensor carpi radialis is secured to the lateral epicondyle of the humerus with a suture anchor. Finally, the wound is closed layer by layer, and posterior lateral splinting for one week is sufficient.
Postoperative rehabilitation
A systematic and comprehensive postoperative rehabilitation program is essential to obtain a good functional recovery, in which an experienced physiotherapist is of paramount importance. Communication between the surgeon and the logistic therapist is very important because the rehabilitation process needs to take into account the surgical approach, the soft tissue conditions, and the surgeon’s knowledge of rehabilitation. Guidelines for routine rehabilitation exercises for postoperative patients are provided in Table 2.
For patients who wish to return to exercise, they must achieve pain-free movement in all directions and good muscle strength (at least 85% of the healthy limb) as indicated by a manual muscle strength test or isometric muscle strength test. A grip strength test with a hand-held dynamometer (at least 85% of the healthy limb) is also required.
During the return to exercise phase, floor pumping, serving, and monitoring the amount of exercise based on the patient’s response will be performed gradually. Initially, 15-20 minute intervals were used, and then the duration of exercise was gradually increased according to the patient’s tolerance level, but two consecutive days of exercise were prohibited.
The authors believe that a professional tennis coach is important for the prevention and rehabilitation of the patient’s tennis elbow. In addition, comprehensive training and rehabilitation of the lower extremity muscles are also important for the whole tennis training process.
Conclusion
There are many reasons for the occurrence of pain in the lateral epicondyle of the humerus in tennis elbow, but there is still no standard treatment plan.
Most patients can obtain symptomatic relief and functional recovery after conservative treatment, and the remaining patients can also obtain a good clinical prognosis with surgical treatment.