Lateral epicondylitis, known as “tennis elbow”, results from overuse of the muscles and tendons that are used to extend your wrist and fingers. The pain is typically located on the outside, or lateral aspect, of the elbow and involves primarily a muscle-tendon unit called the extensor carpi radialis brevis (ECRB). This tendon is used to help stabilize the wrist when the elbow is extended, which occurs during a tennis groundstroke.
Medial epicondylitis, known as “golfer’s elbow” results from overuse of the muscles and tendons that are used to flex the wrist and turned the forearm. Pain and discomfort is typically located on the inside, or medial aspect, of the elbow and involves the tendon known as the common flexor tendon. Forces are increased on the flexor tendon while gripping a golf club during a golf swing.
Both conditions can be caused by other repetitious activities such as throwing and activities requiring repetitious grip, such as shoveling, hammering nails, and gardening activities. Typical symptoms include pain on grip or weakness in grip strength.
The early phase of these conditions is an acute inflammation of the tendon called tendinitis. However, if the overuse syndrome has existed for several months or longer, the tissue can continue to degenerate and form a condition known as tendinosis. This is not a true inflammatory condition but represents chronic degenerative changes in the collagen fibers of the tendon, which results in scar tissue, leaving the injured area in a weak and painful condition.
Diagnosis is typically based upon physical examination. Occasionally, x-rays may show some irregularity or calcium deposits within the tendon. Occasionally, further diagnostic imaging such as MRI or ultrasound is utilized, which confirms the pathology. The use of office musculoskeletal ultrasound now allows for a much quicker diagnosis and earlier intervention.
Treatment for this condition is typically nonsurgical and involves a rehabilitation program that may include rest and stretching exercises, non-provocative exercise, and occasionally use of bands or straps that may take the pressure off the tendon for a period of time. It is imperative to identify and correct any biomechanical abnormality in the swing or stroke mechanics, which led to the problem initially.
Although it is not uncommon for physicians to utilize cortisone-type injections to reduce the inflammation, recent evidence in the sports medicine literature suggests this should not be carried out more than once or twice, as this may further damage the collagen in the tendon.
Traditional surgical treatment requires an incision over the affected tendon area, with the removal of the damaged tissue and repair back to the bone after removing any underlying bone spurs.
Over the past several years, new and innovative technologies have been made available which are much less invasive. There has been a significant increase in the utilization of growth factors, such as platelet-rich plasma, as well as the use of certain types of stem cell therapies, to allow a more aggressive, regenerative healing response. These types of treatment options are referred to as orthobiologics.
Recently, a minimally invasive procedure developed at the Mayo Clinic called percutaneous tenotomy, or the Tenex procedure (www.TenexHealth.com), allows a physician to repair the degenerative collagen using a high energy device on the tip of a very small probe. This can be performed under a simple local anesthetic injection and is performed under ultrasound guidance. It requires no incisions or sutures and typically allows for a quicker recovery and return to activity.
Typically, prevention is the best cure! Spring has arrived, and outdoor activities will increase. Early recognition of symptoms, with early rehabilitation efforts and utilization of a good swing coach to correct poor mechanics, will typically prevent this from developing into a more chronic problem.