Lateral/Medial Epicondylitis

Lateral Epicondylitis

Lateral epicondylitis is also refered to as tennis elbow and is the most common overuse injury of the elbow, observed up to 10 times more frequently than medial epicondylitis. Lateral epicondylitis is usually precipitated by repetitive contraction of the wrist extensors and is characterized by aching pain that is worsened with activity. Early conservative management is the key to symptom resolution, which eventually allows return to activities without restriction. Lateral epicondylitis is an overuse syndrome generally caused by repetitive use of the wrist extensors or sustained power gripping. Lateral epicondylitis can be associated with an imbalance secondary to muscle weakness and soft tissue inflexibility.

Lateral epicondylitis is a result of inflammation, or enthesitis, at the origin of the muscle extensor carpi radialis brevis (ECRB). This inflammation leads to microtears of the tendon with subsequent fibrosis and, ultimately, tissue failure. Less commonly, the attachments of the extensor carpi radialis longus (ECRL), extensor digitorum communis (EDC), or extensor carpi ulnaris (ECU) are involved.

Lateral epicondylitis most often occurs between age 30 and 50. Patients who present acutely (<3 mo) generally respond well to treatment. Chronic cases that are refractory to treatment may take months to resolve.

The patient usually describes lateral elbow pain of gradual onset. The aching pain generally increases with activity. The patient may describe symptoms occurring during simple activities of daily living (ADL), such as picking up a cup of coffee or a gallon of milk. Pain may be present at night. Symptoms are typically unilateral.

Most commonly, the examination reveals localized tenderness to palpation just distal and anterior to the lateral epicondyle. Pain increases with resisted wrist extension, especially with the elbow in extension. The patient may have a weakened grip on the affected side. Elbow range of motion (ROM) is typically normal.

Treatment of Lateral Epicondylitis

Acutely, the goals of treatment are to reduce pain and inflammation. Anti-inflammatory modalities include ice, ultrasound, and phonophoresis. Use of a wrist splint can be helpful because it places the extensor muscles in a position of rest and prevents maximal muscle contraction. Counterforce bracing (tennis elbow strap) is another orthotic alternative that can be used during activity to unload the area of muscle origin at the elbow. Deep tissue and friction massage helps release underlying adhesions and promotes improved circulation to the area.

In the subacute stage, emphasis is placed on the restoration of function of the involved muscle group. Flexibility, strength, and endurance of the wrist extensor muscle group can be achieved through a graded program. ROM for wrist flexion/extension and pronation/supination should be achieved prior to proceeding with a strengthening program. Strength and grip training should progress from isometric to concentric to eccentric contractions of the forearm muscles, especially the wrist extensors.

Nonsteroidal anti-inflammatory drugs (NSAIDs) -- Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Corticosteroids -- Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Analgesics -- Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who experience pain.

If a patient does not seem to be responding to conservative care, a steroid injection about the lateral epicondyle using local anesthetic can be performed. However, the role of corticosteroid injection in tendinopathy remains controversial. Injecting a corticosteroid directly into a tendon can be deleterious. Additionally, corticosteroid injection around a tendon may inhibit collagen repair. That being said, steroid injections in some cases can bring about dramatic, albeit short-term, relief.

For those cases of refractory lateral epicondylitis, surgical resection of the lateral extensor aponeurosis might be considered.

Medial epicondylitis (ME)

is an overuse injury affecting the flexor-pronator muscle origin at the anterior medial epicondyle of the humerus. ME often is discussed in conjunction with lateral epicondylitis (LE), which occurs much more frequently.

ME is characterized by pain over the medial epicondyle. Pain worsens with wrist flexion and pronation activities. Patients may report discomfort even when simply shaking hands with someone. History of an acute injury may be reported (eg, taking a divot in golf, throwing a pitch in baseball, a hard serve in tennis). Up to 50% of patients with ME complain of occasional or constant numbness and/or tingling sensation that radiates into their fourth and fifth fingers, suggesting involvement of the ulnar nerve.

Tenderness with palpation over the anterior aspect of the medial epicondyle is the most consistent finding. Typically, pain is reproduced with resisted pronation or wrist flexion. Occasionally, the area of tenderness extends toward the proximal flexor pronator muscle mass just distal to the epicondyle for approximately 1 inch. Range of motion of the elbow and wrist usually is within normal limits. Patients may have symptoms of ulnar neuropathy (eg, decreased sensation in the ulnar nerve distribution, a positive elbow flexion test, a positive Tinel sign). In more severe cases, decreased sensation is associated with intrinsic weakness and even intrinsic muscle atrophy may be noted.

ME is caused by repetitive use of flexor/pronator muscles, especially with valgus stress at the medial epicondyle. Onset can accompany acute injury. Excessive topspin in tennis, excessive grip tension, improper pitching techniques in baseball, and improper golf swing are common sports-related causes of ME. Causes also may be related to the patient's occupation (eg, those requiring repetitive actions like using a screwdriver or hammer).

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