Tennis Elbow 1

Updated: Jun 10, 2020

In this 3 part series, I plan on addressing one of the most common injuries of the elbow, lateral epicondylitis also known as Tennis Elbow. The plan is to address its etiology, prevalence and some of the most common treatment modalities. And so without further or due, here...we...go. Lateral epicondylitis also termed Tennis Elbow, is one of the most common injuries seen around the elbow joint, its prevalence seems to be somewhere between 1-3% in the general populous and happens to be 7-10 times more common than medial epicondylitis (golfers Elbow)[1].

Observational evidence suggests that its more likely to occur from occupational activities rather than sporting activities, which is rather interesting to say the least since most overuse injuries are usually due to sporting activities like Patellofemoral pain.

But one can imagine that some occupations place high stress on the musculoskeletal system, especially in manual labor where repetitive elbow flexion-extension >2hours, operating vibrating tools > 2hours and overloading elbow extensor tendons >2hours have the highest risk of lateral epicondylitis injury [2] [3] [4].

It has been proposed that the main extensor involved in this pathology is the extensor carpi radialis brevis (ECRB) due to its unique anatomy & involvement in most elbow and wrist functions making it the most loaded muscle surrounding the elbow joint. Which means that it’s at the highest risk of overuse[5], but other tendons are also at risk.

Before I continue, I’d like to clarify the term epicondylitis, specifically the ‘itis’ portion which suggests an inflammatory process and that is a misnomer because histologically there are no inflammatory changes. Rather a dense collection of fibroblasts and disorganized collagen fibers[6]. This is an indication of a degenerative change in the tissue, usually due to repetitive microtrauma, thus, there is an element of chronicity to it. Now a days we refer to this as Tendinopathy rather than Tendinitis. And because it’s a non-inflammatory process, the use of NSAIDs in these cases is redundant.

And since we’re on this topic, I’d like to define the term Tendinitis; it is a relatively uncommon condition, clinically characterized by signs of inflammation such as redness, swelling, hotness and pain. Symptoms only lasts about 3-7 days, depending on the severity of the injury. The onset of symptoms is sudden, and the event leading up to it is usually remembered and is often of traumatic nature. The use of NSAIDs here is warranted since this is an inflammatory process. Making the distinction between Tendinopathy and Tendinitis is crucial because the treatment approach for each is different. However, there are scenarios in which you have new-onset tendinitis on top of a pre-existing Tendinopathy. In medicine we refer to this as acute on top of chronic. In these cases, I may recommend a short course of NSAIDs for a couple of days plus rest to control the initial inflammation and then revert to loading the tissue again to build tolerance.

From my experience this usually occurs due to aggressive rehab protocols where the injured tissue is overloaded beyond its tolerance capacity leading to new onset inflammation and regression of tissue health.

Other times the patient willingly ignores his tendinopathy until it starts 'acting up', and occasionally it's just plain bad luck. To keep this article short, I might delve into the differences between Tendinitis and Tendinopathy in another post because there is a lot that goes into it, but I hope I managed to give you the gist of it.

This concludes part 1 of the series, talk soon.

[1] Cutts, S., Gangoo, S., Modi, N. and Pasapula, C. Cutts, S., Gangoo, S., Modi, N., & Pasapula, C. (2020). Tennis elbow: A clinical review article. Journal Of Orthopaedics, 17, 203-207. doi: 10.1016/j.jor.2019.08.005.

[2] Herquelot E, e. (2013). Work-related risk factors for incidence of lateral epicondylitis in a large working population. - PubMed - NCBI. [3] Seidel, David & Ditchen, Dirk & Hoehne-Hückstädt, U. & Rieger, Monika & Steinhilber, Benjamin. (2019). Quantitative Measures of Physical Risk Factors Associated with Work-Related Musculoskeletal Disorders of the Elbow: A Systematic Review. International Journal of Environmental Research and Public Health. 16. 130. 10.3390/ijerph16010130. [4] Shiri R, e. (2006). Prevalence and determinants of lateral and medial epicondylitis: a population study. - PubMed - NCBI.

[5] Briggs CA, Elliott BG Lateral epicondylitis. A review of structures associated with tennis elbow. Anat Clin. 1985;7(3):149-53.

[6] Andres, B., & Murrell, G. (2008). Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon. Clinical Orthopaedics And Related Research, 466(7), 1539-1554. doi: 10.1007/s11999-008-0260-1.


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