Tennis elbow, clinically referred to as lateral epicondylitis (LE), is a syndrome characterised by pain in the lateral aspect of the elbow and the forearm extensors. Golfer's elbow, or medial epicondylitis (ME), is similar to LE, however it is characterised by pain in the medial aspect of the elbow and the forearm flexors. The nomenclature of both pathologies refer to how stroke dynamics experienced in both tennis and golf traditionally contributed to the pathogenesis of these tendinopathies.

The prevalence of LE is estimated at 1.3% in the adult population compared with an estimated prevalence of 0.4% for ME. Men and women are equally affected.

 

 

The traditional association of lateral epicondylitis with racquet sports players

Pathophysiology and aetiology

The term 'epicondylitis' is a bit of a misnomer, as the pathological changes are not that of inflammation, but of degeneration. Up until recently, LE and ME were regarded as syndromes of overuse, however hypoxia has now been cited as a contributing factor. Forceful and repetitive use of the extensors and flexors from sport or occupational activities are regarded as the main causes of these tendinopathies. Smoking and obesity are two factors which contribute to the pathogenesis of LE and ME.

Commonly, the origin of the extensor carpi radialis brevis is the site of pathology in LE, although the origin of the extensor digitorum communis may also be involved. In ME, the pathological sites are less specific than LE, but pronator teres and flexor carpi radialis are the two most common pathological sites.

History

In LE, the typical presenting complaint is a sharp pain that starts around the lateral aspect of the elbow and radiates following the path of the extensors. The onset of pain is gradual and may be exacerbated by repetitive forearm extension and pronation or heavy loading from occupational and recreational activities discussed below. As a consequence of the pain, there maybe weakness in wrist extension or gripping objects. A good question to ask is to enquire whether or not the patient experiences pain or weakness when holding a coffee cup (or something similar).

ME is characterised by medial elbow pain that typically radiates into the flexors. The pain is made worse by wrist flexion and pronation of the forearm. As with LE, the onset is gradual, the character is sharp and intermittent and made worse from physical activity. There may also be impaired gripping ability. In addition, ME often co-exists with ulnar neuropathy, so there maybe diminished sensation of the ring and little fingers of the affected limb.

Occupational and recreational history are usually the key in pointing to the cause of LE or ME and can be useful in the patient's management. Generally plumbers, butchers, gardeners and string musicians are at a predisposition to developing LE, whilst typists, builders and carpenters are predisposed to developing ME. None of these occupations are exclusive to either condition. Recreationally, racquet sports and fencing predispose patients to LE, whilst rowing, golf, javelin and tennis serving predispose patients to ME.

Other factors in the history to consider are smoking and obesity which both contribute to developing either tendinopathy.

It is always important to gauge how much the pain is affecting the patient's daily life.

Clinical examination

Maudsley's and Mills' tests

Lateral Epicondylitis

Begin as with any Orthopaedic examination: 

  • Look (is there any swelling or erythema?)
  • Feel (note any tenderness)
  • Move (assess motor strength of extensors and note range of movement of elbow and wrist)

Pain maybe elicited through three very simple tests:

  • Maudsley's test;
  • Mills' test;
  • Chair lift test.

Maudsley's test involves a pronated wrist and flexion of the middle finger. Pain over the lateral epicondyle maybe elicited.

Mills' test involves pronation and flexion of the wrist, accompanied with flexion of the fingers. Elbow extension is limited or at least resisted.

The chair lift test involves picking up a chair with an adducted shoulder, extended elbow and pronated wrist. A cruder, but slightly easier test is the 'coffee cup test' where the patient simply picks up a cup full of liquid and again, pain would be elicited at the lateral epicondyle.

 

Medial epicondylitis

As with LE, the look, feel, move approach should be adopted. Any tenderness in ME is likely to be distal and lateral to the medial epicondyle.

ME occasionally co-exists with cubital tunnel syndrome, and may exhibit features of it such as tenderness over the ulnar nerve, diminished sensation in the ring and little finger, and a positive Tinel's sign in which the nerve is lightly percussed eliciting a paraesthetic sensation.

Investigations

History and clinical examination usually can diagnose LE and ME, however when the diagnosis is unclear, MRI scanning can be used to rule out arthritis. X-rays may occasionally show areas of calcification in both LE and ME.

Management

Management for both LE and ME is similar and depends on the patient's choice. These include:

  • conservative management (rest) may resolve LE/ME in many cases;
  • ergonomic adjustments - if aetiology is from occupational/recreational activities, then changing equipment or restricting an activity can improve outcomes;
  • counter-force braces and compression bandaging can distribute the force;
  • physiotherapy involving stretching and eccentric exercises;
  • pharmacological therapy including non-steroidal anti-inflammatory drugs and corticosteroid injections;
  • ultrasound therapy;
  • surgical intervention (where all other management fails).

 

    More recently, other methods of treatment have been cited as management options for LE and ME including extracorporeal shockwave therapy, botulinum toxin, low-level laser therapy, glyceryl trinitrate and autologous blood injection around the affected epicondyle all have an evidence base but are not commonly used in clinical practice.

    Further reading

    Jobe, F.W., Ciccotti, MG., "Lateral and Medial Epicondylitis of the Elbow", J Am Acad Orthop Surg, 1994;2:1-8

    Boxall, N., "Advantage patient: current concepts in treating tennis elbow", Journal of Student Medical Sciences, 2009;1(3)

    "Tennis Elbow - Lateral Epicondylitis", Wheeless' Textbook of Orthopaedics, http://www.wheelessonline.com/ortho/tennis_elbow_lateral_epicondylitis

    "Medial Epicondylitis", Wheeless' Textbook of Orthopaedics, http://www.wheelessonline.com/ortho/medial_epicondylitis

    Advertisement

    Fastbleep © 2019.