THE CLINICAL SYNDROME

• The repetitive microtrauma to the extensor tendons of the forearm that leads to tennis elbow (also known as lateral epicondylitis) is the cause of this condition.

• Microtears at the origin of the extensor carpi radialis and extensor carpi ulnaris are the first step in the pathophysiology of tennis elbow.

• If you continue to overuse or misuse the extensors in your forearm, you run the risk of developing secondary inflammation that becomes chronic over time.

• The pain and immobility caused by tennis elbow may be made worse by the presence of other conditions, such as bursitis, arthritis, or gout.

• Pain from tennis elbow typically originates at the bony origin of the extensor tendon of the extensor carpi radialis brevis at the anterior facet of the lateral epicondyle.

• This is the most common source of pain associated with tennis elbow.

• Pain in the tennis elbow can originate more distally, at the point where the extensor carpi radialis brevis overlies the radial head, or it can originate more proximally, at the point where the extensor carpi radialis longus originates at the supracondylar crest.

• However, this occurs only very infrequently.

• Bursitis can develop in the olecranon bursa, which is located in the posterior aspect of the elbow joint.

• Bursitis can develop as a result of direct trauma to the joint or from overuse of the joint.

• Other bursae that are prone to developing bursitis are located in the antecubital and cubital regions, in addition to being situated between the insertion of the biceps tendon and the head of the radius.

SIGNS AND SYMPTOMS

• The pain associated with tennis elbow is centered around the lateral epicondyle region of the elbow.

• This pain is always present, and it is made significantly worse by any activity that requires active contraction of the wrist.

• Patients report being unable to perform tasks as simple as holding a coffee cup or using a hammer.

• It is common to experience problems sleeping.

• During the course of the physical examination, tenderness along the extensor tendons either at or just below the lateral epicondyle is elicited.

• Tennis elbow is characterized by a band-like thickening that develops within the extensor tendons that are affected in many patients.

• The range of motion in the elbow is unaffected, but there is a decrease in grip strength on the affected side.

• Patients who suffer from tennis elbow have a result on the tennis elbow test that is positive.

• This test is carried out by first securing the patient's forearm, and then instructing the patient to clench their fist and actively extend their wrist while the forearm is held in place.

• The examiner then makes an effort to flex the patient's wrist against their will.

• Pain that comes on suddenly and is severe is a strong indicator of tennis elbow.

TESTING

• Electromyography is a diagnostic tool that can differentiate tennis elbow from conditions such as cervical radiculopathy and radial tunnel syndrome.

• In order to rule out joint mice and other hidden bony diseases, plain radiographs should be taken of every patient who presents with elbow pain.

• The use of ultrasound imaging will be helpful in determining the severity of the tendinopathy and locating any other hidden factors that may be contributing to the patient's pain symptomatology.

• Due to the clinical presentation of the patient, it is possible that additional testing is required.

• These tests could include a complete blood count, uric acid level, erythrocyte sedimentation rate, and testing for antinuclear antibodies.

• If there is a suspicion of joint instability or if the symptoms of tennis elbow continue to be present, magnetic resonance imaging of the elbow should be performed.

• The injection technique that will be described later can be utilized both as a diagnostic tool and a treatment strategy.

DIFFERENTIAL DIAGNOSIS

• Tennis elbow can be a symptom of radial tunnel syndrome as well as, on rare occasions, C6-7 radiculopathy.

• Entrapment of the radial nerve below the elbow is the root cause of radial tunnel syndrome in sufferers.

• In patients with radial tunnel syndrome, the area of the radial nerve that is most tender to palpation is distal to the lateral epicondyle over the radial nerve.

• In patients with tennis elbow, the area of the lateral epicondyle that is most tender to palpation is over the epicondyle.

TREATMENT

• The initial treatment for the pain and functional disability associated with tennis elbow is a combination of physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-2 inhibitors.

• Both of these types of medications reduce inflammation and pain.

• The application of heat and cold to specific areas of the body may also be beneficial.

• Avoid engaging in any activity that requires a repetitive motion and has the potential to make the patient's symptoms worse.

• Patients who do not respond to these treatment modalities may benefit from receiving an injection of a local anesthetic and steroid as the next step in the treatment process.

• Before administering an injection for tennis elbow, the patient is positioned in the supine position with the affected arm fully adducted at the patient's side, the elbow flexed, and the dorsum of the hand supported by a towel that has been folded in half.

• This helps relax the tendons that are being affected by the condition.

• A sterile syringe with a capacity of 5 milliliters is used to draw up a total of 1 milliliter of local anesthetic and 40 milligrams of methylprednisolone.

• The lateral epicondyle is located after the skin that covers the posterolateral aspect of the joint has been sterilely prepared.

• A needle measuring 1 inch in length and 25 gauges in diameter is inserted through the patient's skin, perpendicular to the lateral epicondyle, and into the subcutaneous tissue that lies over the affected tendon.

• This procedure is performed using strict aseptic technique.

• If bone is found, the needle is retracted into the subcutaneous tissue and the procedure is repeated.

• After that, a gentle injection of the contents of the syringe is performed. It ought to feel like there is very little resistance being injected.

• After receiving an injection for tennis elbow, the patient should wait several days before beginning any physical modalities.

• These modalities should include gentle range-of-motion exercises as well as local heat.

• There is also the possibility that low-level laser therapy will be beneficial.

• There's also a possibility that putting a Velcro counterforce orthotic band around the extensor tendons will help relieve the symptoms.

• Exercises that are too strenuous for the patient should be avoided because doing so will make their symptoms even worse.

COMPLICATIONS AND PITFALLS

• The most serious problem that can arise from tennis elbow is a rupture in the tendon that is inflamed.

• This can happen as a result of repetitive trauma or from injections given directly into the tendon.

• Before moving forward with the injection, the clinician needs to make sure that the needle is positioned outside of the tendon.

• This will help ensure that the tendon, which may already be inflamed and damaged, does not rupture.

• Infection is yet another potential risk associated with injection, although this should be an extremely remote possibility if proper asepsis procedures are followed.

• The injection method is risk-free provided that the clinically relevant anatomy is carefully considered.

• In particular, the ulnar nerve, which is vulnerable to damage at the elbow, should be given special attention.

• Patients should be made aware of the possibility that they may experience a temporary increase in pain after receiving an injection, as this affects approximately one quarter of all patients.