Elbow Pain, Lateral & Medial

Robert P. Nirschl M.D., M.S.

Elbow tendonitis/tendinosis is an overuse injury that can result from repetitive motion events frequently found in certain sports or work related activities. Statistics show that nearly one-half of all tennis players will suffer from this injury at some point; however, this group represents less than 5 percent of all reported cases. 

Lateral Elbow Tendinosis (outside of the elbow)
Commonly referred to as tennis elbow or backhand tennis elbow.
Lateral epicondylitis, commonly known as tennis elbow, is a painful condition involving the tendons that attach to the bone on the outside (lateral) part of the elbow. Tendons anchor the muscle to bone. The muscles involved in this condition, the extensor carpi radialis brevis, and extensor digitorum communis of the forearm help to extend and stabilize the wrist (see Figure 1). With lateral epicondylitis, there is degeneration of the tendon’s attachment, which weakens the anchor site and places greater stress on the area. The onset of pain is usually gradual with pain or tenderness felt on or below the elbows bony prominence (epicondyle). This can then lead to pain associated with activities in which this muscle is active, such as lifting, gripping, and/or grasping.
Sports such as tennis are commonly associated with this, but the problem can occur with many different types of activities, athletic and otherwise. Lateral tennis elbow is a very persistent disorder that does not easily resolve itself (symptoms often last for months). 

Figure 1.

Medial Elbow Tendinosis (inside of the elbow)
Commonly referred to as forehand elbow, golfer’s elbow, baseball elbow, suitcase elbow.
Medial tendinosis presents with pain and tenderness centered about the medial elbow.  The medial epicondyle serves as an attachment site for the flexor-pronator muscle group.  Golfers elbow is similar to tennis elbow except the pain and tenderness are felt on the inside of the elbow, on or around the bony prominence.  An additional factor may be a compression of the ulnar nerve (funny bone). It is typically seen in pitching a baseball, the trailing arm in golf and pull-through strokes of swimming. Typically it occurs in middle-aged people often involved in sports or occupational activities that require a strong handgrip. In sports contributing factors include: over-exertion of the trailing arm in golf, opening up to quickly and dragging the arm behind the body when pitching a baseball.

What causes tennis elbow/golfers elbow?
Recent studies show that elbow tendonitis/tendinosis is often due to damage to a specific forearm muscle. When the muscles are weakened from overuse, microscopic tears form in the tendon where it attaches to the epicondyle (bone). This leads to inflammation and pain and if not treated can lead to a chronic condition known as tendinosis.

Overuse – The cause can be both non-work and work related. An activity that places stress on the tendon attachments, through stress on the muscle-tendon unit, increases the strain on the tendon. These stresses can be from holding too small or large a racquet grip or from “repetitive” gripping and grasping activities, i.e. meat-cutting, plumbing, painting, and weaving, etc.

Trauma – A direct blow to the elbow may result in swelling of the tendon that can lead to degeneration. A sudden extreme action, force, or activity could also injure the tendon.

Heredity – Some people may be born with tendons which are less durable (Mesenchymal syndrome). In this case symptoms may occur at an earlier age or occur at multiple sites such as both elbows, shoulders, Achilles, feet, etc.

Who gets tennis elbow/lateral epicondylitis?
Most people who get tennis/golfers elbow are between the ages of 30 and 50, although anyone can get elbow tendonitis if they have the risk factors. In racquet sports like tennis, improper stroke technique and improper equipment may be risk factors.

Athletes are not the only people who get tennis elbow. Many people with tennis elbow participate in work or recreational activities that require repetitive and vigorous use of the forearm muscle.

Painters, plumbers, and carpenters are particularly prone to developing tennis elbow. Studies have shown that auto workers, cooks, and even butchers get tennis elbow more often than the rest of the population. It is thought that the repetition and weight lifting required in these occupations leads to injury.

Signs and symptoms of tennis elbow/lateral epicondylitis
The symptoms of tennis and golfers elbow develop gradually. In most cases the pain begins as mild and slowly worsens over weeks and months. There is usually no specific injury associated with the start of symptoms.

  • Usually gradual onset
  • Recurring Pain may radiate from the elbow down the forearm
  • Extending or straightening the elbow may increase the pain
  • Pain caused by grasping or lifting
  • Dull ache at rest
  • Sharp twinges during or after activity
  • Pain related to activities using the wrist
  • Numbness or tingling in the fingers may be a companion problem

Treatment 
Nonsurgical Treatment 
Approximately 80% to 95% of patients have success with nonsurgical treatment.

  • Active Rest-While rest is important to enhance the healing process, it is important to understand that rest is best defined as the absence of abusive activity, not absence of activity.  “Absolute rest is rust”.  All tissues, particularly injured tendons, require tension and motion to maintain health.  Total immobilization is obviously contra-indicated as it results in muscle atrophy, weakness, and decreased blood vessel supply.  More specifically, immobilization at the elbow results in limited mobility, joint stiffness and can lead to loss of motion and function. 
  • Non-steroidal anti-inflammatory medicines- Drugs like aspirin or ibuprofen reduce pain and swelling.

Rest and medication alone do not cure. Cure requires new blood vessels and collagen protein to heal the damaged tendon. Comfort or pain control is helpful but alone does not specifically improve the injured tendon tissue.

  • Equipment check- If you participate in a racquet sport, your doctor may encourage you to have your equipment checked for proper fit. Looser-strung racquets often can reduce the stress on the forearm, which means that the forearm muscles do not have to work as hard. 
  • Physical therapy- A Specific and gradual exercise program is helpful to bring new blood supply and for strengthening the muscles of the forearm, wrist and shoulder. Your therapist may also perform ultrasound, massage, or electrical muscle-stimulating techniques to improve muscle healing.  Tendons, which attach muscles to bones, do not receive the same amount of oxygen and blood that muscles do, so they heal more slowly. These modalities help increase blood supply to the tendon thus increasing healing and decreasing any swelling or discomfort. 
  • Ice is helpful for pain and swelling control and should be used any time signs of irritation or pain are present. It is important to use ice after exercise and after any activity that causes discomfort.
  • Controlling Abuse with Bracing-It is often difficult for people to completely avoid pain-provoking activities.  Our practice recommends functional bracing (not immobilizing braces such as stiff wrist or elbow splints)  to help disperse forces that otherwise would be absorbed at the site of injury. The Count’R-Force braces have proven very helpful in enabling individuals to begin a rehabilitative exercise program sooner, and complete their daily activities with less pain
  • Steroid injections- Steroids, such as cortisone, are very effective anti-inflammatory medicines. Your doctor may decide to inject your damaged tendon area with a steroid to relieve your symptoms. It is important to note that steroid (cortisone) injections cannot be used long term as to much cortisone can weaken tendons. Research has shown that multiple cortisone injections degrade and weaken the tissues. Over 3 cortisone injections in one small area are not recommended. 

The Count’R-Force original and superior design is curved to fit the forearm better; it is wider and has multiple-straps for better tension control and comfort. Bracing has also proven beneficial in enabling individuals to return to their sport. The principle of the Count’R-Force brace is to give firm yet pliable anatomic functional support and protection for an expanding muscle and moving tendon, while at the same time allowing freedom of joint movement.  The brace decreases internal muscle tension and lends support to injured tendons without pinching blood vessels or nerves or causing excess focal compression.  

The goal of rehabilitation exercises is to promote optimal healing of the injured tissue.  Absolute rest and pain relief by injection or medications offers no curative stimulation to the injured tissue.  Injured tendons must be nourished by increased blood supply.  Rehabilitation exercises are the key to the curative process because they promote strength, flexibility and endurance to the injured area.  The concept is the same as with cardiac rehab for heart attack treatment.

A major goal of rehabilitating the elbow is total arm strength and endurance, which includes the shoulder. The Incidence of injury increases as the body fatigues; therefore; exercise of the elbow and shoulder muscle groups are an important aspect to avoiding injury. You should get in shape to play your sport, not play a sport to get in shape.  

Surgical Treatment
If your symptoms do not respond after 6 to 12 months of nonsurgical treatments, your doctor may recommend surgery. The best surgical procedure for tennis elbow involves removing diseased, pain producing tendon, while protecting healthy tendon. If the recommended surgical technique is used, success is high (97%).

Surgical risks- As with any surgery, although very low, risks can occur.
Things to consider include:

  • Infection
  • Nerve and blood vessel damage
  • Possible prolonged rehabilitation
  • Loss of strength
  • Loss of flexibility
  • The need for further surgery

The most common problem is not a complication but lack of success (3%).

Rehabilitation
Following surgery, your arm may be immobilized temporarily with a splint. About 1 week later, the sutures and splint are removed. After the splint is removed, exercises are started to move the elbow and restore flexibility. Light, gradual strengthening exercises (light weights) are started about 3-4 weeks after surgery.

Your doctor will tell you when you can return to athletic activity. As an example easy tennis could start as early as 4-6 weeks. Play-to-win takes longer (4-6 months).

Nirschl Orthopaedic Center is a leader in sports medicine and general orthopedic services. In addition Virginia Sportsmedicine Institute physical therapy has been rated one of the top sports medicine clinics in the area. If you have an orthopaedic injury, schedule an appointment with one of our doctors today. Visit our websites at nirschl.com and vasportsmedicine.com to learn more about our services. For more info on orthopaedic issues visit our blog at nirschlorthopaedic.com. Follow us on Twitter: @nirschlortho

Nirschl Orthopaedic Center for Sports Medicine & Joint Reconstruction
1715 N. George Mason Drive, Suite 504
Arlington, Virginia 22205
703-525-2200 

© Jane Voigt Tennis 2013