TENNIS ELBOW
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Introduction
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Anatomy
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Causes
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Symptoms
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Diagnosis
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Prevention/Treatment
Introduction
Lateral epicondylitis is sometimes referred to as
Tennis Elbow - not because only tennis players get the
problem, but because the backhand swing in tennis is a common activity that
can cause the problem. There are many other activities that can result
in lateral epicondylitis - such as painting with a brush or roller, running a
chain saw, and using many types of hand tools continuously. Each of
these activities use the same muscles and can result in lateral epicondylitis
when these muscles are overused.
Anatomy
Lateral Epicondylitis is a common condition that causes pain at the
outside bump (or epicondyle) of the
elbow. Tennis is not the only cause of this condition, but tennis
players do get the condition usually as a result of overuse of the
muscles/tendons that they use to hit a backhand shot. The muscles of the
forearm that bend the wrist back (extensors) begin at the lateral epicondyle,
from a common tendon attachment. Bending the wrist back (extension),
turning the hand palm side up, and lifting an object with the elbow straight
are the more common activities that affect these tendons.
Causes
As we age, a tendon is subject to
degeneration within the
substance of the tendon. The term degeneration means that wear and tear
occurs in the tendon over time and leads to a situation where the tendon is
weaker than normal. Degeneration in a tendon usually shows up as a loss
of the normal arrangement of the fibers of the tendon. Tendons are made
up of strands of a material called collagen (think of a
tendon as similar to a nylon rope and the strands of collagen as the nylon
strands). Some of the individual strands of the tendon become jumbled
due to the degeneration, other fibers break, and the tendon loses
strength. The healing process in the tendon causes the tendon to become
thickened as scar tissue tries to repair the tendon. This condition is
called tendinosis.
One theory on the cause of
tendinosis is that small tears in the tendon occur through
overuse. They begin to heal but when re-injured by continued use, the
tendons seem to finally give up on
trying to heal and a condition called angiofibroblastic degeneration begins to
take over. (Think of this as scar tissue that never reaches maturity and
remains weak and painful.) Other physicians feel that the tendon changes
are primarily a result of decreased blood flow in the area, a sort of heart
attack of the tendon. The end result is still the formation of the angiofibroblastic tendinosis tissue. The same events can happen
with repeated strains like hammering a
nail, picking up a heavy bucket, or pruning shrubs.
Symptoms
The symptoms of lateral epicondylitis include tenderness and pain at the lateral epicondyle. This
pain may be made worse by activities that require extending the wrist or
holding an object in the hand with the wrist stiff. Tenderness and pain
usually begin at the lateral epicondyle. Pain may spread down the
forearm with soreness felt in the forearm muscles. Activities like
grasping can make matters worse. Activities such as reaching into the
refrigerator to get a gallon of milk can be a painful process! Some
patients actually lose some motion in the elbow, usually a few degrees of
extension (meaning they can't completely straighten the elbow.)
Diagnosis
The diagnosis of lateral epicondylitis can usually be made from physical examination alone. X-rays of
the elbow may be required if symptoms suggest the possibility of a problem
with the joint. There are some cases of lateral epicondylitis that may
be confused with a different problem that is very similar. Radial tunnel
syndrome, a condition that is caused by compression of the radial nerve as
it crosses the elbow, can appear to be very similar to lateral
epicondylitis. In some cases of lateral epicondylitis that is not
responding to treatment, your doctor may suggest nerve tests of the radial
nerve to make sure that radial tunnel syndrome is not the problem.
Prevention/Treatments
Ice: Ice decreases the size of blood vessels in the sore area,
halting inflammation and relieving pain. Choices of application include
cold packs, ice bags, or ice massage. Ice massage is an easy and
effective way to provide first aid. Simply freeze water in a paper
cup. When needed, tear off the top inch, exposing the ice. Rub
three to five minutes around the sore area until it feels numb.
Rest: Resting the sore area will prevent further injury while
allowing time to heal. An
elbow
strap may help rest the area by taking pressure off of the tendon
attachment at the medial epicondyle of the elbow. A splint worn for a
short period may rest the arm and reduce the pain. Problems can be
avoided by taking frequent breaks as you work or play, improving overall arm
muscle condition, and limiting heavy pushing, pulling or grasping.
Exercises:
As healing continues different types of
exercises are used. Early on, isometrics help maintain
muscle strength without over stressing tissue. Isometrics are exercises
where the muscles are simply tightened but no movement occurs. These
type of exercises seem to allow the muscles to stay fit, but stress the soft
tissues less than other types of exercise. Later, as pain lessens, more
vigorous exercises are used to increase endurance and strength.
Medications:
Anti-inflammatory medications such as
aspirin or ibuprofen may be suggested to decrease the inflammation. An injection of cortisone in the area of
the medial epicondyle may reduce the inflammation and pain.
If all else fails, surgery is available to treat tennis elbow. The surgery usually involves making a small
incision (about 3-4 inches) over the lateral epicondyle. The tendons
that attach to the lateral epicondyle are first released and allowed to loosen
a bit. The tendons that attach to the lateral epicondyle are then split
to reveal the area of
angiofibroblastic tendinosis in the
tendon. This tissue is removed, and any bone spurs that have formed on
the lateral epicondyle are removed as well. This gives a fresh bed of
healthy bone for the tendon to reattach itself to. The split in the
tendon is then sutured together, as is the skin. It usually takes about
3 months for everything to reach maximal healing.
This surgery can usually be done as an outpatient. The surgery can be
done using a general anesthetic (where you are put to sleep)
or some type of regional anesthetic. A regional
anesthetic is a type of anesthesia where the nerves going to only a portion of
the body are blocked. Injection of medications similar to novacaine are
used to block the nerves for several hours. This type of anesthesia, for
example the axillary block, results in a numb
arm.
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