LATERAL ELBOW PAIN: a common problem that can be difficult to treat.

Most people would recognise the term tennis elbow. It is a common elbow complaint that often has nothing to do with tennis! It presents as pain at the outside of the elbow and can extend down the forearm towards the wrist. 

Tennis elbow involves an injury or degenerative process of the tendons that attach to the lateral epicondyle of the humerus – a small bony protuberance just above the elbow. These tendons attach to the muscles that extend the wrist and are involved with gripping. 

The ECRB muscle and tendon is usually involved in tennis elbow (© American Academy of Orthopaedic Surgeons, 2003)

Pain most commonly occurs through repetitive overuse or a sudden increase in loads usually with activities involving forearm supination (turning up the hand), wrist extension (think revving a motorbike) and gripping. This may be a sustained overload and fatigue, such as using a mouse all day everyday for work purposes, or perhaps a sedentary person suddenly gets into the garden on the weekend and spends the day push mowing the lawn and pulling weeds. With both these scenarios there has been an overload to the tissues. One very slowly over time, and one suddenly when they have not been conditioned to do so. 

In both cases we see changes in the tendon structure – known as TEDINOPATHY. Note that we should no longer use the term tendinitis (-itis meaning inflammation) as there is not actually an acute inflammatory process occurring. 

These changes include:

-       Increase in fibroblast activity.

-       Increased neovascularisation (increased blood flow) which involves increased nociception which is why the condition becomes painful.

-       Increased extracellular matrix/ground substance.

-       Disorganised collagen.

Figure source: Pathogenesis and management if tendinopathies in sports medicine (Transl Sports Med)

All these changes contribute to a tendon structure that is not strong, is irritable when subject to load and does not have high capacity. We can see these changes on scans like ultrasound and MRI. Interestingly though, up to 50% of people who are asymptomatic (no elbow pain) also show these changes on imaging and so we need to consider these findings as part of a broader clinical picture, and not just rely on scans alone to form a diagnosis.

So, what can we do to help! 

Pain relief is of course first priority, as people seek help because they are in pain (pain is a great motivator!). 

Activity modification and removing aggravating factors is essential for successful outcomes and are in fact more important than anything that can be done to you in your appointment. 

Key things we may look at and aim to modify: 

-       Take a look at your work station and ergonomic set up. Ensure you are not overreaching for the mouse and your arm isn’t out too far to the side. 

-       You may need to take breaks throughout the day. 

-       Consider a vertical mouse or dictation software.

-       When lifting, keep your palms facing up. 

-       Keep elbows bent so the load is closer to your body. Try not to lift with your arm out stretched. 

Manual therapy and rehabilitation addressing strength and flexibility of the forearm muscles, scapular stabilisers and rotator cuff, upper body, neck flexors and extensors and trunk stabilisers all should be considered. Exercises initially can be prescribed to settle down irritability and are beneficial for pain relief. These are progressed gradually overtime to strengthen and improve capacity and should be individualised and functional depending on each person’s needs and activities. 

Sometimes, only addressing the elbow is not enough. There can be contributing factors from the nerves in the area. For example, the radial nerve can become entrapped between the muscles and facia in the forearm and give pain in the similar area. Looking to the shoulder, neck and trunk and addressing any issues with strength, flexibility and function is also important to improve the overall capacity of the upper limb and help the healing process. Poor neural mobility or poor neural health can be addressed with neural mobility exercises. 

Improving areas of your general health can make a big difference. Improving sleep, diet and considering mental health as a contributing factor to pain experience is essential. 

Realistically, treatment plans can take 6 weeks to 3 months, but measurable goals should be set along the way to keep you on track and motivated moving forward. 

Adjunct therapies can also be considered. Adjunct means that they are used in addition, and never in isolation to the therapies described above. Shockwave therapy can be considered when pain persists beyond three months and where exercise and rehab alone has not been overly successful. Offering reduced pain and improved elbow function and grip strength, shockwave therapy is considered a safe and effective treatment (Spacca G, Necozione S, Cacchio A. 2005). In addition, a study by Beyazal in 2015 showed higher improvements with shockwave therapy when compared with steroid injections at 12 weeks follow-up (Beyazal MS, Devrimsel G, 2015).

Injection therapies like cortisone should be used with great caution and really only when someone is not responding. Before considering cortisone, make sure all underlying factors have been addressed, you’ve complied well with rehab and have given adequate time (3-6 months) to improve. There is evidence for worse outcomes in the longer term, especially for multiple injections (Coombes et al 2013).

There is some evidence to support PRP (platelet rich plasma) injection and is an option that can be considered with full informed consent. You can expect to be sore post injection, and full rehab must be complied with. PRP is referred by your GP and is a considerable out of pocked expense (around $450). 

Thankfully, very few people end up needing surgery, but it may be considered when there are signs of neural compression or failure to respond to good rehab and injection therapies.

References:

 1)    Spacca, G., Necozione, S., & Cacchio, A. (2005). Radial shock wave therapy for lateral epicondylitis: a prospective randomised controlled single-blind study. Europa medicophysica, 41(1), 17–25.

2)    Beyazal, M. S., & Devrimsel, G. (2015). Comparison of the effectiveness of local corticosteroid injection and extracorporeal shock wave therapy in patients with lateral epicondylitis. Journal of physical therapy science, 27(12), 3755–3758. https://doi.org/10.1589/jpts.27.3755

3)    Coombes, B. K., Bisset, L., Brooks, P., Khan, A., & Vicenzino, B. (2013). Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA, 309(5), 461–469. https://doi.org/10.1001/jama.2013.129