Tennis Elbow: Lateral Epicondylitis

author : AMSSM

comments : 3

What are the possible treatments for tennis elbow?

Member Question from mezistrano

"I have a severe case of tennis elbow. For the last four weeks, I have been doing all the stretches recommended by my physical therapist, and I haven't felt any improvements. Before the physical therapy, I stayed off it for three months and still nothing.  What to do? Thoughts?"

Answer from Kenneth Cayce, IV, M.D.
Member AMSSM  

Lateral epicondylitis or “tennis elbow” is a result of tendon overuse with a failure of tendon healing.  Initial symptoms include pain with activity.  As it becomes more chronic, pain is present even at rest.  There is pain with resisted movements and even decreased strength. 

Lateral epicondylitis can be misdiagnosed or confused with other conditions.  One of these diagnoses is Posterior Interosseous Nerve (PIN) Entrapment, which is associated with diffuse pain along the radial nerve, located in the same area.  An EMG/NC (nerve conduction) test can help distinguish these diagnoses.  Other misdiagnoses may include synovitis, plica, arthrosis, and cartilage damage (OCD).
  
The ultimate goal of treatment is to promote tendon healing by creating new blood vessels in the area of weakness and subsequently break down scar tissue.  Treatment consists of multiple therapies. 

Try these first

The first line of treatment consists of anti-inflammatory medications and physical therapy.  Anti-inflammatory medicines can help control pain while participating in therapy. In physical therapy, treatments such as electrical stimulation, ultrasound, heat/cold, and dexamethasone iontophoresis (delivery of medication via electrical current through the skin) can also be used to relieve pain. 

If first line treatments are unsuccessful, a cortisone injection can then be administered.  The injection can help with pain, but does have the possible side effects of infection, dimpling, and skin pigmentation.  Some physicians have also done autologous blood injections (using your own blood) or plasma rich protein (PRP) injections into the area of pain.  These are still controversial treatments as studies have demonstrated both improvement and no benefit. 

Additionally, improved sports technique, including an improved backhand stroke in tennis, and equipment changes, such as low string tension and smaller handles in tennis, may be of benefit. If your swim stroke was the cause of the injury, have a swim instructor evaluate your stroke.

Lastly, a treatment that is still under investigation is Nitroglycerine paste.  Nitroglycerine paste is placed onto the area of pain to bring more blood supply to the area.  There are currently no studies to support this treatment.

Last resort: surgery

Finally, surgery can be an option. Indications for surgery are symptoms lasting longer than one year, failure of a physical therapy program, three failed cortisone injections, and an unacceptable quality of life.  Currently, surgery consists of resecting the damaged tissue followed by formal physical therapy.  Most sports medicine physicians can accomplish this using arthroscopy of the elbow with studies demonstrating promising results.  Treatment with surgery results in 97 percent of patients having significant or total pain relief and return to strength with minimal complications.

Overall, therapy with other non-surgical treatments listed above should be employed in unison.  In the rare instances that no benefit is derived from the combination of non-surgical therapies, surgical consideration can then be offered, generally after one year of unresolving symptoms.

Kenneth Cayce, IV, M.D., is a Primary Care/Sports Medicine Physician at MAX Sports Medicine in Columbus, Ohio.  Dr. Cayce is currently accepting new patients by calling (614) 828-4241 for an appointment.

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date: March 23, 2011