Lateral Epicondylitis: “But I Don’t Play Tennis”

Denise Gardner Hite, DNP, CRNP

Treatment for this common overuse syndrome is generally conservative, with patient compliance essential for a desirable outcome. New approaches may be appropriate for some patients—whether or not they play tennis.

Lateral epicondylitis (LE), or tennis elbow, is an overuse syndrome that primary care providers commonly see. For affected patients, LE can represent an extensive problem, as noncompliance with simple conservative therapies commonly prolongs this condition. For most patients, surgical intervention is considered a last resort.

In patients who develop LE, repetitive wrist dorsiflexion with supination and pronation causes overuse of the extensor tendons of the forearm, resulting in subsequent microtears, collagen degeneration, and angiofibroblastic proliferation.¹

LE affects men and women equally. It occurs in 1% to 3% of the population but primarily in those ages 40 and older who perform relevant repetitive motion. Considerable improvement or complete resolution of LE symptoms can be achieved with conservative treatment, although six to 24 months’ continuation of such a regimen may be required. Apparent remission of symptoms can be interrupted by recurrences.¹

Once a diagnosis of tennis elbow is made, the patient’s response may be, “But I don’t play tennis.”

Patient Presentation and History
Patients with LE usually present with a history of several weeks’ elbow pain of an insidious onset, followed by worsening rather than improvement. Most patients deny any history of direct elbow trauma, although pain can be secondary to an acute event.²

The most commonly reported symptom is increased pain with overhand lifting and point tenderness over the lateral epicondyle or just distal to this area. Frequently patients report weakness or decreased grip strength.

The diagnosis of LE is based on the history and physical exam and may be supported by x-ray findings. Diagnosis may be prefaced by a routine patient history regarding onset of symptoms, aggravating or alleviating factors, hand dominance, occupation, and recreational activities. A more pressing history of recent repetitive motion activities, such as raking leaves, painting, or keyboard use, may illuminate the cause of symptoms.

The clinician should inquire about the effectiveness of any home self-treatments, such as NSAIDs or other pain medication, orthotics (ie, a brace or strap), or other supportive measures. An atypical presentation (eg, elbow pain just distal to or below the lateral epicondyle) might suggest a more complex diagnosis, such as radial tunnel syndrome. Such a case may warrant a more comprehensive exam; referral to an orthopedic specialist would be suggested. A differential diagnosis for LE is shown in the table^2,3 below.

Physical Examination
A detailed history will usually direct the physical exam, enhancing its basic principles, and provide a preliminary diagnosis. The examining clinician should begin by observing for any noticeable deformity. Subtle or obvious swelling can be present over the lateral epicondyle, with localized erythema. Elbow joint effusion may indicate intra-articular disease.⁴

In the assessment for elbow range of motion, 0° (full extension) to 140° of flexion, and 50° of pronation (palm down) and supination (palm up) is required. Instability is checked with the patient’s arm fully extended. The examiner grasps the elbow with both hands and gently applies medial, then lateral pressure, observing for any ligament laxity.

Palpation of the bones should begin over the medial epicondyle and progress to the olecranon, then to the lateral epicondyle. Direct palpation over the lateral epicondyle increases the pressure over the origin of the extensor musculotendinous structures—specifically, the extensor carpi radialis brevis and extensor digitorum tendons. This pressure generally reproduces the pain associated with LE.

The most revealing diagnostic test in the physical exam is resisted extension of a dorsiflexed clenched fist on the affected side (see the figure, below). Other physical tests for assessing this pain are with resisted extension of the long finger and resisted supination of the affected extremity. These maneuvers will elicit distinct pain at the lateral epicondyle and guarding. Neurovascular status should be assessed distally.

A brief exam of the shoulder and wrist on the affected side is suggested for completeness and to rule out other etiologies, particularly in the event of a fall or other traumatic injury.

Radiographic Imaging
Plain film x-rays are obtained to rule out fracture, tumor, or degenerative changes. There is no clear evidence in the literature that plain film x-rays are helpful with the initial diagnosis, and repeat x-rays at subsequent visits are not required when no further trauma has occurred. In cases of extreme LE refractory to conservative treatment, further evaluation with MRI is required.⁵

Treatment
Treatment for LE is generally conservative. The use of NSAIDs, rest, ice, and a tennis elbow strap (ie, a nonarticular proximal forearm strap or brace) are considered first-line treatment options.¹ The purpose of a tennis elbow strap is to relieve pressure over the lateral epicondyle by increasing pressure over the forearm muscles. Correct application of the strap is essential to alleviate pain.

Before turning to surgical intervention (of which a number of options exist for patients whose pain does not respond to conservative treatment⁶), the clinician may consider use of corticosteroid injections, which are relatively safe and usually have a short-term effect (ie, two to six weeks). Injection therapy for LE is usually considered appropriate for patients with chronic pain and disability that is not relieved by more conservative means, or who experience acute pain with functional impairment.⁷ Before performing corticosteroid soft-tissue injections, clinicians should consult the appropriate governing agency regarding this advanced practice privilege.

Patients who comply with orthotics and NSAID use and are able to avoid repetitive motion are most likely to see an enduring resolution of symptoms when steroid injections are administered as adjunct therapy. A review of the literature suggests no significant benefit from physical therapy or ultrasonography.^8-10

Platelet-Rich Plasma Injections
Local injection of platelet-rich plasma is an alternative based on the understanding that platelets contain growth factors which aid in healing. This has been demonstrated as an effective treatment for LE.^11,12 Whole blood obtained from the patient is centrifuged, with platelet-rich plasma then collected for local injection over the lateral epicondyle.

The cost of platelet-rich plasma therapy averages between $300 and $400 per injection (C. Whitney, personal communication, July 14, 2009). According to Mishra et al,¹² one injection is ordinarily sufficient.

Patient Education
In-depth education prepares patients for long-term management of LE. Discussion explaining the causes, pathology, duration, and treatment may lead to better self-management for this chronic condition. Exacerbations are easily provoked by return to repetitive activities or direct trauma.

Clinicians who care for patients with LE are urged to emphasize the importance of complying with conservative therapies, avoiding repetitive activities, and adhering to ongoing conservative treatment measures. Follow-up is recommended six weeks after these treatment measures are begun; they should be continued if the patient’s symptoms are improving. Otherwise, further follow-up or referral to an orthopedic specialist can be made at the clinician’s discretion.

Conclusion
Lateral epicondylitis is a common elbow problem that can be diagnosed without difficulty, easily aggravated, and annoying for patients. Noncompliance with recommendations to use orthotics, avoid repetitive activities, and adhere to prescribed medication regimens is the most likely explanation for lack of improvement.

Whether or not your patient plays tennis, appropriate education and compliance with the agreed-on treatment support the optimal outcomes for this vexing condition. The ball is in their court.

References
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2. Murphy KP, Guiliani JR, Freedman BA. Management of lateral epicondylitis in the athlete. Operative Techniques Sports Med. 2006;14(2):67-74.

3. Kaminsky SB, Baker CL Jr. Lateral epicondylitis of the elbow. Tech Hand Up Extrem Surg. 2003;7(4):179-189.

4. Boyer MI, Hastings H 2nd. Lateral tennis elbow: “Is there any science out there?” J Shoulder Elbow Surg. 1999;8(5):481-491.

5. Pfahler M, Jessel C, Steinborn M, Refior HJ. Magnetic resonance imaging in lateral epicondylitis of the elbow. Arch Orthop Trauma Surg. 1998;118(3):121-125.

6. Lo MY, Safran MR. Surgical treatment of lateral epicondylitis: a systematic review. Clin Orthop Relat Res. 2007;463:98-106.

7. Cardone DA, Tallia AF. Diagnostic and therapeutic injection of the elbow region. Am Fam Physician. 2002;66(11):2097-2100.

8. Smidt N, Assendelft WJ, Arola H, et al. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Ann Med. 2003;35(1):51-62.

9. Struijs PA, Kerkhoffs GM, Assendelft WJ, Van Dijk CN. Conservative treatment of lateral epicondylitis: brace versus physical therapy or a combination of both: a randomized clinical trial. Am J Sports Med. 2004;32(2):462-469.

10. D’Vaz AP, Ostor AJ, Speed CA, et al. Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial. Rheumatology (Oxford). 2006;45(5):566-570.

11. Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Curr Rev Musculoskelet Med. 2008;1(3-4):165-174.

12. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. 2006;34(11):1774-1778.