Tennis elbow and golfer's elbow

Synonyms: lateral epicondylitis (tennis elbow), medial epicondylitis (golfer's elbow)

Tennis elbow and golfer's elbow are considered to be overload tendon injuries, which occur after minor and often unrecognised trauma to the proximal insertion of the extensor (tennis elbow) or flexor (golfer's elbow) muscles of the forearm.

Epidemiology¹

• Tennis elbow is estimated to have a prevalence of 1-3% of the population and an incidence of 4-7 per 1,000 people years. The peak incidence is between 35 and 54 years of age. Men and women are affected equally. It accounts for two thirds of persistent elbow pain seen in primary care.

• Golfer's elbow is the most common cause of medial elbow pain; however, the incidence is about one seventh as common as tennis elbow² .

• Tennis elbow and golfer's elbow may be seen in any age group if hobbies, jobs or sports activities can lead to overuse injuries.

Aetiology^{1 3}

In tennis elbow, repetitive overuse of the extensor carpi radialis brevis and the common extensor tendon causes micro-tears, initiating a degenerative process. Histologically, granulation tissue, micro-rupture, an abundance of fibroblasts, vascular hyperplasia and unstructured collagen are seen. There is a notable lack of traditional inflammatory cells such as macrophages, lymphocytes or neutrophils, detracting from previous theories that the condition had an inflammatory basis. The term 'epicondylitis' is therefore increasingly thought to be a misnomer, with clinicians reverting to the informal names of tennis/golfer's elbow or using terms such as epicondylalgia.

A thickening of the tendon occurs which, if not treated, can progress to tendon disrepair and eventual degeneration.

Causes of tennis elbow

• Tennis - classically, although less so since the advent of lighter tennis rackets and two-handed backhands. Tennis is not the cause in the majority of people with tennis elbow.

• Jobs involving repetitive heavy lifting or the use of heavy tools.

• Jobs involving movements in an awkward posture - eg, arms lifted in front of the body, hands bent or twisted, and precision movements, particularly squeezing and twisting movements.

• New and unaccustomed strains such as DIY, gardening, lifting a new baby, moving house, carrying luggage.

A similar process occurs in golfer's elbow. Although it was thought that the pronator teres and flexor carpi radialis were most commonly affected, the literature suggests all muscles are affected equally except for palmaris longus⁴ .

Causes of golfer's elbow

• Golf and other sports involving gripping or throwing.

• Jobs and hobbies using repetitive elbow movements - eg, DIY, computer use, gardening, chopping, climbing or painting.

• Use of vibrating tools.

Presentation

Tennis elbow^{1 5}

• Usually a history of gradual onset.

• Usually unilateral but some cases are bilateral. The dominant arm is involved in 75% of people.

• Pain and tenderness over the lateral epicondyle of the humerus, radiating into the forearm, and pain on resisted dorsiflexion of the wrist, middle finger or both. A tender spot can usually be identified just below the lateral epicondyle on the outside of the elbow.

• The onset of pain is usually gradual and worse with use of affected muscles - eg, opening a jar. Due to pain, the person may report not being able to hold items such as cups.

• Pain is exacerbated by active and resisted movements of the extensor muscles of the forearm. For example, pain on resisted extension of the middle finger is typical in tennis elbow.

• Movements of the elbow are normal. If the range of movement is restricted, consider other diagnoses.

• Check for Tinel's sign - tap lightly on the medial elbow over the ulnar nerve. It is positive if testing generates paraesthesia without pain. A negative sign helps to exclude cubital tunnel or other neurological conditions.

• Mills' test:

  • Straighten the patient's arm and palpate the lateral epicondyle.

  • Fully bend (flex) the wrist.

  • Pronate the patient's forearm.

  • If this is painful, the test is positive.

• Cozen's test:

  • Elbow in 90° of flexion, patient makes a fist and deviates wrist radially with forearm pronated.

  • Resisted extension of the wrist.

  • Pain in the area of lateral epicondyle is a positive result.

Golfer's elbow⁴

• Pain and tenderness are maximal over the medial epicondyle, radiating into the forearm. Pain is aggravated by wrist flexion and pronation.

• Dull ache at the medial epicondyle.

• The onset of pain is usually gradual and aggravated by using the affected muscles - eg, grasping objects and shaking hands.

• It is worsened with affected muscle use - eg, forearm rotation or grasping, opening a jar.

• Golfer's elbow test: pronate and flex the wrist and forearm at the same time (turns from palm up to palm down and bends the wrist back towards them). A result is positive when pain is located over the attachment of the wrist flexor muscles on the medial aspect of the elbow.

• An associated ulnar neuropathy may cause decreased sensation and/or a tingling sensation in the 4th and 5th fingers and, in more severe cases, muscle weakness in the hand.

Enquire about activities which may have caused the tendinopathy.

Differential diagnosis ¹

• Olecranon bursitis.

• Elbow arthritis.

• Cervical nerve root entrapment.

• Radial tunnel syndrome - this is due to compression of the posterior interosseous nerve, and tenderness is more distal and more anterior.

• Medial ligament strain (golfer's elbow).

• Radiation of pain from shoulder or wrist injuries.

• Carpal tunnel syndrome.

Investigations²

• These are usually not required but may be indicated if the diagnosis is uncertain - eg, CRP, elbow X-ray, MRI, ultrasound.

• Nerve conduction study and electromyography may be indicated if ulnar nerve involvement is suspected in patients with golfer's elbow.

• Infra red thermography and laser Doppler flowmetry may be helpful in difficult suspected cases of tennis elbow.

Management¹

Much of the evidence which is available refers to tennis elbow; however, as the pathology is the same for golfer's elbow, treatments used are similar. The following are some of the management options used:

• Apply heat or ice to help relieve pain.

• Modify activities causing or exacerbating the symptoms for six weeks. Involve a physiotherapist if possible.

• Activity restriction: avoid tasks that involve high force, hand-gripping or pinching, or use of high-amplitude vibrating handheld tools.

• Rehabilitation exercises. The key to treatment is to increase the strength of the tendons gradually, while avoiding any activity that overloads the tendons. Rehabilitation exercises include painless passive wrist flexion and progressive resisted wrist extension.

• An orthosis (for example, a forearm strap, or a wrist or elbow brace) may be helpful.

• Offer analgesia such as paracetamol or topical NSAIDs such as ibuprofen gel. Advise people using the latter of the potential fire hazard of fabric which comes into contact with the gel.

• Consider an oral NSAID if symptoms persist.

• Steroid injections should not be offered routinely as there is very little evidence that they afford anything more than short-term relief. However, this may be appropriate in some circumstances. As with all treatments, a prior discussion should be held with the patient about the risks and benefits. If considered, steroids should be injected into the point of maximum tenderness. Extra care is required with injecting golfer's elbow, to ensure avoiding the ulnar nerve. Superficial injections should be avoided, as they are ineffective and may cause skin atrophy.

• Treatment of tendinopathies with topical GTN for up to six months appears to be superior to placebo and may therefore be a useful adjunct to the treating healthcare professions. Longer-term results have shown neither benefit nor long-term harm. This is used on an off-label basis.

If there is no response after six weeks

• Re-consider the diagnosis.

• Refer to a physiotherapist if this has not already occurred. Physiotherapy may include exercises, massage, ultrasound therapy or taping.

When to refer to a specialist¹

• If the diagnosis is in doubt.

• There is severe pain or functional impairment.

• Symptoms have not responded to 6-12 months of treatment in primary care.

Treatments which may be offered in secondary care⁶

• Autologous blood products - eg, platelet-rich plasma (PRP): a sample of the patient's blood is centrifuged and then the heaviest layer of plasma (with a higher concentration of platelets) is injected back into the patient. Evidence of efficacy was determined by the National Institute for Health and Care Excellence (NICE) to be inadequate. Therefore, current recommendations are that this can only be done where there are "special arrangements for clinical governance, consent and audit or research"⁷ . Subsequent trials have produced varying results⁸ .

• Hyaluronan gel injection: this gel is injected into the joint. It is more commonly used in arthritic joints. Despite the fact that the problem is not thought to be within the elbow joint, efficacy has been demonstrated for tennis elbow in clinical trials. A Canadian trial of over 300 patients found that this treatment was significantly better than control in improving pain at rest and after maximal grip testing. It was highly satisfactory by patients and physicians and resulted in better return to pain-free sport compared to controls⁹ .
  

• Other injectable biologic treatments such as bone marrow aspirate concentrate (BMAC) and autologous tenocyte injection (ATI) are still under investigation.

• Botulinum toxin: is used in very severe cases. It is injected into extensor digitorum longus muscles for the third and fourth fingers, thus paralysing them on a temporary basis. This takes the load off the tendon, but is disabling in the short term.

• Extracorporeal shock wave treatment¹⁰ . Although effective for other tendinopathies, this has not been shown to be effective for treating tennis elbow. However, NICE encourages further research into this. A meta-analysis found that it was more effective than ultrasound therapy¹¹ .

Surgery⁶

Release of the extensor/flexor origin is occasionally indicated for patients who do not respond to a sustained period of conservative treatment. Arthroscopic tendon release is a minimally invasive technique with promising long-term optimal clinical and functional outcomes in patients with chronic lateral epicondylitis

Prognosis¹²

• Tennis elbow is a self-limiting condition. The average duration of a typical episode is about six months to two years, but most patients (89%) recover within one year. 5-10% do not resolve and may require further treatment such as surgery.

• Golfer's elbow is also a self-limiting condition with a similar prognosis.

Prevention

• Patients often have to modify their activities or the particular techniques that led them to develop this overuse injury.

• This may need to include the help of a coach for sporting activities.