Epicondylitis – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Epicondylitis – Causes, Symptoms, Diagnosis, Treatment and Ongoing care
Basics Description Tendon injury characterized by pain and tenderness at the tendinous origins of the wrist flexors/extensors on the epicondyles of the humerus May be acute (traumatic) or chronic (overuse) 2 types: Medial epicondylitis or “golfer’s elbow”: Involvement of the wrist flexors and pronators on the medial epicondyle Lateral epicondylitis or “tennis elbow”: Involvement of the wrist extensors and supinators on the lateral epicondyle May be caused by many different athletic or occupational activities Common in carpenters, plumbers, gardeners, and politicians Usually occurs unilaterally on the epicondyles of the dominant arm Lateral epicondyle involvement is more common than medial. Epidemiology Predominant age: >40 Predominant sex: Male = Female Incidence Very common site of overuse injury Lateral > Medial Risk Factors Repetitive wrist motions: Flexion/pronation → medial Extension/supination → lateral General Prevention Limit overuse of the wrist flexors, extensors, pronators, and supinators. Use proper techniques when working. Use lighter tools that have smaller grips. Pathophysiology Acute (tendonitis): Inflammatory response to injury Chronic (tendonosis): Overuse injury Tendon degeneration, fibroblast proliferation, microvascular proliferation, lack of inflammatory response Etiology Repetitive wrist motions Tool/racquet gripping Shaking hands Sudden maximal muscle contraction Direct blow Diagnosis History Occupational activities Sport participation Direct trauma Duration of symptoms Treatments or medication use Pain with gripping Sensation of mild forearm weakness Physical Exam Localized pain just proximal to the affected epicondyle Increased pain with wrist flexion/pronation (medial) Increased pain with wrist extension/supination (lateral) Medial epicondylitis: Tenderness at origin of wrist flexor tendons Increased pain with resisted wrist flexion and pronation Normal elbow range of motion Increased pain with gripping Lateral epicondylitis: Tenderness at origin of wrist extensors Increased pain with resisted wrist extension/supination Normal elbow range of motion Increased pain with gripping Diagnostic Tests & Interpretation Imaging None required Anterior-posterior/lateral radiograph if decreased range of motion or trauma Magnetic resonance imaging for recalcitrant cases Diagnostic Procedures/Surgery Local injection of anesthetic to document resolution of symptoms Differential Diagnosis Elbow osteoarthritis Fractures of the epicondyles Posterior interosseous nerve entrapment (lateral) Ulnar neuropathy (medial) Synovitis Medial collateral ligament injury Referred pain from shoulder or neck Treatment May take weeks to months to resolve Majority of patients will improve with conservative treatment Relative rest with reduction of aggravating activities Changing technique of activities Ice to area for 10 minutes b.i.d. Elbow straps during activity (counterforce bracing) (1)[B] Medication First Line Nonsteroidal anti-inflammatory drugs (NSAIDs): Good for short-term relief. There are no data to support long-term usefulness (2)[B]. Second Line Corticosteroid injections (3)[B] help relieve pain in acute setting; no effect in long-term outcome. Additional Treatment Physical therapy: Begin once acute pain resolved Focus on eccentric strength training. Grip exercises Ultrasound (4)[B] Corticosteroid iontophoresis General Measures Relative rest Issues for Referral Failure of conservative therapy Additional Therapies Botulinum toxin injections (5)[B] Platelet-rich plasma injections (6)[C]: Involves the injection of a concentrated portion of the patient’s plasma. Specifically, the platelet-rich portion of plasma is used. The localized injection of the concentrate leads to a local inflammatory response causing the platelets to degranulate, releasing growth factors, which then stimulate the physiologic healing cascade. Prolotherapy: Involves the injection of a dextrose solution into and around the tendon attachment. This stimulates a localized inflammatory response, leading to increased blood supply to the area, which increases the flow of nutrients and healing mediators to stimulate tendon healing. Research is currently being performed to look at efficacy of use in epicondylitis. Complementary and Alternative Medicine Acupuncture (7)[A] Surgery/Other Procedures May be indicated in refractory cases Involves debridement and release of the involved tendons Can be performed open or arthroscopically (1)[B] Ongoing Care Prognosis Good: Majority resolve with conservative care References 1. Dunkow PD, Jatti M, Muddu BN. A comparison of open and percutaneous techniques in the surgical treatment of tennis elbow. J Bone Joint Surg.2004;86-B:701. 2. Green S, et al. Non-steroidal anti-inflamatory drugs for treating lateral elbow pain in adults. Cochrane Database Syst Rev. 2001;(4):CD002267. 3. Assendelft W, Green S, Buchbinder R, et al. Tennis elbow (lateral epicondylitis). Clin Evid. 2002:1290–300. 4. Smidt N, van der Windt DA, Assendelft WJ, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002;359:657–62. 5. Wong SM, Hui AC, Tong PY, et al. Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2005;143:793–7. 6. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. 2006;34:1774–8. 7. Trinh KV, Phillips SD, Ho E, et al. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology (Oxford). 2004;43:1085–90. Additional Reading Wilson JJ, Best TM. Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician. 2005;72:811–8. See Also (Topic, Algorithm, Electronic Media Element) Algorithm: Pain in Upper Extremity Codes ICD9 726.31 Medial epicondylitis 726.32 Lateral epicondylitis Snomed 73583000 Epicondylitis (disorder) 53286005 Medial epicondylitis of elbow joint (disorder) 202855006 Lateral epicondylitis (disorder) Clinical Pearls Tendon injury characterized by pain and tenderness at the tendinous origins of the wrist flexors/extensors on the epicondyles of the humerus 2 types: Medial epicondylitis or “golfer’s elbow”: Involvement of the wrist flexors and pronators on the medial epicondyle Lateral epicondylitis or “tennis elbow”: Involvement of the wrist extensors and supinators on the lateral epicondyle May take weeks to months to resolve Majority of patients will improve with conservative treatment. NSAIDs 1st line; steroid injection 2nd line Ice to area for 10 minutes b.i.d. Elbow straps during activity (counterforce bracing) Physical therapy as symptoms improve Original article and pictures take http://health.tipsdiscover.com/epicondylitis-causes-symptoms-diagnosis-treatment-and-ongoing-care/ site