Epicondylitis (tennis elbow, golfer's elbow)

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This article will describe a condition such as epicondylitis of the elbow joint, symptoms and treatment of this pathology.

So, this is the most common disease associated with overload of the muscles of the forearm, which is often also called “tennis elbow.” However, repeated wrist extension occurs not only in tennis players, but also in ordinary people. Most patients with so-called “tennis elbow” have never held a racquet in their hands.

What happens inside with lateral epicondylitis?

Despite the fact that in the name we see the ending “-itis”, which refers us to inflammation, in fact, during microscopy of damaged tendons, no signs of an inflammatory reaction were found. Rather, the phenomena of degeneration of even and smooth tendon fibers into a shapeless collagen mass are revealed.

The fact is that the proximal part of the tendon fibers has a very poor blood supply, especially at the site of attachment to the bone. The main mechanism of damage is considered to be microtrauma, which, in conditions of insufficient oxygen supply, leads to degenerative changes in the structure of the tendons. Most often, these changes are found in the extensor radialis brevis tendon 1-2 cm distal to the site of attachment to the lateral epicondyle of the humerus. Since the localization of pain is in the elbow area, the condition is called “lateral epicondylitis,” although movements and stress on the elbow itself are usually painless.

Lateral epicondylitis (tennis elbow)

Lateral epicondylitis is a disease in which the muscle attachment site on the lateral epicondyle of the humerus becomes inflamed. This condition is often called “tennis elbow” because this problem is quite common among people involved in this sport. However, lateral epicondylitis is not limited to athletes. The main cause of the disease is overstrain of the muscles in the area of ​​their attachment to the epicondyle of the humerus. Such overexertion can occur, as we have already noted, when playing tennis, but it can also occur during any other monotonous work with the hands (sawing wood, painting a wall, etc.). As a rule, the disease occurs between the ages of 30 and 50 years.

Anatomy

The lateral epicondyle is a protrusion on the outer surface of the humerus just above the elbow joint. Several muscles are attached to the lateral epicondyle, which mainly extend the hand. You can learn more about the anatomy and function of muscles in the corresponding section of our website. At the site of attachment of these muscles to the epicondyle there are small tendons consisting of a special protein - collagen, which in fact has only a slight elasticity (no more than 5%). We clarified this figure because many Russian-language sites describing lateral epicondylitis mindlessly repeat the erroneous opinion that “Tendons consist of collagen fibers - thin elastic strands.” The elasticity of tendons is determined by a completely different protein - elastin.

Causes

Sport. As we have already noted, the most common cause of lateral epicondylitis is overstrain of the muscles attached to the lateral epicondyle (the short extensor carpi radialis, the extensor digitorum, the extensor of the little finger and the extensor carpi ulnaris are attached by a common tendon to the lower part of the epicondyle; just above and separately from them to the humerus the extensor carpi radialis longus is attached).

Scientific studies have proven that among all these muscles, a particularly important role is played by the short extensor carpi radialis, which stabilizes the entire hand in an extended position with the elbow joint straightened. This stabilization is especially important when playing sports. When this muscle is overloaded, microtears occur in it in the area of ​​attachment to the epicondyle of the humerus, microtears appear in it, which, in turn, leads to inflammation and pain.

In any case, the coach should play an important role in the prevention of lateral epicondylitis in athletes, since incorrect striking technique significantly increases the risk of this disease.

In addition, the short extensor carpi radialis is located in such a way that when flexing and extending the elbow joint, the upper part of the muscle can be injured, which will also lead to inflammation and pain.

Professional activity. It is a mistake to think that lateral epicondylitis can only affect tennis players or athletes in general. Monotonous movements, especially when you have to hold the lesson on weight for a long time, can also lead to damage to the muscles attached to the lateral epicondyle. Artists, painters, gardeners, carpenters... The list goes on and on. Scientists even studied the frequency of this disease, and it turned out that it was statistically significantly more common among car mechanics, cooks and butchers compared to people in other professions. In all these cases, the professions have one thing in common - the need to repeatedly lift something with a straightened hand.

Age. Another cause of inflammation in the muscle attachment area is age-related changes in muscles and tendons.

Sometimes the disease can develop without any apparent reason, in which case it is called “sudden” lateral epicondylitis.

Symptoms

As a rule, the disease develops gradually. At first the pain is slight and intermittent, but over several weeks or months it gradually progresses and may become constant. Often the onset of pain is not preceded by any injury.

The most common symptoms of lateral epicondylitis are:

• Pain or burning sensation on the outside of the elbow;
• Decreased strength of the forearm muscles that extend the hand and fingers.

These symptoms are aggravated by stress on the muscles that attach to the lateral epicondyle of the humerus (holding a racket, tightening screws with a screwdriver, etc.).

Most often, pain occurs on the leading side (right in right-handed people and left in left-handed people), but the disease can occur on both sides.

Overstrain of the muscles and tendons in the elbow area is the main cause of the development of epicondylitis. Repetitive forceful movements of the elbow joint can cause hyperextension of the elbow tendons. It doesn't have to be extreme loads in professional tennis. Hammering nails, carrying buckets of water in the garden, trimming bushes - all this can lead to the development of tennis elbow.

When tissue is damaged, inflammation develops, which is a protective reaction of the body. Leukocytes migrate to the site of inflammation, clearing it of damaged tissue and promoting healing. In medical terminology, diseases accompanied by inflammation have the ending -itis. For example, inflammation of the tendons is called tendonitis. Accordingly, inflammation of the tissue near the lateral epicondyle is called lateral epicondylitis.

It should be noted that tennis elbow is not always accompanied by tissue inflammation. In the absence of inflammatory changes in the tendons, the disease is called tendinosis. With tendinosis, stretching and microtears lead to degenerative changes in the tendon. In such a tendon, the arrangement of collagen fibers is disrupted. The tendon cells begin to be replaced by fibroblasts - cells that produce a slightly different type of collagen, not as strong and without an orderly arrangement of fibers. The tendon gradually degenerates: it becomes thicker due to the growth of defective connective tissue. Naturally, such a tendon can be damaged even with minor injuries.

The exact mechanism of development of epicondylitis is still unknown. One common hypothesis is that the tendon that attaches to the lateral epicondyle develops microtears due to overload. Restoring the integrity of the tendon is hampered by continued stress, which can also lead to the formation of new damage. The growth of connective tissue at the site of injury leads to weakening of the tendon and pain.

Diagnosis

Tell your doctor about how the disease developed, how you think it started, and how quickly the pain or other symptoms progressed. Pay special attention to the specifics of your physical activity - what kind of work you do, what sport you do and how often you do it.

To diagnose lateral epicondylitis, your doctor will ask you to perform special hand movements (diagnostic tests). Typically, these special tests allow you to establish the diagnosis without any doubt, but in some cases, ultrasound, x-ray or even magnetic resonance imaging may be necessary.

Treatment

In the vast majority of cases, conservative (non-surgical) treatment is possible. It is effective in 80-95% of cases.

Principles of self-medication :

1. If pain appears, completely eliminate movements/exercises that provoked pain for several days. If you play tennis, pay attention to the size of the racket itself and the tension of the strings - when you resume training, you may need to change the racket. To relieve pain, it is recommended to take anti-inflammatory drugs (for example, ibuprofen every 4-6 hours) until the pain stops completely.

2. If pain reappears, apply cold (cryotherapy) to the outside of the elbow joint for 15-20 minutes several times a day. Cryotherapy is continued for 3-4 days.

3. After a significant reduction in pain, local cold is replaced by local heat (several times a day), which finally removes the pain.

4. After pain disappears permanently, begin stretching exercises. Using the other hand, slowly bend the wrist of the affected arm until a feeling of tension and slight pain appears in the elbow area, stay in this position for 10-15 seconds, slowly shaking the hand. Repeat three sets 10 times a day.

5. Once the stretching exercises are completely pain-free, begin strengthening and stretching exercises. Take a hammer or other heavy object in the hand (the back of the hand is facing upward, the elbow is bent about 100-120 degrees). The hand and forearm are supinated and returned to their original position. 10 approaches, rest 2-3 minutes, 2 more times 10 approaches (2-3 times a week).

6. Repeat a similar exercise, but the hand is turned with the back surface down (picture). 10 approaches, rest 2-3 minutes, 2 more times 10 approaches (2-3 times a week).

Other exercise options:

Orthotics:

Left and center: orthoses for the treatment of lateral epicondylitis (tennis elbow) of the “wristband” type, its center should be in the upper third of the forearm along the posterior outer surface - this reduces some of the load on the enthesis. The “wristband” can be used not only for treatment, but also for prevention.

Elastic bandages around the elbow joint are practically useless.

Right: in addition to such “wristbands,” orthoses that immobilize the hand in a position of slight dorsiflexion are used for therapeutic immobilization.

There was even one study where the authors compared these two most common immobilization options (50 patients, 25 in each group, no statistical advantage in either group, but the authors preferred the wristband due to greater convenience and cosmetics).

(Altan and E. Kanat. Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices Journal: Clinical Rheumatology, Springer London, ISSN0770-3198 (Print) 1434-9949 (Online), Volume 27, Number 8 / August 2008) .

Another option for conservative treatment is taping, which reduces the load in the area of ​​the lateral epicondyle.

Injection of corticosteroid drugs . Local single (less often double) administration of drugs such as diprospan, kenalog or hydrocortisone can very effectively relieve pain, but you need to understand that treatment with corticosteroids without modifying the load and identifying the causes of pain is not the most optimal way. Moreover, in our opinion, treatment of lateral epicondylitis should begin with modifications of loads, exercises, orthoses, taping, and only if the effect is insufficient, proceed to the injection of corticosteroid drugs.

Extracorporeal shock wave therapy. The essence of this method is that sound vibrations cause microtrauma, which, in turn, stimulates the healing process. In some ways, the principle of action is similar to the homeopathic approach - like is treated with like. Unfortunately, at present this technique still has an experimental status and most of the studies are of an advertising nature or are generally carried out with serious flaws. On the other hand, there are a number of serious scientific studies in which shock wave therapy has shown to be effective. In any case, it cannot currently be considered as a first-line treatment option.

Surgery.

In cases where there is no acceptable effect from conservative treatment within 6-12 months, the solution is seen in surgical treatment.

Almost all surgical methods for treating tennis elbow involve separating the muscles from the area of ​​attachment to the condyle of the humerus, removing chronically inflamed and altered tissue, and reattaching the muscles to the bone.

The operation can be performed either in the traditional open way (through an incision 4-6 cm long) or arthroscopically (through two punctures 1 cm long). It is difficult to compare these techniques with each other, but it is worth noting that open surgery probably allows you to more closely see all the changes in the area of ​​muscle attachment to the bone.

In any case, the operation is inevitably accompanied by risks of complications, which, although rare, can arise despite all the skill of the surgeon:

• Infectious complications (need for repeated operations)
• Damage to blood vessels and nerves
• Slow growth of muscles to bone, resulting in a long rehabilitation period
• Decreased forearm strength
• Decreased flexibility of movements

After surgery, the arm is immobilized (immobilized) with an orthosis for 1-2 weeks, which reduces muscle tension. After this, they begin physical exercises, which are selected individually by the doctor. Stretching exercises begin no earlier than 2 months after surgery. Return to sports activities usually occurs 4-6 months after surgery. Fortunately, in most cases, the strength of the forearm muscles is completely restored after such operations.

Who may have external or internal epicondylitis of the elbow joint?

According to statistics, men suffer from elbow pain no less often than women.

Most often these are middle-aged people from 35 to 54 years old.

Not everyone associates the onset of symptoms with unusual or excessive exercise. It happens that epicondylitis begins on its own without any obvious cause. The truth is that we don't really know why this pathology occurs.

In addition to the lateral (also known as external), there is also medial (also known as internal) epicondylitis of the elbow joint. It occurs in 10-20% (according to different authors) of cases of all epicondylitis. The only difference is that the pain appears not from the outside, but from the inside of the elbow joint, since the extensors of the wrist are involved in this process, not the flexors.

Medial epicondylitis of the elbow joint is also called “golfer’s elbow,” but golfers in our latitudes are even less common than tennis players.

Symptoms and diagnosis

Patients with lateral epicondylitis typically have pain in the elbow, which intensifies when holding a weight in the arm during extension. Playing tennis or similar sports activities may actually cause epicondylitis, but it is often associated with other activities. On palpation in the area of ​​tendon attachment, about 1 cm distal to the middle part of the epicondyle, compaction and pain are noted. In addition, there is a decrease in muscle strength with resistance to grip and with supination of the hand. There are also tests such as the chair rise (with the arm pronating) and the coffee cup test (in which the patient lifts a full cup of coffee). Typically, these tests cause pain in the elbow. The diagnosis of lateral epicondylitis is usually made based on the clinical picture. Epicondylitis can be of moderate or severe severity.

With medial epicondylitis, pain is localized in the medial part of the elbow. Symptoms (pain) in patients with medial epicondylitis develop gradually (with the exception of acute trauma). Muscle weakness when grasping is also noted. Patients may have a history of playing golf, basketball, or volleyball. On palpation in the area of ​​the flexor-pronator tendons (5-10 mm and distal to the middle part of the medial epicondyle), induration and tenderness are noted. In addition, pain increases when the wrist resists forearm flexion and pronation to 90°. Flexion contractures can develop in professional athletes due to muscle hypertrophy. It is necessary to differentiate medial epicondylitis from tunnel syndrome and ulnar nerve neuritis. There is a simple "milking" test (simulated milking) that causes increased pain in medial epicondylitis.

However, sometimes there is a need for instrumental diagnostics (imaging) for differential diagnosis with other diseases. It has been noted that 5% of people with a primary diagnosis of lateral epicondylitis have radial tunnel syndrome. Radial tunnel syndrome is compression of the posterior interosseous nerve (deep branch of the radial nerve) in the radial tunnel. Many patients with this syndrome have a history of activities involving frequent pronation and supination of the forearm. The most common MRI finding in radial tunnel syndrome is swelling, denervation, or atrophy in the muscles innervated by the posterior interosseous nerve.

MRI diagnostics helps to make an accurate diagnosis. But normal visualization is only possible with high-field devices (magnetic field power 1 tesla or more).

Ultrasound is a fairly informative research method that allows you to visualize this pathology.

EMG study is necessary only for signs of conduction disturbances (for tunnel syndromes and neuritis).

Diagnosis of epicondylitis

In most cases, questioning and inspection are sufficient.

As a rule, the appearance of the hand does not change, with rare exceptions you may notice a slight swelling or change in skin color (this is more likely from repeated injections with glucocorticoids).

The most characteristic symptom of epicondylitis is pain in the area of ​​the protruding epicondyle of the humerus - these are the bones on the sides of the elbow joint, on the outside and on the inside.

The pain intensifies with load on the arm. For lateral epicondylitis of the elbow joint, this is extension at the wrist, for medial epicondylitis, this is flexion. Also painful will be shaking hands, carrying heavy objects (kettle, pan), all movements that require a strong grip. For example, pull-ups or barbell presses can be painful, while push-ups do not cause any pain. This is because the muscles involved work specifically in the wrist, and not in the elbow.

The range of motion may be painful in extreme positions, this is especially noticeable with severe symptoms.

If in doubt, the doctor may prescribe additional tests: X-ray, MRI, CT, electroneuromyography.

Treatment of epicondylitis

Getting rid of elbow pain is a long process that must be approached conscientiously. Hospitalization is not necessary to treat epicondylitis. The treatment regimen is prescribed by the doctor; it depends on the qualifications of the specialist, the duration of the disease and the degree of forearm dysfunction.

Main goals of treatment:

• pain relief;
• activation of local blood flow;
• preservation (restoration) of the entire range of motion of the forearm;
• prevention of muscle atrophy

If epicondylitis occurs as a consequence of another disease, then the underlying ailment (rheumatism, gout, osteoarthritis, bacterial infection, etc.) is first treated. In addition, recovery is achieved using the following measures.

Security mode

First of all, it is necessary to limit movements that provoke pain and protect the elbow, ensuring it rests. Therefore, recovery begins with the elimination of physical activity.

1. Immobilization

Immobilization of the elbow is one of the conditions for recovery, as it protects the elbow and provides it with rest. The doctor will recommend the type of immobilization:

• in case of intolerable pain, the joint should be fixed in a stationary state using a soft bandage; a modern bandage is comfortable, does not cause inconvenience and relieves pressure on the elbow, redistributing pressure;
• sometimes (in case of severe pain) immobilization is carried out with a light plaster (splint) for up to 7 days, fixing the joint at an angle of 80 degrees;
• if the course is chronic, then, if possible, the joint and forearm should be fixed with an elastic bandage all day.

1. Wearing orthoses.

Orthoses seem to “turn off” the affected area. They are fixed in the upper part of the forearm (in the form of “wristbands”). They are removed at night and used during wakefulness.

1. Change of professional activity.

Only after the painful phenomena have subsided can you begin the previous loads. In case of relapses, it is necessary to change profession, since systematic overstrain of a vulnerable joint can provoke deterioration.

1. Refusal from active sports.

Only after the pain disappears can you gradually load the joint, starting with a minimal load. It is advisable to give up active sports, or at least avoid exercises that cause sudden movements of the arms.

Drug therapy

Drug treatment is used to combat the underlying disease and, in the form of symptomatic therapy, to reduce inflammation and relieve pain. Typically, pharmacotherapy is based on the following key points:

• taking non-steroidal anti-inflammatory drugs,
• external use of ointments, gels and rubs with herbal or synthetic active ingredients; In addition to the analgesic effect, when rubbed, they provide a massage effect;
• corticosteroids (joint blockades from 1 to 4 injections with an interval of 3 days - 1-2 weeks);
• sometimes the doctor prescribes antibiotics to relieve the inflammatory process;
• blockades with double-distilled water improve trophism of joint tissues; although they are painful, they are quite effective;
• taking mineral complexes and vitamins that strengthen bone tissue

Corticosteroids are prescribed for severe pain. But during the first 24 hours, the administration of hydrocortisone can cause increased pain, so it is often mixed with an anesthetic. After the administration of corticosteroids, the pain is relieved after 2-3 days. Pharmacotherapy should be combined with careful treatment of the affected limb, with the use of an orthosis or bandage.

Physiotherapy

Physiotherapy is an important part of treatment and is effectively used for elbow pain. It has proven its effectiveness in improving joint health and is often the main method of therapy for problems with it. The range of its use for this disease is extensive:

• shock wave therapy is especially effective for this disease, therefore it is prescribed first;
• acupuncture gives good results when used correctly by a qualified specialist;
• autoplasmotherapy;
• ozone therapy;
• laser therapy;
• cryotherapy;
• all types of electrophoresis;
• ozokerite, paraffin and naphtholone applications, when used in a course, give stable positive dynamics;

Depending on the severity of the period, the doctor varies the procedures and combines them. Usually 1-2 courses are prescribed in 5-10 sessions. Physiotherapeutic procedures activate metabolic processes, increasing local blood flow. Thanks to the activation of local blood circulation, the process of updating the cellular composition of the affected structures is launched.

The European Center for Orthopedics and Pain Therapy has all the necessary physiotherapeutic equipment of the latest generation. Qualified specialists will prescribe an individual treatment regimen, taking into account the patient’s health status, age and contraindications to physical methods.

Physiotherapy

Exercise therapy helps restore elbow function, activate blood circulation in the problem area, and stimulate the formation of synovial moisture. Static exercises are recommended to stretch and strengthen the muscles of the arm, flexors and rotation, and build muscle mass. Regular exercise corrects muscle imbalances and prevents further damage. Proper technique helps strengthen tendons and gently stretch muscles.

Exercises are prescribed by a specialist after acute symptoms subside. The purpose of the exercises is to train muscles and increase the elasticity of ligaments. For exercises to be helpful, you need to do them regularly. The first exercises are carried out under the supervision of a specialist; later, after the correct technique is fully mastered, you can perform them independently. If the movement is difficult to do, you can help yourself with your healthy hand. Sports equipment is selected after consultation with a doctor.

Examples of exercises:

• the shoulders are motionless - bend and straighten the forearms;
• clench your fists with your elbows bent;
• press your palms together, bend your elbows;

The exercises should be performed at a slow pace, holding the hand in a certain position for 15-20 seconds. Each exercise should be repeated up to 10 times.

Remember! If acute pain occurs, the exercise must be stopped immediately!

Massage

A qualified massage helps to increase metabolism in the affected area. But it must be done carefully, kneading the pain points and lightly massaging the sore area. Targeted massage must be performed every day, 2-3 courses up to 8-10 days.

Surgery

If the pain does not stop, exacerbations follow one after another, muscle atrophy progresses, surgical intervention may be suggested.

The types of interventions can be different, as well as the type of anesthesia, which is chosen together with the doctor. The stitches are removed after 2 weeks, after which time rehabilitation can begin.

• tenotomy - the surgeon carefully excises the tendon in the area of ​​its attachment to the bone itself;
• Sometimes arthroscopy is used, where a puncture is made instead of an incision. This procedure is less traumatic;
• neurotomy - if the radial nerve is involved in the process, it is cut;
• myofasciotomy - the part of the periosteum to which the tendon is attached is removed;
• in some cases it is necessary to lengthen the extensor carpi brevis tendon; this operation has recently become the most popular

But surgical interventions are still rarely resorted to, since conservative treatment methods are usually effective.

The European Center for Orthopedics and Pain Therapy employs experienced specialists who will help you cope with this unpleasant illness in the most gentle but effective ways.