Golf and tennis are not the only recreational activities that can cause elbow pain, yet they each are commonly used to describe epicondylitis. Repetitive activities can lead to chronic tendinosis of the medial or lateral epicondyles. Medial epicondylitis (“Golfer’s Elbow”) involves attachment site of the wrist flexors whereas lateral epicondylitis (“Tennis Elbow”) involves attachment site of the wrist extensors. Both of these are commonly caused by repetitive activities but can also be seen with lifting or forceful gripping and repetitive manual work-related activities. These repetitive activities may occur at the elbow or the wrist. Medial and lateral epicondylitis typically does not represent a large inflammatory response but rather a chronic degenerative pattern with disorganized collagen consistent with tendinosis.
Patients typically present with maximal point of tenderness over the medial or lateral epicondyle. Pain is insidious with worsening overtime but may be exacerbated by a specific injury. Pain severity can vary significantly and should be quantified based on the effects to activities of daily living. Weakness may be seen with decreased grip or wrist strength.
Both medial and lateral epicondylitis are diagnosed clinically. Physical exam is essential for the diagnosis. Although pain with palpation over the effected epicondyle is the classic diagnostic finding, this can also lead to a large differential. Examination of resisted wrist motion will help to support the diagnosis. With the elbow in full extension both resisted wrist flexion and extension should be assessed. Pain with resisted wrist flexion is consistent with medial epicondylitis and pain with resisted wrist extension assesses for lateral epicondylitis. Unilateral elbow pain may also be evaluated by having the patient provide passive terminal wrist extension (medial) and flexion (lateral). Wrist range of motion and strength testing stresses the attachment sites of the respective tendons at the elbow. Pronation, supination, and grip strength testing may exacerbate either of these conditions. The epicondyles are extraarticular so if a joint effusion is noted or patient complains of pain with elbow range of motion, additional differential diagnoses must be considered including intraarticular causes. Nerve pain or paresthesia may cause unilateral symptoms particularly with injury or compression to the posterior interosseous or ulnar nerves. Tinel’s sign can be beneficial in differentiating signs of nerve involvement evaluation for tingling, numbness, or shock-like symptoms.
Radiographs are reserved for continued pain resistant to conservative treatment or if the patient reports an acute onset of symptoms. Plain films and advanced imaging can assist with evaluating for other underlying causes.
Mainstay treatment includes NSAIDs if appropriate for the patient, counter force brace, and activity restrictions or modifications based on severity. Counter force braces help offset the mechanically load to the tendon attachment site at the elbow. Physical therapy is an effective treatment option for patients to provide both symptom improvement and prevention. Activity modifications and attempts to prevent symptoms may be difficult for athletes or manual labor workers. Appropriate biomechanics can assist with preventing reoccurrence and is often guided a physical therapist, athletic trainer, or qualified coaches. Maintaining proper performance techniques extends beyond the elbow to include mechanics through the upper extremity such as the shoulder, forearm, and wrist. Poor techniques can place undue stress on the tendon attachments leading the chronic tendinosis associated with epicondylitis. Secondary management options include glucocorticoid injections or surgery. Injections are more commonly used in lateral epicondylitis but are only shown to have short-term benefits. Many providers avoid medial injections due to the ulnar nerve proximity. Surgery remains a last resort or in patients with an underlying cause that could benefit from surgical intervention.
You can see Sarah Bolander, MMS, PA-C speak at a 2019 Skin, Bones, Hearts & Private Parts CME/CE conference in Destin, Myrtle Beach, Pensacola Beach, Orlando, or Las Vegas.