Lateral Epicondylitis/Tennis Elbow is an over and repeated using inflammatory micro-tearing of the tendons that are attached to the forearm muscles on the outside and upper side of the elbow joint. The forearm muscle that is originated from the lateral epicondyle tendon on the elbow joints partially causes inflammation or torn as a result causes pain for some work of overuse and repeated. Pain, swelling, tenderness, and decreased range of motion are more common sign symptoms of tennis elbow or elbow upper side pain. The symptoms are more commonly found in tennis players and that is why called it tennis elbow or lateral epicondylitis.
Causes of Lateral Epicondylitis
Sports like tennis is the first causes of tennis elbow or lateral epicondylitis and elbow upper side pain, rowing, or strength training
Manual labor like painting, carpentry, or turning screws for bike or hardware, motorbike working
Heavy lifting from one place to another etc from market to home
- Previous elbow joints fracture, a major operation, joints dislocation
The playing of musical instruments, such as the piano, guitar, harmony
Long time working at a computer or a supermarket cash register to counting money
- Long time writing, typing, editing
Elbow bursitis, tendinitis, bursitis,
- Road traffic accident and laceration of elbow joint upper side.
- Radiating pain, paresthesia, itching numbness
Posterolateral elbow plica syndrome
Posterolateral rotatory instability (PLRI)
Radial nerve entrapment syndrome or injury to elbow joints
Radial tunnel syndrome is one of the major syndromes that are lead to the following problem
palpation 3 to 4 cm distal may feel pain and anterior to the lateral epicondyle area pain
pain may feel with resisted third-finger extension
acute or chronic pain with resisted forearm supination
- Osteoporosis of elbow joint
Capitellar osteochondritis dissecans and injury
Triceps tendonitis may lead to tennis elbow or lateral epicondylitis
Radiocapitellar osteoporosis and osteoarthritis
The risk for the specefic occupations are sports, and domestic activities that demand an extension of the wrist are myriad. More common examples are plumbing; playing a musical instrument; painting; weaving; raking; using screwdrivers, pliers, and hammers; cutting meat; turning doorknobs; fishing; engaging in arm wrestling, racket sports, and other twisting movements; and lifting objects with an extended wrist.
Symptoms of Lateral Epicondylitis
- Pain in the outer elbow joint is the first symptom of tennis elbow.
- Pain may be felt when the elbow movement, touch
- Pain may be spread to the whole upper arm, forearms muscle, and even hand
- Paresthesia itching, numbness, and tingling sensation may be felt
- The pain may be felt in simple works such as unscrewing the cap of the bottle, brushing teeth, squishing a towel after a bath, playing a manual fan.
- In case of severe symptoms of tennis elbow is just lifting a cup of tea or coffee.
- Pain also may be severe in case of strong griping and with the arm in flexible comparing before.
- The pain may go away when the arm is resting and may increase at night and sleeping time.
Diagnosis of Lateral Epicondylitis
Physical exam for tennis elbow or lateral epicondylitis and elbow upper side pain should focus on the neurovascular territory of the involved compartment
Observe skin for lesions, swelling, or color change that seen in the inner forearms muscle pain
When palpating over the compartment, you are observing temperature, tension, tenderness
Check pulses, blood pressure, temperature
Evaluate two-point discrimination and sensation
Evaluate motor and sensory function of the elbow joint
Pain when getting out of bed
Inability to keep hand for a prolonged time
- On examination – In the physical appearance your doctor can see any abnormality such as swelling, skin rash, wort, skin change cyanosis, paling is not found in a physical examination in both sides of the elbow.
- Palpitation – In this examination patient may feel pain, tenderness when pressure creates in the hand. It may worsen in the morning. Tenderness to palpation is generally most notable about 5 to 10mm distal to the lateral epicondyle at the insertion of the flexor-pronator mass.[rx] The pain is generally increased with resisted wrist flexion and pronation, with resisted wrist pronation being the most sensitive exam for finding the tennis elbow, lateral epicondylitis.[rx] When testing, the elbow should be flexed at 90 degrees to isolate the pronator teres.[rx] Flexion contracture may be a late finding in an untreated case of medial epicondylitis.[rx]
- Laboratory tests – Leukocytosis is one of the most important tests for tennis elbow or lateral epicondylitis and elbow upper side pain that supports the possibility of infection and bone-related disease. Blood cultures, urine examination, or other possible primary sites of tennis elbow or lateral epicondylitis and elbow upper side pain, a bone infection that obligatory when a septic infectious elbow joint is being considered for examination. The and elevated inflammatory condition markers like ESR or CRP include suggesting an infectious or inflammatory disease condition of the tennis elbow or lateral epicondylitis and elbow upper side pain.
- A serum uric acid level – It is often considered by clinicians and doctors when got tennis elbow or lateral epicondylitis and elbows upper side pain, pseudogout is suspected, but it is not a reliable and dangerous condition as it may be spuriously elevated or high in acute inflammatory conditions or acutely during a or not
- Random blood glucose – The reference values for a normal random glucose test in an average adult are 80–140mg/dl (4.4–7.8 mmol/l), between 140-200mg/dl (7.8–11.1 mmol/l) is considered pre-diabetes, and ≥ 200 mg/dl is considered diabetes according to ADA guidelines you should visit your doctor or a clinic for additional tests to over sure.
- Ultrasound – It is basically done to investigate the thickness of the fascia, ligament injury with tennis elbow or lateral epicondylitis and elbow upper side pain are likely to have a thickened tendon with the associated fluid collection and that thickness values >4.0 mm that are the diagnostic of in tennis elbow or lateral epicondylitis and elbow upper side pain[rx]
- Musculoskeletal ultrasound – It can further visualize the tendon and bony attachment of the thigh sites, muscles, ligaments, and nerves. Ultrasound can also be used to identify the area and extent, nature of the injury tennis elbow or lateral epicondylitis, and elbow upper side pain and used to evaluate periodically during the recovery phase. The most common findings on ultrasound are focal, hypoechoic changes in the common flexor tendon position, how much thickening of the tendon sheath, partial or full-thickness tears, and tear of the tendon, neovascularization using Doppler, and cortical irregularities at the medial epicondyle.[rx][rx] Ultrasound did for dynamic imaging studies, which can provide the additional benefit in regards to evaluation for ulnar nerve subluxation and tennis elbow, lateral epicondylitis, ulnar collateral ligament instability with valgus stress.
- Radiographs of the joint – Conventional x-ray and radiography is the most widely used imaging modality and allows for the detection of bone fractures, osteoporosis, and abnormal pathologies condition like fracture, osteoporosis, erosions, osteonecrosis, osteoarthritis, or a juxta-articular bone tumor, neoplasm. Characteristic features of tennis elbow or lateral epicondylitis and elbow upper side pain include marginal osteophytes formation, joint space gradually narrowing, subchondral sclerosis formation in tennis elbow or lateral epicondylitis, and elbow upper side pain
- CT Scan – High contrast CT scan is more effective to diagnose tennis elbow or lateral epicondylitis and elbow upper side pain. Abnormal tendon, ligament, cartilage, muscle and osteophyte, synovial fluid. It also helps to identify the bone tumor, necrosis, abnormal joint condition, etc.
- MRI – It is called magnetic radical imaging is also helpful to find the bone conditions, abnormal tendon, ligament, cartilage, muscle and osteophyte, synovial fluid. It also helps to identify the bone tumor, necrosis, abnormal joint condition, etc. It is the final stage test to confirm that all tennis elbow or lateral epicondylitis and elbow upper side pain or any other abnormality suspected others condition forearms pain, such as carpal tunnel syndrome, soft tissue injury and bone tumors, osteonecrosis, osteomyelitis, arthritis, and stress fracture.[rx,rx]
- Bone scintigraphy – It is the most important test to diagnose bone cancer, neoplasm, fractures, necrosis of bone, and joints. It also helps to identify the tendon, sprained ligament, cartilage, muscle spasm, sprain, and strain tennis elbow or lateral epicondylitis and elbow upper side pain.
- Muscle Biopsy – Muscle biopsy is basically done to investigate abnormal congenital problems such as dutchmen muscular dystrophy, myasthenia graves, hemophilia, etc. A small part of the cell or tissue is collected from the thigh and send to investigate other abnormalities.
- Nerve Conduction velocity test – It a special test for leg pain or thigh pain. It is the procedure where test the sensation of the peripheral nerve stimuli to send the central nervous system means brain. It helps to identify the nervous system problem from the central to the peripheral cell.
Treatment of Lateral Epicondylitis
The treatment of tennis elbow or lateral epicondylitis and elbow upper side pain is following
- Protection – Protection means the save the injured joint and muscle of the tennis elbow or lateral epicondylitis and elbow upper side pain from further injuries and dislocation, sprain, strain. It can be done by the tapping process or adhesive bandage.
- Rest – After an injury from the elbow front side and the tennis elbow and lateral epicondylitis or upper side, elbow pain is kept in rest for some time today to prevent injury and accelerate the healing. It is an excellent manual process to protect tennis elbow or lateral epicondylitis and elbow upper side pain. The modification or avoidance of painful daily activities usually leads to symptomatic pain relief.
- Ice – The application after acute injury is helpful for the healing process of tennis elbow and lateral epicondylitis or upper side, elbow pain. It basically constricted the peripheral blood vessel that helps to prevent edema, swelling, or accumulated water. It can be used alternatively by ice and heat therapy at the same time.
- Compression – It is the most important manual techniques to protect the swelling, effusion and keep the tendon, ligament, cartilage intake and regenerate the joint cartilage for tennis elbow and lateral epicondylitis or upper side, elbow pain
- Elevation – Elevation is the process to prevent swelling, edema, and fluid accumulation in tennis elbow and lateral epicondylitis or upper side, elbow pain. Your doctor may advise elevating the hand at the same position as the heart vertically. The hand must be elevated just a small high comparing to the heart position in sleeping times.
- Physiotherapy – It is one of the most common and effective non-pharmacological treatments in the world. It has a variety of treatment module to erase acute and chronic pain. It is especially helpful in muscle spasticity, spasms related to tennis elbow or lateral epicondylitis, and elbows upper side pain front side and backside pain. Inflammatory and noninflammatory pain is treated by ultrasound, MRI, Shortwave, microwave, wax therapy, IRR, laser therapy, interferential current therapy, iontophoresis. Some studies have reported good outcomes with physiotherapy regimes of stretching and strengthening, with more favorable results than rest and reduced activity at short-term follow-up.[rx]
- Deep transverse friction massage – AIt is a special type of massage technique called transverse friction massage is often used to treat tennis elbow and golfer’s elbow patients. It is applied to the tendons and the muscles, using the tips of one or two fingers to heal tennis elbow and lateral epicondylitis or upper side, elbow pain.
- Transcutaneous electrical nerve stimulation (TENS) – It is called TENS devices that help to transfer electrical impulses that are helpful for the treatment of tennis elbow and lateral epicondylitis or upper side, elbow pain to the nervous system through the skin. These are supposed to keep the pain signals from reaching the brain by blocking pain message signals.
- Extracorporeal shockwave therapy (ESWT) – It is a physiotherapy device that generates shock or pressure waves that are transferred to the tissue through the skin for healing tennis elbow and lateral epicondylitis or upper side, elbow pain. This is assumed that to improve the circulation of blood in the tissue and speed up the healing process.
- Eccentric exercises – It is partial help to healing tendons that are the mainstays of physiotherapy regimes. A stable shoulder and scapula function and strength are necessary for correct elbow functioning; strengthening exercises of the scapular stabilizers that are including the lower trapezius, serratus anterior, and rotator cuff muscles.
- Epicondylar counterforce braces – It is working by reducing tension in the wrist extensors group of muscle. The elbow straps, clasps, or sleeve orthoses have been indicating as superior for a pain reliever and grip strength when compared with other types of treatment [rx] We have seen patients with secondary nerve problems due to prolonged use of a counterforce brace.
- Percutaneous radiofrequency thermal treatment – A radiofrequency electrode pad is attached percutaneously under an ultrasound guideline which produces a thermal effect in injured elbow joints or tennis elbow when activated, inducing visual microanatomy and removing all pathological injured tissue. Good outcomes have been reported, and no reduction in tendon size has been observed in this case.[rx]
- Acupuncture – It is the China-oriented acute and chronic treatment system where are needle is used to stimulate the pain receptor to reduce pain. It is also helpful in some spasticity formation pain, stroke, hemiplegia, and chronic rheumatoid arthritis pain in the hand, and tennis elbow or lateral epicondylitis and elbow upper side pain.
- Extracorporeal shock-wave therapy (ECSW) – It has been proposed as an alternative to non-operative management for tennis elbow or lateral epicondylitis. It worked by the generator of specific frequency sound waves that are applied directly onto the overlying skin of the tennis elbow or lateral epicondylitis tendon.
- The use of low-level laser therapy – It has been proposed due to the stimulating effect of laser on collagen or types 2 collagen production in tendons to increase the healing of tennis elbow. Although laser was not initially viewed as particularly useful among lateral epicondylitis therapies, a recent study has indicating some short-term benefits when using an adequate dose and wavelength.[rx]
- Diet – Diet may be normal or according to the doctor mentions food you can take for you, such as papaya, banana, potato, nut cereal, seasonal fruits, and drink of water. In your daily routine meal must have magnesium, calcium, iron, zinc, folate, vitamin B complex, Vitamin A, Vitamin C, etc.
The medication for tennis elbow or lateral epicondylitis and elbow upper side pain are
- Non-steroidal anti-inflammatory drugs (NSAIDs) – It is considered to be the fast-acting nonsteroidal anti-inflammatory drugs (NSAIDs) as including acetylsalicylate, naproxen, ibuprofen, indomethacin, and etodolac, ketorolac in pain is acute. NSAIDs drugs work by inhibiting cyclo-oxygenase enzyme to prevent the synthesis of prostaglandins, prostacyclin, and thromboxanes. It has also some side effects of aspirin at high doses when used are including tinnitus, hearing loss, and gastric intolerance.
- Nerve relaxant – It is basically used to reduce neuropathic pain, inflammation, nerve root entrapment, myalgia, neuralgia, and fibromyalgia, and thigh pain in the front side or backside. Your doctor may prescribe gabapentin, pregabalin, vitamin B1, B6, B12, etc. Major side effects are abdominal pain, nausea- vomiting.
- Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, tennis elbow, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, etc. A side effect may be nausea- vomiting, abdominal pain, cramping
- Topical diclofenac, camphor, menthol, and nitroglycerin – or glyceryl trinitrate has shown short-term benefits in lateral epicondylitis, and tennis elbow but overall results for treatment for tendinopathy or lateral epicondylitis and tennis elbow have been mixed depending on the site of application.[rx]
- Corticosteroid injections are commonly used to treat LE. The way in which they work is excellent and; they must help to control local inflammatory, soft tissue injury, and pain mediation.[rx] Cortisone injections should be avoided in most cases, not only a short-term good result but it is advisable (such as a professional tennis player in mid-season), as most patients fully improve without corticosteroids injection and better long-term results can be achieved without injection.[rx] The side-effects including changes in coloration of the skin, fat atrophy, and abdominal cramp, gastritis, muscle wasting, and vomiting problem.
- Autologous blood injections – These are thought to work by stimulating an inflammatory response that will bring in the necessary micronutrients to promote healing. Short-term good results have been reported recently; however, no benefit in the long-term follow-up has been found and its use is only recommended for those cases when other modalities of treatment have failed.[rx,rx]
- Platelet-rich plasma injections (PRP) – These types of preparations are thought to contain high concentrations of growth factors to heal the tennis elbow, which could basically increase tendon healing. The general technique involves patient-blood extraction, centrifugation process, and re-injection of the plasma into the lateral epicondyle directly. Good outcomes have been reported.[rx,rx] No major side effect is not found
- Botulinum toxin A injections – It basically act by diminishing muscle tone. Reducing the tension on the lateral epicondylitis insertion could be beneficial for pain relief in elbow. Good short-term results have been published,[rx] but as yet there is no consensus on its use and the effects may be conditioned by the technique, the operator, and the dose.
- Surgery – The surgery is typically not required at all, however, if no benefit is seen with the above mention conservative treatments for 6 to 12 months, then surgical management may be considered to be done. Given the proximity to the ulnar nerve and ulnar collateral ligament /UCL, an open surgical technique is preferred. The operative treatment involves debridement of the degenerated tendon, the release of the common flexor tendon at the medial epicondyle, and cortical drilling of the epicondyle to increase vascularity. If there is concomitant ulnar neuropathy and all other associated condition, a transposition is also performed at the time of surgery.[rx]
Hold a weight in your hand.
Rest the affected arm on a table with your palm facing down, allowing your hand to hang off the edge of the table.
Use your free hand to bend the affected wrist back as far as you can while lifting the weight.
Gradually lower the hand with the weight in it.
Repeat about 10 to 15 times.
After a short break, repeat this types set of exercises two more times.
It’s important not to use heavyweights. The weight should be about 30% of the maximum weight you can hold. Slight pain is okay, but you shouldn’t put too much strain on the arm.
Eccentric strengthening exercises
At first rest the elbow of the affected arm on a table, with your forearm upright. Turn your forearm so that the palm of your hand is facing away from you.
Hold a full bottle in the affected hand.
It is gradually lower the arm with the bottle, making sure not to bend your wrist.
If possible allow the bottle to fall into your free hand and move the affected arm back to the upright starting position.
Pass the bottle from the freehand back up to the affected hand.
Repeat about 10 to 15 times.
After a short break, repeat this set of exercises two more times.
It’s best to do strengthening exercises three times a day.
The aim of stretching exercises is to stretch and improve the the wrist extensor muscles in the forearm. These exercises are most likely recommended in order to improve the mobility, strengthening the muscle(range of movement) of the arm and wrist. They can either be done actively or passively. By “actively,” we mean you do them yourself. In passive exercises, a physiotherapist or training partner stretches that part of the body for you.
Stretch the affected arm out in front of you, with your palm facing directly downwards.
Relax your wrist, allowing your hand to dangle down.
Using your other hand, push the affected hand down and pull it towards your body.
Hold the stretch for about 30 to 45 seconds.
Have a break (about 30 seconds).
Repeat three times.
People are advised to do these stretching exercises about twice a day.