Lateral Epicondylitis - Elbow pain: Diagnosis, Treatment, and Outcomes
A little about me...
I am currently employed as a Physicians Assistant in occupational medicine, treating orthopedic injuries, which I have done for over 11 years. Other than being a trained orthopedic physician assistant, I also reference valuable resources on a regular basis. The Official Disability Guidelines (my favorite) are a valuable reference for health care professionals treating patients with injuries, especially work injuries. The Official Disability Guidelines (ODG) guidelines provide a summary of studies on treatments, diagnoses, surgeries, therapies, medications, etc. I use the ODG guidelines on a daily basis for researching and referencing current evidence based literature on patients who I see.
If you have ever had lateral elbow pain, you know, it can be quite debilitating. Lateral elbow pain is typically referred to as epicondylitis. I know, I know, you are saying, "so what?" and "what the heck does that mean?" Well, the elbow has 2 epicondyles, a medial and a lateral, located on the inside and outside of the elbow. If you feel your elbow with your arm in an extended position, you should be able to feel the two bumps (or bones) that are your epicondyles. Epicondylitis occurs when one of these bumps becomes inflamed or irritated. The term literally means inflammation of the epicondyle.
Medial epicondylitis refers to inflammation and irritation of the inside portion of your elbow (the side closest to your body). Lateral epicondylitis refers to inflammation of the outside portion of your elbow (the side that is farthest away from your body) and can usually cause pain that extends down the muscles and tendons into your forearm and wrist. It can also cause numbness, pain, tingling, and weakness down your ulnar nerve, which is a nerve that runs on the outside of your elbow directly beside the lateral epicondyle. It is the nerve that you hit when you hit your "funny bone." This nerve goes down into your forearm and down into your pinky and ring fingers. Sometimes when the lateral epicondyle is inflamed, it can affect this nerve and cause compression or irritation.
You may ask: How did I get this? What can I do to prevent it?
Lateral epicondylitis can result from overuse of the arm and elbow, such as in tennis players – which is why this is sometimes referred to as tennis elbow. It can also result from a traumatic injury to the elbow joint, such as hitting the elbow on something or from a fall or car accident. This condition can usually be treated non-operatively (without surgery), but occasionally, in only about 5% of cases, surgery will be required, but only after a lot of non-operative treatment for a period of about 6 months to a year.
What does the ODG guidelines say about Lateral Epicondylitis?
As per the Official Disability Guidelines, lateral epicondylitis can successfully be treated without surgery in 95% of patients. The Official Disability Guidelines provide a specific outline of the standard criteria for surgery for this condition. One of the criteria states that at least 12 months of non-operative treatment with physical therapy, exercise, bracing, medications, modification of activities, and rest should be tried. This almost always results in resolution of this condition. In a small number of cases (5%), surgery will be necessary and would include debridement of the epicondylar area or a release of the tendons and decompression of the ulnar nerve. I would like to provide you with more information about some of the non-operative treatments that are recommended for this condition to help you to avoid surgery.
For Research Purposes, Please answer the following...
Have you had treatment for lateral epicondylitis?
Medications: NSAIDS (NON-STEROIDAL ANTI-INFLAMMATORY MEDICATIONS
When you initially see your doctor about lateral elbow pain, the first treatment that he/she will likely recommended is a nonsteroidal anti-inflammatory medication. Examples of nonsteroidal anti-inflammatory medications (NSAIDs) include ibuprofen, naproxen (Advil), nabumetone (Relafen), celecoxib (Celebrex), etc. Nonsteroidal anti-inflammatory medications can be quite effective, if taken on a regular basis, for inflammation at the elbow. Your doctor will recommend that these medications be taken once or twice every day regardless of whether you have pain or not. This recommendation will be very important to follow, as the use of a nonsteroidal anti-inflammatory medication can help to decrease pain and inflammation when taken on a regular basis.
Your doctor will also likely prescribe a brace for you. Typical bracing for this condition would include a tennis elbow strap, which is a band support strap that goes on your forearm, just in front of the elbow, and helps to take the tension off the muscles and tendons that go into the lateral epicondylar area. This helps to release the pull that these tendons have on the lateral epicondyle, allowing it to rest and heal. If you think of a rubber band that is constantly being pulled and becomes weak because of the constant pressure, this is the same idea. The tennis elbow strap will, in a way, release the pressure on the rubber band, giving your elbow time to heal with the use of nonsteroidal anti-inflammatory medications.
Another option for bracing of this condition would include an elbow extension splint, which is worn at night. This helps to prevent flexion (or bending) of your elbow while you are sleeping at night. Again, consider the rubber band. When you flex (bend) your elbow, you are causing increased pressure on the tendons that attach at the lateral epicondyle in your elbow. Keeping your arm in extension (straight) will help to prevent the tension being constantly placed on your elbow, especially at night. It is generally recommended that patients wear an elbow extension splint for a period of at least 4-6 weeks and for maintenance treatment after that point.
Your doctor will also tell you to modify your activities. This would include staying away from any activities that may aggravate the elbow. The obvious activity would be tennis, but there are other activities that can aggravate the elbow. There are many activities that would not be expected to cause this condition and they would include any activities that involve constant gripping (as in a tennis racket), such as knitting, raking, painting, typing, weight lifting, and carpentry. It is very important that you stay away from any activities that might aggravate the condition, especially during the first 1-3 months of treatment. If you are actively receiving treatments, but are still participating in activities that constantly aggravate the elbow, it is unlikely that you will improve. Modifying your activities can allow your tendons and bones to heal, which will ultimately lead to resolution of your condition.
EXTRACORPOREAL SHOCKWAVE THERAPY
Another treatment for this condition is called extracorporeal shockwave therapy (ESWT). This is a type of stimulation treatment. Although studies have not found substantial benefit from the addition of this treatment for this condition, many doctors still consider it to be a good treatment option. More recent research on this topic has shown that it only produces a response that is similar to patients who had physical therapy alone and the addition of this treatment does not generally accelerate or enhance the recovery time. If this treatment is recommended, it is generally only recommended in patients who do not respond to initial treatments, including physical therapy, medications, activity modification, and bracing for a period of at least 6 months. Your doctor will never refer you for this treatment initially and it will only be considered if you continue to have pain for a long period of time and other treatments are not helping. This treatment would generally be recommended to be trialed before surgery is considered in most cases.
Therapeutic Modalities for Elbow Pain
Initial treatment can also include a course of physical therapy. Your doctor will typically recommend that you be referred for physical therapy for at least 4-6 weeks. The physical therapist will apply topical modalities, such as electrical stimulation, ice, heat, ultrasound, etc. The therapist will also perform active exercises with you and can instruct you on exercises that can be performed at home. It is very important to maintain an active, regular exercise program with performance of the exercises that the physical therapist has instructed you in. A regular exercise program can be very effective for this condition when combined with nonsteroidal anti-inflammatory medications, bracing, and activity modification.
Current evidence based literature states that a steroid/anesthetic injection is not specifically recommended in the treatment of lateral epicondylitis and is only capable of providing short term relief of less than 6 weeks. One study (http://www.medscape.org/viewarticle/582329) states that, in the short-term, a corticosteroid injection helps relieve symptoms from lateral epicondylitis. However, after 6 weeks, physical therapy would be superior to a steroid injection for symptom relief. A doctor may recommend an injection before you start a course of PT to help calm down the inflammation and provide some improvement in your pain to help you progress in a therapy program. However, there is one study (http://jama.jamanetwork.com/article.aspx?articleid=1568252) that states that a steroid injection can actually increase the risk for a poor outcome and greatly increase the risk for re-injury. Overall, the use of steroid injections to treat tennis elbow has been increasingly discouraged because of lack of long-term efficacy and high recurrence rates.
Another type of injection is called a platelet rich plasma injection or an autologous blood injection. This literally involves injecting some components of your blood into the elbow. Although research on this type of injection is inconclusive, it is usually recommended to be considered as an option before surgery. There are some studies that show that this type of injection can be therapeutic in patients who fail to respond to other standard treatment. However, this injection is still not recommended on a standard basis in the treatment for lateral epicondylitis.
SURGERY AND WHAT TO EXPECT
If you still have pain after the above conservative treatments, your doctor will usually recommend surgery. Surgery for this condition is usually a lateral epicondylar release or debridement. Surgical time is usually very short and does not usually require an inpatient stay. Most of the time, it can be performed in an outpatient setting. After surgery, a course of physical therapy is recommended. Current evidence based literature recommends about 12 sessions of therapy over 12 weeks, which is usually sufficient to rehabilitate the elbow. However, the post-operative recovery period could take up to 6 months.