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HelenaLiira

Elbow Tendinopathy (Epicondylitis)

Essentials

Prevalence

  • Lateral tendinopathy (lateral epicondylitis or tennis elbow) is caused by repetitive strain on the extensor muscles of the wrist and fingers which results in irritation of the tendon insertion on the humerus. Likewise, medial epicondylitis is caused by strain on the flexor muscles.
  • According to Health 2000 (a health survey carried out in Finland) the prevalence of elbow tendinopathies shows no gender preference. The prevalence of lateral tendinopathy was 1.1% and that of medial tendinopathy 0.3%.
  • The most important risk factors are forceful use of the arm, repetitive work movements and bent positions of the wrist.
  • Smoking is the most important individual controllable risk factor.

Signs and symptoms

  • A patient with elbow tendinopathy presents typically with pain that localises around the epicondyle, particularly whilst gripping something with the forearm extended.
  • Resisted isometric testing should be carried out with the forearm extended. Extension (lateral tendinopathy) and flexion (medial tendinopathy) of the wrist are resisted. Pain at the insertion site of the tendon constitutes a positive finding.
  • A measurement of hand grip power and pain during gripping may also be used as diagnostic tools, and they also serve as functional capacity indicators. Hand dominance has an effect on grip power, and a 10% side difference in grip power is normal.

Diagnostic criteria

  • Lateral tendinopathy
    • Resisted extension of the wrist causes pain at the lateral epicondyle and
    • the epicondyle is tender on palpation.
  • Medial tendinopathy
    • Resisted flexion of the wrist causes pain at the medial epicondyle and
    • the epicondyle is tender on palpation.

Differential diagnosis

  • Local strain symptoms, tendinitides and injuries in the forearm
  • Arthrosis of the elbow joint and ulnar nerve entrapment.
  • Proximal problems originating from the plexus or the cervical spine nerve root areas, e.g. disc prolapse and radicular compression
  • Nerve entrapment of the deep motor branch of the radial nerve (Frohse's syndrome) is rare and is associated with extension weakness of the fingers.
  • ENMG Clinical Neurophysiology in Diagnostics is necessary in some cases for the differential diagnosis.

Treatment

Acute phase

Prolonged symptoms

  • Glucocorticoid injections are not recommended for the treatment of tendinopathy because they increase the recurrence of the pain within a 3-12 month follow-up period despite providing good short-term (less than 6 weeks) pain relief .
  • Orthotic supports, such as adhesive tape or splints, may improve symptoms and, if necessary, they may be used short term in order to alleviate pain.
  • Gradually increasing strengthening exercises may have some effect on both the symptoms and recovery of chronic tendinopathy, but scientific evidence is inconsistent. Provide the patient with appropriate patient education materials.
  • Shock wave therapy has been studied in several comparative studies, but its effect in terms of pain and function in chronic tendinopathy has not been proven .
  • Ultrasound may improve symptoms of chronic tendinopathy. The treatment effect is very small, and study results are not totally consistent.
  • Topical application of nitrate ointment may be effective in the treatment of prolonged tendinopathy pain (extemporaneous preparation: glyceryl trinitrate 2% mixed with a cream).
  • Botulinum toxin may alleviate pain caused by chronic tendinopathy in short term, but it may cause temporary reduction of hand grip strength .
  • Do not treat lateral tendinopathy of the elbow with platelet-rich plasma injections .
  • Surgical therapy is not recommended, as there is no evidence of its effect on pain .

Occupational disease

  • Appropriate arrangements at work and support from occupational physiotherapist may be indicated when tendinopathy becomes prolonged.
  • Epicondylitis may be considered as an occupational disease in certain circumstances. In accordance with national legislation, the patient may be eligible for reimbursement payments.

    References

    • Ikonen J, Lähdeoja T, Ardern CL ym. Persistent Tennis Elbow Symptoms Have Little Prognostic Value: A Systematic Review and Meta-analysis. Clin Orthop Relat Res 2022;480(4):647-660. [PubMed]
    • Chen Z, Baker NA. Effectiveness of eccentric strengthening in the treatment of lateral elbow tendinopathy: A systematic review with meta-analysis. J Hand Ther 2021;34(1):18-28. [PubMed]
    • Karanasios S, Tsamasiotis GK, Michopoulos K ym. Clinical effectiveness of shockwave therapy in lateral elbow tendinopathy: systematic review and meta-analysis. Clin Rehabil 2021;35(10):1383-1398. [PubMed]
    • Hüseyin Ünver H, Bakilan F, Berkan Tasçioglu F ym. Comparing the efficacy of continuous and pulsed ultrasound therapies in patients with lateral epicondylitis: A double-blind, randomized, placebo-controlled study. Turk J Phys Med Rehabil 2021;67(1):99-106. [PubMed]
    • Shahabi S, Bagheri Lankarani K, Heydari ST ym. The effects of counterforce brace on pain in subjects with lateral elbow tendinopathy: A systematic review and meta-analysis of randomized controlled trials. Prosthet Orthot Int 2020;44(5):341-354. [PubMed]
    • Heales LJ, McClintock SR, Maynard S ym. Evaluating the immediate effect of forearm and wrist orthoses on pain and function in individuals with lateral elbow tendinopathy: A systematic review. Musculoskelet Sci Pract 2020;47():102147. [PubMed]
    • Krogh TP, Bartels EM, Ellingsen T et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med 2013;41(6):1435-46. [PubMed]