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Cascade Orthopaedics Practice Newsletter
November 2013
Thanks for being a patient of Cascade Orthopaedics! While many patients visit us for a specific problem, they or their loved ones often have other unrelated orthopaedic concerns. We are producing a monthly newsletter with the intent to provide a source of information and to serve as an educational resource for our patients on some common problems, and give advice on maintaining musculoskeletal health. Our goal is to help you prevent problems, and recognize what conditions might be causing pain and disability. We may also suggest resources that might be available to help you prevent or manage problems.  Cascade's Website
 

TENNIS ELBOW  (LATERAL EPICONDYLITIS)  

 

If you have persistent pain over the outer side of your elbow, you could be suffering from tennis elbow.  Tennis elbow, or "lateral epicondylitis," is tendinosis (tendon injury) of the forearm's extensor muscle tendons at/near the elbow.  The anatomy overview section below will help you understand more about the involved body parts.  The name "tennis elbow" may suggest it is caused by playing tennis.  In reality, though, most cases of tennis elbow are not related to tennis.

 

ANATOMY OVERVIEW    

 

There are 3 bones coming together at the elbow:  the upper arm bone (humerus);  2 forearm bones (ulna, radius).  A lot of the elbow movement works like a hinge in which the forearm bones flex and extend, pivoting about the end of the humerus.  There are two bone prominences at the elbow end of the humerus:  lateral epidondyle on the outer side; medial epicondyle on the inner side.

 

 

  There are many muscles that work to extend fingers and wrist.  Several of these muscles develop from tendons that originate at the lateral epicondyle of the elbow.  Tennis elbow involves injury to the extensor muscle tendon.  The supinator muscle (muscle that supinates, or rotates the forearm in clockwise direction) also originates at the lateral epicondyle.  In tennis elbow, it makes sense that activities that promote more wrist extension and forearm supination aggravate the elbow pain.

 

There is another condition called golf elbow (or medial epicondylitis).  It's basically tennis elbow's second cousin.  But it involves the flexor muscle tendons near the medial epicondylitis and causes the inner elbow pain.  The basic treatment principles are similar for both tennis and golf elbows.

 

 

WHAT ARE THE TYPICAL SYMPTOMS?   

The most common symptom is pain over the outside part of the elbow, aggravated with certain activities that involve the forearm, wrist or hand.  Specifically, it is the wrist extension or forearm supination (see Anatomy Overview section for explanation) activities that will tend to worsen the pain.  Such activities may include using hand tools, playing tennis or, in severe cases, simply holding a coffee mug.  Shaking hands may also cause discomfort.  The worst area of pain and tenderness may not be right over the lateral epicondyle (where the bone sticks out on the outer side of the elbow), but sometimes a small distance beyond it.

 

  

WHAT CAUSES TENNIS ELBOW?   

Tennis elbow pain usually develops over time due to repetitive overuses of the forearm's extensor muscles, instead of due to a specific trauma.  As mentioned before, most cases of tennis elbow are not associated with tennis.  Anyone who is exposed to overuse of wrist extensor muscles is at risk of developing it.  Tennis elbow may be seen as an occupational injury among mechanics, carpenters, computer specialists, painters and musicians.  Tennis elbow can certainly be a sports injury, as well, and tennis is right up there amongst various sports that can predispose you to tennis elbow.

 

 

TREATMENT   

As with most musculoskeletal conditions, the initial treatments are conservative, starting with simple activity modifications.  Increasingly more invasive treatments can be considered for cases that do not respond to conservative measures.  Vast majority of tennis elbow cases get better with nonsurgical treatments.  Cascade Orthopaedics offers a complete array of tennis elbow treatments, from braces and physiotherapy to surgery and the cutting-edge PRP treatment (see below).

 

Non-invasive treatments: 

Activity modification is central to the treatment of tennis elbow... try to cut back on activities or motion that bother your elbow.  Ergonomic adjustments may also be considered to, for example, improve your computer station setup that may have been previously suboptimal.  Elbow brace ("counter-force" elbow strap) may help.  Pain medications such as anti-inflammatories (NSAID's - examples include ibuprofen and naproxen) may provide relief.  NSAID's are generally taken orally, although there are also topical formulations available by prescription that you can apply directly to the elbow.  For tennis elbows that are actually associated with repetitive tennis injuries, one may look into correcting the offending problems.  Those include excessively large racket grip, excessively heavy racket, excessively tight racket string tension, or improper backhand stroke.  Physical therapy (PT) can also be helpful.  PT can consist of developing an exercise program to stretch and strengthen forearm muscles, as well as physical modality treatments such as ultrasound.  Acute pain flare-up may be dealt with repeated application of ice (10-20 minutes at a time), NSAID's, and refraining from pain-inducing activities.

 

Cortisone injections:

A cortisone injection can be beneficial to some patients for a couple of reasons, even though there is not much medical literature to demonstrate its long-term efficacy.  With pain that is severe and debilitating, cortisone injections can often bring about rapid, drastic relief.  The response to the injection can also serve a diagnostic purpose.  In our experience, we also see some instances where the pain level is reduced with a cortisone injection and then never rises back to the previous pain level, especially when the injection is coupled with other measures such as activity modifications and exercise program.

 

Platelet-rich plasma therapy (PRP):

PRP is a new injection therapy that has been shown in clinical studies to provide good long-term benefits for tennis elbows.  It is a procedure worth considering for any patient with chronic tennis elbow pain that has not improved after many months of other nonsurgical measures.  The procedure is fairly simple and done in the clinic.  It involves drawing your own blood, then using a machine to extract PRP, which is a high concentrate of platelets.  Your PRP is then injected into your injured extensor muscle tendon.  Unlike cortisone injections which reduce inflammation, PRP promotes inflammation.  But how does that help with the tendinosis and pain?  Inflammation may give off a negative connotation, but it is actually the body's way of repairing soft tissue injuries.  During inflammation, various growth factors come to the injured tissue site to locally promote blood flow and collagen production, ultimately leading to regeneration of the injured tissue.  With chronic tennis elbow, you are left with tendinosis because your body's healing mechanism was not sufficient.  When PRP is injected into the injured tendon, it helps kick-start this regenerative, healing process.  Most patients report considerable improvement by 12 weeks following PRP injection, with much of the improvement taking place between weeks 6~12.

 

Surgery:

Surgery is considered in rare cases where the pain has not responded to any of the above measures.  The surgery is an outpatient procedure in which the diseased tendon tissue is debrided.

 

If you have questions or wish to schedule an evaluation, please call us at (253) 833-7750. 


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