Clinical Notes on musculoskeletal problems around the elbow

Tennis Elbow

Tennis elbow is a problem with the extensor mechanism of the wrist

Please keep in mind as you read this that tennis is not the only reason for pain around the elbow. Many other sports apart from tennis can be involved in similar problems and the condition is also seen among those who have never played tennis in their lives. Tennis technique and tennis equipment can certainly be implicated but be prepared to cast your "net" wider - if you can excuse the tennis related pun!

Read more about the treatment of tennis elbow and tennis elbow tendonitis

• Tennis elbow is by far the commonest of the two conditions 
• Pain at the lateral epicondyle of the elbow
• History of overuse - but not necessarily related to tennis or tennis like sports
• If tennis elbow is due to sport check for recent change of technique or recent change of equipment - different size tennis racket grip is a common trigger.
• Tennis elbow pain is made worse by gripping or lifting objects
• May get pins and needles or referred pain to the web space of the thumb and index finger - due to entrapment of the posterior interosseous branch of the radial nerve at the elbow
• Expect to find normal range of elbow passive movement
• Main tennis elbow sign is pain ++ on resisted extension of the wrist - especially if the joint is held in the extended position while this is tested - the pain is felt at the lateral epicondyle (or outer side) of the elbow during this test
• In more than 90% of tennis elbow cases the inflammation is at the anterior bony facet of the lateral epicondyle where the common extensor tendon has its teno-osseous junction 
• Take care with referred pain - the place the patient points to as the source of the pain is not always accurate. The actual inflammatory focus is nearly always at the junction of tendon and bone. Injection into the bit where the patient says it hurts is a common reason for failure of tennis elbow treatment - see below.

Treatment of tennis elbow

Three options - bear in mind that the natural history is for spontaneous resolution in the majority of cases

1. Conservative treatment - Avoid provoking activity or change tennis equipment (grip size of the tennis racket). Short term NSAID and reassure strongly. Consider using epicondylar clasp for symptom relief - particularly if continuing to play tennis during this treatment phase
2. Physiotherapy treatment - reasonable success rate although may require several treatments before substantial improvement is seen. Treatment needs to be backed up by education on stretching and prevention of recurrence. Not back to playing tennis until symptoms almost gone
3. Injection treatment of steroid and local anaesthetic - the most cost effective option. No difference from physiotherapy in long term outcome but works more quickly and is much more cost effective.

Injection technique for tennis elbow treatment

(see also the section on Injection Tips below)

• Use an orange (25G, 0.5x16) needle for this injection treatment
• I use triamcinolone - 10mg made up to a total volume of 1ml with local anaesthetic (lidocaine or prilocaine) - but hydrocortisone acetate is also suitable and may be a better choice if you are not experienced with injections
• Inject the treatment solution around the bone of the lateral epicondyle at its anterior aspect by "peppering" droplets around the periosteal tissue. I do not try to infiltrate the periosteum itself as this is extremely painful and carries no additional benefit in outcome. 
• Advise the patient to have "relative rest" for about a week - that is to do their normal day to day activities but to avoid anything likely to provoke the problem - even if they feel better. No tennis until pain free.
• Give advice on how to prevent recurrence - warm up before tennis matches or other sports

Golfers Elbow 

Similar comments apply to the ones above in relation to tennis players and tennis equipment. It's not only golfers who develop problems at the inner side of the elbow joint. I'm not entirely sure how the condition came to have the "golfers" label applied but I guess the "golfers" phrase stuck over the years and the term "golfers elbow" has now sunk into regular common use. Maybe golfers became envious of tennis players and wanted an epithet of their own ..

Golfers Elbow is a problem with the flexor mechanism of the wrist

• Golfers elbow is much less common than tennis elbow
• Pain at the medial epicondyle or inner side of the joint
• History of overuse in golfers elbow pain
• Expect to find normal range of movement on passive testing of the joint
• Main "golfers" sign is pain on resisted flexion of the wrist - more so if tested with the elbow held in the extended position during testing
• The site of inflammation is almost invariably at the teno-osseous junction where the common flexor tendon meets the medial epicondyle at its anterior aspect.
• The pain may be felt by the patient more distally in the muscle belly of the flexors in the forearm - this pattern of referred pain can sometimes cause confusion.

Treatment of golfers elbow

Three options - bear in mind that the natural history is for spontaneous resolution in the majority of cases

1. Conservative. Avoid provoking activity or change sports equipment (grip size of tennis racket or golf clubs). Short term NSAID and reassure strongly. Consider using epicondylar clasp for symptom relief.
2. Physiotherapy - reasonable success rate although may require several treatments before substantial improvement is seen. Treatment needs to be backed up by education on stretching and prevention of recurrence.
3. Injection of steroid and local anaesthetic - the most cost effective option. No difference from physiotherapy in long term outcome but works more quickly and is much more cost effective.

Injection technique for golfers elbow

(see also the section on Injection Tips below)

• Use an orange (25G, 0.5x16) needle
• I use triamcinolone - 10mg made up to a total volume of 1ml with local anaesthetic (lidocaine or prilocaine) - but hydrocortisone acetate is also suitable and may be a better choice if you are not experienced with injections
• Inject the solution around the bone of the medial epicondyle at its anterior aspect by "peppering" droplets around the periosteal tissue. I do not try to infiltrate the periosteum itself as this is extremely painful and carries no additional benefit in outcome. 
• Advise the patient to have "relative rest" for about a week - that is to do their normal day to day activities but to avoid anything likely to provoke the problem - even if they feel better.
• Give advice on how to prevent recurrence

Pulled Elbow

• Pulled elbow is only really seen in very young children - typical age 3 to 6 years
• Radial head in older children and adults is held in place by the annular ligament and by the shape of the radial head itself
• Shape of radial head in young children is conical and thus the ligament cannot adequately protect it against traction in the line of the limb
• Pulled elbow is normally caused by  traction injury - classically being swung between the hands of parents when walking
• Sudden onset elbow pain with loss of movement and guarding against movements
• Children with pulled elbow are unable to fully extend the elbow
• Treatment is by simple reduction technique
• Grasp the forearm with one hand while using the other to support behind the elbow
• Apply pressure as if pushing the forearm back in towards the hand you have behind the elbow
• Gently pronate and supinate the forearm while taking the elbow towards the extended position and maintaining the compression pressure described above
• Reduction of pulled elbow is usually felt with a click and full movement immediately restored

Arthritis of the Elbow

• Elbow arthritis can be due to rheumatoid arthritis or osteoarthritis or other seronegative disease
• If OA then often secondary to trauma - particularly fracture of the radial head
• Elbow arthritis or arthritis of the elbow presents with pain and stiffness
• RA signs - local heat, swelling (best seen in the dimple over the radial head at the posterior aspect of the elbow) and synovial thickening. May see rheumatoid nodules.
• All arthritis types cause loss of range of motion - with flexion more affected than extension

This summary of tennis and golfers elbow, is intended as a brief overview for patients and for their physicians.

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Author: Gordon Cameron
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