Tennis and Golfer’s Elbow (Epicondylitis)
What is the difference between tennis and golfer’s elbow?
Both tennis and golfer’s elbows are conditions which lead to pain around the elbow. Tennis elbow refers to pain felt over the outside bump (lateral epicondyle) of the elbow while golfer’s elbow refers to pain localized around the inner bump (medial epicondyle) of the elbow. Both conditions have pain which often radiates further down the forearm and is associated with use of the elbow or wrist. The names are given historically to the conditions but medically they are known as lateral and medial epicondylitis and most patients who get one or either of the conditions don’t play either sport.
What causes tennis and golfer’s elbow?
The specific cause is unknown and, whilst it is called epicondylitis suggesting inflammation around these areas, there is very little inflammatory tissue identified if the tissue is biopsied. It most likely relates to degeneration which occurs in the tendons attaching to these bones, in particular extensor carpi-radialis brevis when referring to the lateral epicondylitis.
What are the symptoms?
In either condition, the symptoms relate to pain which is worse with movement of the elbow, which doesn’t settle despite rest and is often made worse by stretching of the tissues. Active use of the muscles attaching to that area causes pain (ie. Extension of the wrist in the case of tennis elbow and flexion of the wrist in golfers elbow). The conditions are often associated with a generalised ache that is worse when gripping or when the elbow is knocked.
What is the treatment for tennis and golfers elbow?
First line treatment is to stop the irritation to the area by avoiding excessive use of the forearm muscles that have tendons attached to the epicondyle. This often involves avoiding tight gripping or heavy lifting. For example, the use of a screwdriver, gripping a steering wheel or a lawnmower handle tightly or carrying bags with small handles should be avoided. Protecting the arm when doing these activities by using the forearm or other musculature around the body is recommended, and avoiding tight gripping by having a thicker handle or grip on instruments being held helps to prevent over-tightening of the tendons.
Smoking also has a negative factor on tendons, as it leads to deterioration of tendons and also inflames nerves, making the pain worse. If these measures fail to settle the symptoms over a period of time, physiotherapy or hand therapy is recommended. They will work on stretches of the musculature to effectively lengthen the muscle belly, taking the stress off the origin of the muscles. Usually, these measures are all that is required. A hand therapist or physiotherapist might supplement these by recommending a forearm strap or brace.
If these measures fail, a trial of a steroid injection is an option but can lead to calcification around the tendon insertion. It can also lead to degeneration of the tendon itself. Other things recommended are a trial of platelet rich plasma injections (PRP).
What is the role of surgery?
Unlike a lot of orthopaedic surgery which can be highly successful, epicondylar surgery for tennis and golfer’s elbow has mixed results. In those patients who have tried all of the non-operative measures including rest, significant courses of physiotherapy, have stopped smoking, reduced stress on the region and have failed to improve with steroid injections, then surgery is an option. However, at Glenelg Orthopaedics we believe that this should always be the last option. In most cases, patients improve without any consideration of surgery and as such other measures should always be pursued before going down this path.
Are there any tests that should be done to confirm epicondylitis?
There are investigations to exclude other causes of pain such as arthritis, when x-rays are warranted. In the case of golfer’s elbow, assessment of the ulnar nerve (cubital tunnel) to ensure that the nerve has not been trapped at the elbow, which can be a cause of pain at that site, is worthwhile. To confirm epicondylitis and at the time of steroid injection, an ultrasound can be undertaken. It is rare for such an ultrasound not to show mucinous degeneration and often demonstrates a tear of the tendon, which is a common finding. The report of a tear in the tendon can be worrying for the patient. However, the patient can be reassured that the tear is not sinister and in fact, surgical treatment for tennis elbow or golfer’s elbow involves releasing of the tendons involved; in other words, causing a tear in the tendon itself. Therefore a tear does not require urgent surgery to repair it, but in fact is part of the condition.
At Glenelg Orthopaedics you can be reassured that we will provide a holistic approach to the treatment of all conditions including tennis and golfers elbow, offering all options and recommending the best approach for you.