How To Fix Tennis Elbow. Lateral Epicondylitis

Introduction to Tennis Elbow (Lateral Epicondylitis)

[00:00] Do you have tennis elbow and you never even played tennis it can happen. I'm Dr. Paul Zalzal. I'm Dr. Brad Williams. Hey, we have a guest. I'm Dr. John Haverstag. Welcome to Talking with Docs. You're in the right place. You're watching a video about your health. You're not watching a video about used cars, although those are important too. Dr. Haverstag is an upper extremity

Anatomy and Common Causes

[00:20] surgeon, he's here today to talk to us about lateral epikondylitis or tennis elbow. So let's start at the beginning. What is lateral epikondylitis? So it is a collection of tendons right here at the lateral epikondyle. So it's the bony outer side of our elbow and that's where a lot of the muscles

[00:40] and tendons originate to extend our wrist back and our fingers and it's very prone to aging, micro tears and tissue damage. Okay and how did tennis get associated with this? I think back in the day the people that were working on this were finding that it was in more in athletes people

Symptoms and Common Activities That Trigger It

[01:00] People who are more active in lawn tennis back are really not. So it's probably the backhand move with the tennis, right, where you're getting the rest? Absolutely. But more commonly, it's repetitive work type stuff. People that use a lot of screwdrivers. These are hands to make a living. So don't be disparate if you don't play tennis and you have this problem. So how does it show up? I'm assuming with pain. Yeah.

[01:20] Absolutely is the predominant thing and it's usually it might be a little bit more global, but it's on the outside of your elbow It's not on the inside. It's not in the front. It's usually worse with activity and can be very very difficult pain at first Okay, okay, and so those are the symptoms you'll have so you're like, okay something's going on I'm gonna go see my healthcare professional. What are some of the

How It's Diagnosed Clinically

[01:40] signs that the healthcare professional is going to look for to make the diagnosis of lateral epikendrolysis. I think the most important thing is pain at that specific location. You know, so if you can touch around with one finger or a thumb and you're saying my pain is right in this one spot specifically, that's the number one thing.

[02:00] you might also have some weakness to extend your wrist or your fingers or with repetitive motions. Okay and that extension might also reproduce the pain. So you've got tenderness at the site and maybe it's provoked by extending the wrist, extending the fingers, maybe with some weakness and that's the kind of things that your healthcare professional is going to look for on

Imaging: When X-rays, Ultrasound, or MRI Are Needed

[02:20] physical examination. Okay, after physical examination we always go to investigation. So, in orthopedics we usually get an x-ray. Is there any point in getting an x-ray for this? Not really. Okay. If you have other things going on, if you've got a fall, if your elbow is kind of stuck and you can't move it, those are great reasons to have an x-ray. But with this specific diagnosis

[02:40] If everything else has been normal, you do not need further imaging. Okay. Is there any rule for an ultrasound and an MRI because guaranteed someone is going to put it, hey, I'm pushing my doctor to try to get an MRI and an ultrasound because I don't believe that my doctor knows what they're talking about. I would say it's low if you meet these things that we've been discussing here, but sometimes for surgical planning

[03:00] before we go to the operating room we'll get an ultrasound or an MRI but typically if the diagnosis is so focused in that pain you don't need these other people. I always get an x-ray. I always ask for an x-ray even no matter what. Make sure there's not like a tumor. Yeah make sure there's nothing else going on in the body. Personally that's my approach. There you go. Any case. Okay so

Initial Treatment: Bracing and Support

[03:20] So you've got the history, the physical examination, the investigations, plus or minus. Now how do we treat tennis elbow, aka lateral epicondylitis? So when your pain is acute and you're having trouble moving your arm and perhaps doing simple things at home, sometimes wearing a brace

[03:40] on your wrist, which doesn't totally make sense initially, it's a little bit counterintuitive, can relax the muscles that are being stressed up here at your elbow. So if it's just started, if it's a lot of pain, you're having trouble functioning, getting a simple wrist brace or something like a wrist roller-blading guard can

[04:00] help for a few weeks. I wouldn't wear it over the long term. So just something to restrict flexion and extension of your wrist? Yes. Okay, so it does not have to be fancy? So bracing. Okay. You know, some people will find also success with what we call a counterforce brace. So it's a band, you've probably seen them, it's like a wide watch band almost that's wrapped below

Physical Therapy and Eccentric Strengthening

[04:20] the elbow and that seems to alter the force and take some of the pressure off. So many people have seen those. Sometimes athletes seem to wear them. Okay, it's worth a try. Absolutely. As long as you don't make it too tight and cut off the circulation or pinch the nerves. Okay. Alright, so you've got some kind of bracing, the wrist or even up here. Physical therapy, role for physio.

[04:40] physical therapy. Yeah, so range of motion, they have some pain treatments they can do and over the long run things like specific stretches and strengthening. So strengthening that is eccentric has proven to work in this condition and that means taking a load while the muscle is getting longer.

[05:00] So we've got the bracing, the physical therapy. Is there a role for injections of any kind, either cortisone or PRP or anything like that? Yes, so cortisone has been our standard go-to for a long time. It seems to work pretty well and it's probably best at taking a pain away quickly, but the interesting new earth

Injections: Cortisone vs. PRP

[05:20] thing is that it might not make a big difference in the medium or the long term. So after six weeks, it seems like it doesn't make a big difference compared to no injection or perhaps a different type of injection. Okay. Any rule for PRP? Paul mentioned PRP. It's fancy. Yeah. So PRP does have some good evidence in this specific

[05:40] problem and location. So it's better in the medium and the long term and that's what probably most people are interested in. I would say that this is one of the more common things that PRP actually has some evidence to back up its use in this sort of a pathology.

[06:00] opposed to injecting it in your knee for arthritis, for example. I'd say a couple things we glossed over. The first one for me I'd say is if you do this and it hurts, maybe don't do that. So like if it's tennis, I'd say stop playing tennis for a little while. If it's your job, it's obviously a little more tricky, but if you can modify your job. And then the second one for me is what about medications either orally or topically? What about

Medications and Activity Modifications

[06:20] the role of anti-inflammatories for something like this. Yeah, that can certainly help the pain. You know, it was thought that this was an inflammation problem. Now we know that it's not actually an inflammation problem. It's more of a degenerative problem and we call it like tendinitis. Well, tendinosis, itis implies inflammation and that's not technically how

[06:40] happening after the first few days. There's almost a misnomer then. That's right. Okay. So medications, topical oral, acetaminophen, anti-inflammatory, these can help your pain, which is initially part of the problem. And activity modification is a huge one. So forceful gripping, lifting, especially with your palm down is an

[07:00] exacerbating things because when you lift with your palm down, all the forest is originating at this sore spot. So if you turn your palm up, if you're able to in that situation, favoring your palm uplifting can certainly rest the area. Okay, good to know. Harvesting carrots. Be careful. You can harvest carrots.

[07:20] Well, yeah, don't do it like that. But so now you've done all the non-operative stuff. We are surgeons. We like to talk about definitive surgical treatment if it plays a role. Where does it fall for lateral apokondylytus? Is it common? It's not common. No, it is done because there are certain circumstances where this is lasting 6 to 12

Surgery: When and How It's Done

[07:40] months and that's problematic for people. But most often I recommend surgery if this has been going on for a year. Some people say six months. We do know that the vast majority, like 98 percent, are going to get better over six to 12 months. It's a long time, but the symptoms are typically improving over that period. And make no mistake, this can

[08:00] very debilitating. We're not minimizing the symptoms that you have. So if you were going to get an operation, what would it look like? What do you do? Yeah, so the zone of tendon that is deranged, it's kind of microscopically deranged. There might be some tears. You might have an ultrasound that says there's a partial thickness tear or one or five millimeters. But

[08:20] What the surgery does is it involves removing that disease tissue. There's some redundancy in the tendons around so you can repair around it, but mostly we're taking out that disease tissue either through an open approach or arthroscopic and there's some fancy ways to do it with a needle in a special office. Alright, so there's surgical intervention.

[08:40] which we always reserve for after the non-operative stuff has failed. That's the activity modification, anti-inflammatories, physical therapy, bracing, topicals, and time. Once all that's used up, and I'm just like, okay, maybe we need to do surgery, recognizing there's risks with surgery, heart attack, stroke, death, blood clotting.

[09:00] infection, pneumonia is probably one of the biggest problems with surgery in this area is that it comes back again. You do the surgery and you still have pain after or you have a relief for a while and then it comes back again which can happen as well. So common, not so common, this sort of thing? It's a common problem for

[09:20] people in general because we're lifting, we're reaching, we're typing all of the time. But the good news is for the vast majority of people, it's going to get better over weeks and months with these simple treatments. Because it interferes with typing, we're not going to get a lot of comments from the people with it. Leave a comment. Actually, if you had an experience with lateral leprechaun, like maybe your quiches are upside down.

[09:40] or a short comment.

[10:00] Remember, you are in charge of your own health. Dragon's Den. Thanks, Dr. Halberstock. Thank you so much. We'll see you next time.