Tennis and Golfers Elbow

Lateral epicondyltis also called tennis elbow and medial epicondylitis called golfers elbow is a condition affecting the forearm muscles on the humeral bone at the elbow called the lateral and medial epicondylitis respectively.

Pathology

Lateral epicondyltis (tennis elbow) and medial epicondylitis (golfers elbow) are conditions affecting the forearm muscles on the humeral bone at the elbow called the lateral and medial epicondylitis respectively. This condition, as well as bicep tendon ruptures, occurs in patients between 30-50 years old. Lateral and medial epicondylitis are often associated with a minor traumatic event and rupture of the distal biceps tendon with a major traumatic event.

However, all three conditions are considered the result of a degenerative process in the muscle tendon structure and not the result of an inflammatory process.

1-2% of the population will experience lateral epicondylitis and biceps tendon ruptures. Medial epicondyltitis occurs 1/10th as often.

Most hand activity occurs in the palm down position which may indicate why tennis elbow is ten times more common than golfers elbow.

A biceps tendon rupture occurs when a heavy eccentric load is placed over the elbow, like lifting a heavy object.

In contrast, tennis and golfers elbow occurs with repetitive use of the hands and forearms; for example, repetitive and forceful forearm rotation and wrist extension and flexion movements.

Tendons Involved in Tennis Elbow

  • In all cases the Extensor carpi radialis brevis
  • In some of cases the Extensor digitorum communis

Tendons Involved in Golfers Elbow

  • Pronator teres
  • Flexor carpi radialis

In 30% of golfers elbow cases cubital tunnel syndrome, or compression of the ulnar nerve at the elbow, occurs as well.

Partial or complete rupture of the biceps tendon at its insertion occurs secondary to an eccentric load on the biceps tendon. This is a result of forceful contraction of the biceps while the elbow is simultaneously extending. The use of oral steroids has been associated with an increase incidence of distal biceps tendon ruptures.

Common Symptoms

  • Associated weakness of grip
  • Radiation of the pain down the dorsal forearm or towards the shoulder

Lateral epicondylitis and medial epicondylitis both present with pain as the initial complaint. The severity of the pain typically correlates with the severity of the condition and will dictate which treatment options are initially taken.

Treatment

Common treatment of tennis elbow, golfers elbow and a partial biceps tendon ruptures consists of activity modification, splinting, anti-inflammatory medication, and therapy.

Therapy

  • Stretching exercises
  • Isometric strengthening
  • Concentric muscle strengthening
  • Eccentric muscle strengthening

These strengthening exercises are done sequentially and there is no advancement until the previous exercises can be accomplished without pain. A conservative approach can take six to nine months to be successful. If pain persists beyond this time, surgery is required.

Types of Surgical Techniques

  • Direct approach
  • Indirect approach.

Each category has several different techniques described. The technique used will depend on the surgeons experience and how quickly the patient wants to return to heavy lifting.

Complete distal biceps tendon rupture, is an urgent condition that is treated surgically. The incisions used for repair are small and cosmetic. Surgery is preferably done within one week of injury but for an optimum result, no later than two weeks.

A tendon graft may be necessary if a repair is attempted after two weeks. The biceps muscle shortens quickly and cannot be put back on the radial tuberosity bone without a graft.

The postoperative rehabilitation must be performed carefully over a six month period before return to full normal function is obtained.