Elbow Pain

Elbow Pain: Lateral Epicondylitis

Elbow pain can have a major affect on your life and lateral epicondylitis, more appropriately “Lateral elbow tendinopathy” (LET) or “tennis elbow” is the most common cause.

Elbow pain from lateral elbow tendinopathy is a painful and prevalent condition affecting the lateral or outside of the elbow. There is controversy over the exact cause, however, most agree that an element of overuse of the forearm extensors is implicated.

There is a broad range of symptoms ranging from mild temporary pain responding to simple pain relief measures, exercise/stretching and activity modification, to pain that is debilitating pain from the outer elbow that can spread down the forearm. This can lead to loss of function of the affected limb having a major impact on professional and social life.

elbow pain

Athletes participating in sports involving overhead arm motions are subject to elbow pain from injuries, mainly lateral epicondylitis, which has been suggested to occur in over 50% of athletes that use overhead arm motions. Pain is located where the tendon of the common extensor muscles attach to the lateral epicondyle of the humerus.[1]

It often begins with excessive use of the wrist extensor muscles and repetitive microtrauma can lead to inflammation, however, the initial inflammatory response is followed by degenerative changes with disorganization of collagen which then leads to structural failure or tearing of the tendon.

In the general population prevalence of elbow pain from lateral elbow tendinopathy is between 1% to 3%, with increasing occurrence in those with occupational risk factors to as high as 41%. Generally affecting women and men equally and around 40 to 50 years of age onset. While usually self limiting, symptoms will persist over 1 year in up to 20%, and in symptoms recur in 8.5% within 2 years. Up to 5% of patients claim sickness absence, averaging 29 days per year.[2]

Risk Factors

Elbow flexion/extension and wrist bending greater than 2 hours a day is a strong significant risk factor for elbow pain and epicondylitis, along with high physical workload and repetitive motions.[3]. There is a positive association between biomechanic exposure involving the elbow and/or wrist and lateral epicondylitis incidence,[4] indicating ergonomics to be a considering factor.

There is an increased risk of elbow, forearm and hand symptoms with computer work over 2 hours a day.[5] Using an ergonomic alternative mouse design for computer workers with elbow pain, lateral epicondylitis symptoms dropped from 2/3 to zero after 6 months.[6]

Redesigning work task from diversified computer use to intensified computer mouse work significantly increased diagnoses of lateral epicondylitis in air traffic workers.[7] There is a 2 to 4 times greater risk for arm symptoms using a computer mouse for greater than 5.6 hours per week compared to less than 5.6 hours per week.[8] The odds of forearm pain is 8 times higher when working more than 30 hours per week with a mouse device.[9]

There are a number of studies linking computer, keyboard and mouse use to elbow pain. It may be a causative, incidental, aggravating or perpetuating factor, or a combination; however, the ease of use and often economical advantage of ergonomic interventions should not be overlooked, especially when neck and/or back pain exists. In my case, it was a combination of aggravating and perpetuating factors as I will discuss later for some personal and professional insight.

Keeping a mouse or keyboard to maintain a neutral position of the arm and wrist is good ergonomic practice. Having the mouse in line with the shoulder, avoiding too low placement of the elbow in relation to the mouse/keyboard, and the use of arm support can reduce muscle activity in the arm as well as the neck and shoulders.[10].

Use of ergonomic keyboards wrist pads can help reduce wrist extension by keeping the wrist in a neutral position, thus minimizing tension forces in the forearm.[11] In one study, it was concluded “Therefore, angles ranging from 0 degrees to -30 degrees in general provide significant reductions in exposure to deviated wrist postures and muscle activity and comparable performance.”[12]

We have focused on computer use which has become vastly prevalent in working society, however, as elucidated in a 2019 review in the journal Human Factors, force, repetition, posture, vibration are risk factors associated with epicondylitis; primarily forceful, repetitive work requiring non-neutral postures.

Testing

elbow pain tests

1. Resisting wrist extension will stress the extensor muscles and produce pain. 2. Stretching the extensors with the elbow straight will also stress the muscles and tendon producing pain.

Treatment For Lateral Epicondylitis Elbow Pain

Elbow pain due to lateral elbow tendinopathy, or tennis elbow, although frequently diagnosed, is often difficult to treat.It is common to see prolonged symptoms and relapses often occur. Typically, lateral epicondylitis is a working diagnosis based on symptoms and examination. If x-rays are negative for pathology, corticosteriod injections and/or physical therapy are usually offered. If no improvement is notes or symptoms worsen, an MRI is the next step in evaluation.

The condition may arise suddenly as a result of overactivity, or may be a gradual problem that worsens over time. Although the trend is towards using the term “tendinosis” or “tendinopathy” is seen due to lack of inflammation in chronic cases, initial inflammation in acute cases should be addressed. Ice can be used as well as compression bracing.

Stretching/Exercise

For cases of elbow pain that do not improve with anti-inflammatory and/or activity modification, addressing the degenerative nature of the condition is important. Eccentric exercises have demonstrated some encouraging results and many consider it to be a first line method of conservative treatment.

Stretching can be helpful provided there is no major muscle tear. Overzealous stretching or exercise with significant tears of either the extensor radialis brevis or longus can complicate treatment. Knowing the extent of of any common extensor tendon tear is important as over-exercising a significant tendon tear can cause further damage, however, the first line of evaluation is x-ray and not MRI.

Eccentric exercise or lengthening of the muscle under load is an effective therapeutic approach. It is important to do this correctly. If you are doing a bicep curl, the lowering is the eccentric phase of the exercise, sometimes called the negative when done slowly.

A device called the Elbow Flexbar is designed specifically for this and allows a progressive means of doing the exercise. This tool for eccentric exercise can effectively lengthen the muscle-tendon complex and is thought to result in structural remodeling, hypertrophy, and increased tensile strength of the tendon.[13]

Stretching can be applied slowly with the elbow in extension (arm straight), forearm in pronation (palm down), wrist in flexion (wrist bending down) and with ulnar deviation (wrist slightly bent outward) according to tolerance. Hold the stretch for 30 to 45 seconds. This can be done three times before and after the eccentric exercise.

*This is a very specific type of exercise/stretch, it is not the typical hold weight in hand and extend (bend up) wrist to strengthen. It is not always that simple. It may be the forearm flexors that are weak and overloading the extensors is a compensation, producing chronic irritation. Rounded shoulders in typical poor posture can rotate the arms in and place undue stress on the forearm extensors – that is why we emphasize posture correction and ergonomics.

Manual Therapy

Another approach is manually engaging the tissue. While some promote transverse friction massage, I have used Active Release, which combines lengthening of eccentric exercise with direct tissue manipulation for degenerative tendinopathy stimulating the regeneration of soft tissues and the resorption of inappropriate scar tissue/fibrosis. Either specific location(s) as dictated by examination or along the entire kinetic chain to address fibrosis and dysfunctional soft tissue within the region. Soft Tissue Flossing is a method to simulate this therapy.

Actively engaging the soft tissues has been an emerging rehabilitation treatment, sharing clinical reasoning with regenerative injection techniques which attempt to affect the pathological changes of the tendon, while being non-invasive rehabilitation approach to the tendon and surrounding tissues. Engaging tissues in this manner is theorized to potentially remodel and regenerate soft tissues by activation of endogenous release of growth factors and cellular mediators.[14]

Injections

Corticosteroid injections can offer short term pain relief, however, long term consequence can be further tendon degeneration. An ultrasound investigation assessed the common extensor origin tendon 6 months after injection finding a decrease in tendon thickness with an increase in erosions in the cortical bone of the lateral epicondyle, indicative of further degeneration.[15]

elbow injectionsMore recently platelet rich plasma (PRP) injections have been used taking the patient’s own blood and extracting growth factors and injecting into the painful site. PRP injections, for elbow pain due to treatment resistant lateral epicondylitis of over 6 months, has been found to be a safe, effective method to reduce symptoms and can reduce the need for surgery.[16,17]

Botulinum toxin has been used and works through blocking acetylcholine receptors which causes temporary paralysis of the muscle, which halts further microtrauma, giving the tendon time to heal. Although elbow pain relief can be obtained, there are complications with weakness of the wrist extensors and decreased grip strength.

Currently, stem cell injections are being used as a method of improving tendon healing. Traditionally taken from the patient, umbilical stem cells are now being used. While we await more studies, stem cell therapy is promising and may be an effective treatment for patients, especially for those who have failed conservative treatment. Stem cells contain some growth factors that PRP lacks.

Another method is combining PRP and Stem Cells. In one study, this method noted improvement at 2, 6, and 12 weeks after treatment.[18] Stem cells and combinations are increasing being used by professional athletes, however, it is not covered by insurance as of this writing. Costs vary, with stem cells being the more expensive option.

Bracing

Braces can be an effective means to reduce symptoms as an adjunct to treatments. Counterforce braces with forearm strap to limit force and expansion of the the extensors, and wrist extension splint to help to relax the extensor tendons. A forearm strap alone can improved elbow pain and daily activities at 6 weeks compared to physical therapy.[19] I also use an elbow compression sleeve for relief.

In another study, the subjects were divided into 3 groups: strengthening exercises, arm strap, and both. Significant symptom improvement was noted in all groups over time, however, at 1 year, the authors found no superiority in treatment among groups.[20]

A recent study[21] confirms previous effectiveness of bands and sleeves, with the addition of sensory function as well as motor function. Improvements were noted in both categories with better joint position sense as well as pain reduction and better grip strength. This shows a synergistic or coupling effect on the sensorimotor system with bracing.

Both forearm band and sleeve type bracing proved better than no brace. Differences between the two braces were not statistically significant, but some differences were noted related to degree of motion. The the elbow sleeve showed better joint position reproduction scores at 110°, while the forearm band showed better scores at 70°.

Another recent study[22] found counterforce bracing for lateral epicondylitis and concluded, “The counterforce brace provides significant reduction in the frequency and severity of pain in the short term (2 – 12 weeks), as well as overall elbow function at 26 weeks, compared with the placebo brace.”

Personal Experience

I have had a prior experience with elbow pain from lateral epicondylitis during rehabilitation from my first shoulder surgery. In the middle of rehab, I developed elbow pain that threatened completion of rehab for repair of the rotator cuff of the left shoulder.

When conservative measures failed, I received a corticosteroid injection and it worked very well, allowing me to complete rehab. I have never experienced lateral epicondylitis in my left arm again. Evidently, inflammation was the culprit and quick anti-inflammatory measures resolved it permanently.

Some years later, I was using a leaf blower on the roof of my house. A difficult task that took about an hour. Failing to alternate sides to equalize the force and vibration, I used my dominant right arm. Soon after, I developed elbow pain that would prove difficult to resolve.

I visited my Orthopedist for an exam and x-rays. Lateral epicondylitis was the diagnosis. Based on my previous experience, I opted for the steroid injection. Elbow injections are painful compared to shoulder injections, however, relief was not offered. I used stretching and eccentric exercise with the flexbar with no improvement.

One day I was using a staple gun and had my wrist in an awkward position. As I squeezed the staple gun, I felt an intense pain in the forearm and found myself back in the office. An MRI was ordered and it revealed a 3/4 tear of the common extensor tendon and a tear of the extensori carpi radialis longus.

With that confirmed diagnosis, surgery was recommended. I left the office with a Medrol Dosepak and was given the details of surgery, basically no use of my dominant hand for 3 months. I reasonably managed it with ice – a special sports wrap that works well with the elbow, a compression wrap – my elbow’s best friend, and mouse/keyboard pads.

After some time, I decided to take the Dosepak and it helped minimally, however, after some physical exertion, I had to do something. Surgery is the last option, so I opted for PRP. I am one week post injection and improvement is slow. With PRP, it takes about 3 weeks for maximum effect.

Is it reasonable to think it will heal a badly torn tendon? Probably not, however; looking at 3 months of not using my dominant hand, I will try PRP, then Stem Cell, possibly combination in order to avoid surgery if possible. And so it goes.

As fate would have it, 10 days post-PRP, I sustained another injury which has proven complicated as I now have signs of elbow instability prompting an investigation into something which would vastly increase the complexity of resolution – ligament damage. Due to my Orthopedist changing to a different practice, the new management is posing obstructions to further treatment related to insurance, therefore, diagnosis is postponed pending location of a new Orthopedist.

New Orthopedist was very good; evaluation, order MRI, and injection into the elbow joint. The cortisone injection helped, must have been a lot of inflammation.

New MRI: Full thickness near complete tear of the origin of the common extensor tendon with a few intact posterior fibers, propagating to articular surface with a full thickness tear of the ulnar attachment of the radial collateral ligament. Biceps tendinopathy. Bone marrow edema at the olecranon and elbow joint effusion.

The bone marrow edema indicates the level of inflammation and, along with the joint effusion, the reason the injection provided relief. The relief continues a little over a week post-injection, although attenuating as some of the pain and elbow locking has ensued. The RCL (radial collateral ligament) tear explains some of the elbow locking into extension. Unfortunately, the common extensor tendon is hanging on by a thread and the addition of another ligament tear certainly complicates the issue.

The radial collateral ligament attaches below the lateral epicondyle of the humerus, and below to and partially over the annular ligament and inserts into the side of the ulna. It is closely blended with the tendon origin of the supinator (palm up motion).

The follow up appointment with the Orthopedist post-MRI is delayed due to insurance issues (Wow is all I will say about that), however, I am sure surgery is the only remedy at this point. Concerns are the complication with the new tear, chance of ligament rupture, procedure, length of recovery, and likelihood of regaining normal strength. And so it goes.

References:

1. Sports Medicine 1998 Sep;26(3):193-205
2. Sports Medicine Open 2019 Mar 20;5(1)
3. American Journal of Industrial Medicine 2013 Apr;56(4)
4. Arthritis Care & Research 2016 Nov;68(11):1681-1687
5. International Journal of Industrial Ergonomics 2002;30:277–294
6. International Journal of Human–Computer Interaction 2001;13:13–40
7. Ergonomics 2006 Sep 15;49(11):1052-67
8. International Journal of Occupational and Environmental Health 1996 Jul; 2(3):185-194
9. Occupational and Environmental Medicine. 2003 Nov;60(11):e14
10. Scandinavian Journal of Work, Environment & Health 1998 Feb;24(1):62-73
11. Journal of Orthopaedic Sports & Physical Therapy 2004 Oct;34(10):638-49.
12. Ergonomics 2005 Dec 15;48(15):1793-808.
13. North American Journal of Sports Physical Therapy 2010 Sep 5(3)
14. PeerJ. 2015 May 19;3:e967
15. Journal of Orthopaedic Surgery 2015 Apr;23(1):1-5
16. Journal of Orthopaedics 2018 Jan 31;15(1):239-241
17. Journal of Clinical and Diagnostic Research 2015 Jul; 9(7)
18. The Journal of Natural Science, Biology and Medicine 2014 Jul;5(2):389-91
19. Hand (N Y). 2014 Dec;9(4):419-46
20. Chir Organi Mov. 2008 Jan;91(1):35-40
21. Journal of Shoulder & Elbow Surgery 2019 Jan;28(1):e10-e17
22. Journal of Shoulder & Elbow Surgery 2019 Feb;28(2):288-295

Author Bio

Stephen Ornstein, D.C. has treated thousands of neck, shoulder and back conditions since graduating Sherman Chiropractic College in 1987 and during his involvement in Martial Arts. He holds certifications as a Peer Review Consultant from New York Chiropractic College, Physiological Therapeutics from National Chiropractic College, Modic Antibiotic Spinal Therapy from Dr. Hanne Albert, PT., MPH., Ph.D., Myofascial Release Techniques from Logan Chiropractic College, and learned Active Release Technique from the founder, P. Michael Leahy, DC, ART, CCSP.