“But I don’t play tennis”- a comment heard in sports medicine offices around the world when talking about the most common cause of elbow pain – Tennis Elbow. Lateral epicondylitis is the term that describes pain at the lateral aspect of the elbow or the part that faces forward when standing like a soldier. Medial epicondylitis is on the inner side of the elbow the part that rests against the body when standing straight.
It can be the bane of the patient’s existence especially if they have dealt with it for months and months. Unable to lift a coffee cup, pull a gallon of milk or water out of the fridge, open a jar of almond butter? You can see how quickly annoying this diagnosis can become. The problem is it is not usually a sudden rip tear or pop that leads to it. It is usually insidious, peeking its head out every now and then, not really affecting daily life or workouts. You might then see it recur every time you go to grip heavily. In the CrossFit world, we are talking about anything that requires a grip—lots of things. Pull-ups, deadlifts, heavy farmer carries, kettle bell swings, dumbbell squat snatches, rowing, etc. Gradually, the pain might then infiltrate daily activities and then you say “Whoa something is not right. But I didn’t do anything.” So, insidious and slow can be just as bad as a sudden rip or tear. If you look at my original post in 321GoMD about tendonitis, you can see the tendon fibers that start to get little microtears in them that then need a chance to heal except they never got the chance. What this reiterates is please please please listen to your body. Do not ignore the subtle changes that can occur with exercise. Tendonitis always wins. If you don’t listen, things can get so bad that it leads to- not tendonitis but tendonosis. This is where the tendon degenerates and loses the inflammatory or healing changes. It then goes on to be replaced by scar tissue which as we all know is not healthy normal tissue. Dr. Nirschl promoted the concept based on the histology seen in the tendon at the time of surgery and coined the term angiofibroblastic hyperplasia as seen here with normal tendon followed by pathologic tendon.
Anatomically the extensor tendons are the tendons that start at the lateral epicondyle, muscle bellies run down the forearm and they end in tendon attachments to the wrist bones and finger bones. These tendons straighten or extend the wrist and fingers. The flexor tendons start at the medial epicondyle run down the forearm and attach to the wrist and fingers to flex them or curl them down.
Treatment is aimed at alleviating symptoms and decreasing stress across the elbow joint. There are a multitude of treatment options starting from conservative to aggressive. I make recommendations for patients based on what they have tried, how severe the symptoms are, and how much interference the condition has with normal, work, and fitness activities. When it does not get better we can start with PT, tennis elbow strap, stretches, strengthening, massage, chiropractic treatments, ART, iontophoresis, cortisone injections, PRP injections, surgery. If one of these options worked best and was the end all be all, there would not be a list of options. Some of these work quicker than others, but I will never recommend surgery on someone who has only had it for 2-3 months. Cortisone has its side effects and PRP has been shown in some studies to have promising results and others not as good. PRP is platelet rich plasma injection where one draws a small vial of blood and spins it down to get concentrated growth factors in the plasma that are then injected into the area to try to stimulate healing. Surgery is undertaken when things are not going well and the pain and dysfunction is inhibiting normal life. In picture below of a right elbow with fingers to the right of the picture, the ECRB is the tendon which is responsible for the pain that occurs.
Here is a test hold your wrist out straight and then try to push down on the back of your wrist with your other hand. The ECRB is firing when that occurs. After release of the tissue it can take about 3 months to get back into the swing of things with heavy lifting sometimes even longer. Initially you can move your elbow but have to protect it for 6 weeks then gradual strengthening takes place. The condition on the medial side is similar it just hurts with wrist flexion, but the treatments and the surgery are similar. So remember, listen to your elbows and don’t let your tennis elbow knock you out of the game, set or match.