Nursing of Acute and Intensive care Clients

Spring 2018

LATERAL EPICONDYLITIS
(tennis elbow)

DEFINITION
✓ “Tennis elbow” is a misnomer for a
condition that occurs frequently on
the lateral condyle of the elbow.
The muscle tendon outside the
elbow is inflamed and this is caused
by repeated strain of a muscle
called the extensor carpi radialis brevis
(ECRB).

✓ The prevalence is 1-3% of the

population and it equally affects
both men and women.1

CAUSES
• Overuse - can cause gradual wear and tear of the muscle over time.
Repetitive, forceful work or leisure activity often causes the tendon to swell. 2
• Activities - Some professions that require repetitive use of the elbow and
weight lifting causes injury through time. This includes Painters, plumbers, and
carpenters who are particularly prone to developing tennis elbow. Studies
have shown that auto workers, cooks, and even butchers are also
affected.3
• Age - The peak incidence is between 40 and 50 years of age.1
• Unknown - Lateral epicondylitis can occur without any recognized
repetitive injury. This occurrence is called "insidious" or of an unknown
cause.

PATHOPHYSIOLOGY

Sudden flexion of the wrist while the extensors are contracted (awkward back-
hand) or from repeated gripping (cumulative trauma disorders)

Tearing in or near the insertion of the common extensor tendon on the lateral
condyle of the humerus. This may include the extensor digitorum, extensor carpi
radialis longus (ECRL), and extensor carpi ulnaris. 4

Inflammation

Maladaptation in tendon structure

Pain over the lateral epicondyle. Pain is located anterior and distal from the
lateral epicondyle.5

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 Nursing of Acute and Intensive care Clients
Spring 2018

CLINICAL MANIFESTATION
1. Pain - Usually felt upon resisted movement. pain begins as mild and slowly
worsens over weeks and months.
2. Weakness on the wrist, generalized.
3. Tenderness - Which is an indication of inflammation.
*There is usually no specific injury associated with the start of symptoms. The symptoms are often worsened
with forearm activity, such as holding a racquet, turning a wrench, or shaking hands. The dominant arm is
most often affected; however both arms can be affected. 6

DIAGNOSTIC TESTS
1. Physical Examination 7
Mills' test
− Straighten the patient's arm and palpate the lateral epicondyle.
− Fully bend (flex) the wrist.
− Pronate the patient's forearm.
− If this is painful the test is positive.
Cozen's test
−Elbow in 90° of flexion, patient
makes a fist and deviates wrist
radially with forearm pronated.
− Resisted extension of the wrist.
− Pain in the area of lateral
epicondyle is a positive result.
2. Laboratory test - Increased C-reactive protein
3. Imaging studies6
• X-rays - Provide clear images of dense structures like bone. May be
taken to rule out arthritis of the elbow.
• Magnetic resonance imaging (MRI) scan - MRIs scans show details of
soft tissues , and will help determine for a possible herniated disk or
arthritis in your neck. Both of these conditions often produce arm
pain.
• Electromyography (EMG) - Ordered to rule out nerve compression .
Many nerves travel around the elbow, and the symptoms of nerve
compression are similar to those of tennis elbow.

NURSING MANAGEMENT
1. Activity modification and restrictions. Encourage rest.
2. Apply PRICE for acute pain and heat if chronic.
3. Administer prescribed medications.

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 Nursing of Acute and Intensive care Clients
Spring 2018

• Non-steroidal anti-inflammatory medicines (NSAIDs) - Such as

ibuprofen (Advil, Motrin), naproxen (Aleve), and
aspirin reduce pain and swelling.8,9
• Steroid injections - Can be given for short term relief. Steroids, such
as cortisone, are very effective anti-inflammatory medicines.
Steroid injections can be repeated after six weeks to two months.
• Hyaluronan gel injection - It is a gel like medication which is administered
to arthritic joints. Has been effective in clinical trials.10
• Botulinum toxin - Usually for severe cases for its paralytic effect.
• Autologous blood products – Platelet-rich plasma (PRP) is derived from
the patient’s blood. Once processed it contains growth factors that
helps in healing injuries. Current research on PRP and lateral
epicondylitis is very promising. 6 On the other hand, evidence of PRP
efficacy was determined by the National Institute for Health and Care
Excellence (NICE) to be inadequate.11
4. Place a forearm support band or brace to the affected part – Bands have a
reasonable reputation for prophylaxis and treatment of mild cases of tennis
elbow. It is found to be effective in one study due to mechanical inhibition
during the use of hands.12
5. Refer to other physical treatments.
• Physical therapy - Specific exercises are helpful for strengthening the
muscles of the forearm. The therapist may also perform ultrasound,
ice massage, or muscle-stimulating techniques to improve muscle
healing.
• Acupuncture - Results are conflicting and limited.1
• Extracorporeal shock wave treatment - Shock wave therapy sends
sound waves to the elbow. These sound waves create "microtrauma"
that promote the body's natural healing processes.6 Although
effective for other tendinopathies, this has not been shown to be
effective for treating tennis elbow.13
6. Assist and prepare for surgical interventions
• If symptoms don’t respond to treatment for 6 to 12 months. Then the
doctor may recommend surgery. Surgery is not the primary
treatment.14
• Most surgical procedures for tennis elbow involve removing diseased
muscle and reattaching healthy muscle back to bone . Release of the
extensor/flexor origin is occasionally indicated for patients who do not
respond to a sustained period of conservative treatment .
• There is no sufficient evidence for the effectivity of surgery as a
treatment.15,16
Types of surgery 6
a. Open surgery - The most
common approach to
tennis elbow repair is
open surgery. This involves
making an incision over
the elbow. Open surgery
is usually performed as an
outpatient surgery. It
rarely requires an
overnight stay at the
hospital.

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 Nursing of Acute and Intensive care Clients
Spring 2018

b. Arthroscopic surgery - Tennis elbow can also be repaired using miniature

instruments and small incisions. Like open surgery, this is a same-day
or outpatient procedure.
Common complications
• Infection (less than 1%)
• Nerve injury (less than 1%)
• Neuroma – swelling of
nerve tissue (less than 1%)
• Bleeding (less than 1%)
• Stiffness of the elbow (1–
2% of cases). This is usually
self-limiting, improving
over a three-six month
period.
• Partial/incomplete
symptom relief
• Weakness of your wrist (1-2% of cases). This improves with
physiotherapy.
• Complex regional pain syndrome (1 in 3,000)
• Need for further interventions and/or procedures

NEW CLINICAL FINDINGS IN THE TREATMENT OF TENNIS ELBOW

1. ESWT has the potential of replacing surgery in many orthopedic disorders
without the surgical risks. The complication rates are low and negligible.17
Additionally, several studies investigated the effect of shockwave therapy in
patients with lateral epicondylitis of the elbow, and the success rate ranged
from 68% to 91%. 18,19
2. There is strong evidence suggesting that acupuncture is effective in short-term
pain relief for lateral epicondyle pain.20 Moreover, one study presented that
acupuncture or moxibustion was superior or equal to conventional treatment,
such as local anaesthetic injection, local steroid injection, non-steroidal anti-
inflammatory drugs, or ultrasound.21
3. Autologous blood injection is more effective than corticosteroid injection but
not more effective than platelet-rich plasma injection in treating lateral
epicondylosis.22 On the other hand, corticosteroids were marginally superior to
autologous whole blood in relieving pain on plantar fasciopathy at 2–6 weeks.
Autologous whole blood provided significant clinical relief on epicondylopathy
at 8–24 weeks.23 Another study also concluded that autologous blood injection
was more effective than steroid injection in the short term follow up in tennis
elbow.24
4. Lateral epicondylitis is a common diagnosis that responds well to conservative
treatment. Surgical intervention is necessary when symptoms do not improve
or when improvement is unsatisfactory after at least six months of treatment,
which occurs in 4–16% of cases.25 Arthroscopic surgery for the treatment of
recalcitrant lateral epicondylitis showed good results, representing an effective
and safe technique. The shorter the duration of pain before surgery and the
lower the preoperative DASH, the better the postoperative results are. 26

RESOURCES:

1 Tennis elbow; NICE CKS, October 2012

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 Nursing of Acute and Intensive care Clients
Spring 2018

2 Orchard J, Kountouris A; The management of tennis elbow. BMJ. 2011 May

10342:d2687. doi: 10.1136/bmj.d2687.
3 van Rijn RM, Huisstede BM, Koes BW, et al; Associations between work-related factors

and specific disorders at the elbow: a systematic literature review. Rheumatology

(Oxford). 2009 May48(5):528-36. doi: 10.1093/rheumatology/kep013. Epub 2009 Feb
17.
4 D. M. Walz, J. S. Newman, G. P. Konin, and G. Ross, Epicondylitis: Pathogenesis,

Imaging, and Treatment, RadioGraphics, January 1, 2010; 30(1): 167 - 184. Level of
Evidence: 2C
5 Tuomo Pienimäki, M.D Ph.D et al. Associations Between Pain, Grip Strength, and

Manual Tests in the Treatment Evaluation of Chronic Tennis Elbow. The clinical
journal of pain 18: 164-170 2002
6 American Academy of Orthopaedic Surgeons. 2018. Tennis Elbow (Lateral Epicondylitis).

Retrieved from https://orthoinfo.aaos.org/en/diseases--conditions/tennis-elbow-lateral-epicondylitis/

7 Physiofixblog. 2018. Tennis Elbow (Lateral epicondylitis ). Retrieved from

https://physiofixblog.com/elbow-pathology/
8 WebMD. 2016. What Is Tennis Elbow? Retrieved from https://www.webmd.com/pain-

management/tennis-elbow#2
9 Pattanittum P, Turner T, Green S, et al; Non-steroidal anti-inflammatory drugs (NSAIDs)

for treating lateral elbow pain in adults. Cochrane Database Syst Rev. 2013 May
315:CD003686. doi: 10.1002/14651858.CD003686.pub2.
10 Coombes BK, Bisset L, Vicenzino B; Efficacy and safety of corticosteroid injections

and other injections for management of tendinopathy: a systematic review of

randomised controlled trials. Lancet. 2010 Nov 20376(9754):1751-67. doi:
10.1016/S0140-6736(10)61160-9. Epub 2010 Oct 21.
11 Autologous blood injection for tendinopathy; NICE Interventional Procedure

Guidance, January 2013

12 Meyer NJ, Walter F, Haines B, Orton D, Daley RA. Modeled evidence of force

reduction at the extensor carpi radialis brevis origin with the forearm support band. J
Hand Surg [Am] 2003;28(2):279–287. [PubMed]
13 Extracorporeal shockwave therapy for refractory tennis elbow; NICE Interventional

Procedure Guidance, August 2009

14 Flatt A., Tennis elbow. Proc (Bayl Univ Med Cent). 2008 Oct; 21(4): 400–402.

15 Buchbinder R, Johnston RV, Barnsley L, et al; Surgery for lateral elbow pain.

Cochrane Database Syst Rev. 2011 Mar 16(3):CD003525. doi:

10.1002/14651858.CD003525.pub2.
16 Jobe FW, Ciccotti MG. Lateral and medial epicondylitis of the elbow. J Am Acad

Orthop Surg. 1994;2(1):1–8. [PubMed]

17 Wang, Ching-Jen. Extracorporeal shockwave therapy in musculoskeletal disorders.

Journal of Orthopaedic Surgery and Research20127:11

18 Several studies investigated the effect of shockwave therapy in patients with lateral

epicondylitis of the elbow, and the success rate ranged from 68% to 91%
19 Radwan YA, ElSobhi G, Badawy WS, Reda A, Khalid S: Resistant tennis elbow: shock-

wave therapy versus percutaneous tenotomy. Int Orthop. 2008, 32 (5): 671-7.
10.1007/s00264-007-0379-9.

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 Nursing of Acute and Intensive care Clients
Spring 2018

20 K. V. Trinh S.-D. Phillips E. Ho K. Damsma. Acupuncture for the alleviation of lateral

epicondyle pain: a systematic review. Rheumatology, Volume 43, Issue 9, 1
September 2004, Pages 1085–1090,
21 Gadau, M et al. Acupuncture and moxibustion for lateral elbow pain: a systematic

review of randomized controlled trials. BMC Complement Altern Med. 2014; 14: 136.
22 Lin-Chuan, Chou Tsan-Hon Liou, Yi-Chun Kuan, Yao-Hsien Huang, Hung-Chou Chen,.

Autologous blood injection for treatment of lateral epicondylosis: A meta-analysis of

randomized controlled trials. Physical Therapy in Sport Volume 18, March 2016, Pages
68-73
23 Konstantinos Tsikopoulos, AlexiosTsikopoulos, Konstantinos Natsis. Autologous whole

blood or corticosteroid injections for the treatment of epicondylopathy and plantar

fasciopathy? A systematic review and meta-analysis of randomized controlled trials.
Physical Therapy in Sport Volume 22, November 2016, Pages 114-122
24 Nipun Jindal, Yusuf Gaury, Ramesh C Banshiwal, Ravinder Lamoria, and Vikas

Bachhal. Comparison of short term results of single injection of autologous blood and
steroid injection in tennis elbow: a prospective study. J Orthop Surg Res. 2013; 8: 10.
25 Knutsen E.J., Calfee R.P., Chen R.E., Goldfarb C.A., Park K.W., Osei D.A. Factors

associated with failure of nonoperative treatment in lateral epicondylitis. Am J Sports

Med. 2015;43(9):2133–2137.
26 Alexandre Tadeu do Nascimento, Gustavo Kogake Claudio. Arthroscopic surgical

treatment of recalcitrant lateral epicondylitis – A series of 47 cases. Published online

2016 Dec 21. doi: 10.1016/j.rboe.2016.03.008

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