Epicondylitis: causes and therapies

Known as tennis elbow, this health issue doesn’t really just affect tennis fans. Here’s how to recognize and deal with it.

The elbow is a very important joint that unites the forearm (portion between elbow and wrist) and arm (portion between shoulder and elbow) and that allows us to make precious movements for everyday life: that’s why even a slight pain can be very annoying.

The elbow has a particularly complex structure: it consists of three different joints (called humerus-radial, humerus-ulnar and radio-ulnar) held together by a single articular capsule strengthened by two collateral ligaments, external and internal.

At the origin of a painful symptomatology of the elbow there can therefore be several causes, but one of the best known and most frequent is the so-called epicondylitis, more commonly known by the definition of “tennis elbow”. Here’s everything you need to know about it.

What is epicondylitis

«It is a tendonitis, that is, a tendon inflammation associated with muscle contracture, which develops at the point where the epicondyloid tendons insert on the humerus.

In particular, what is affected is the tendon that inserts above the elbow joint, on the outer side of the arm, which acts as a link between the short radial extensor muscle of the carpus and the humeral lateral epicondyle, a small bony protrusion placed above the condyle of the humerus» explains Andrea Grasso, orthopedic surgeon and traumatologist of the Italian Neurotraumatological Institute.

If, on the other hand, the tendon that inserts on the inner side of the arm is affected, it is called epitrocleitis, also known as golfer’s elbow.

Epicondylitis	Tendon that fits on the outer side of the arm
Epitrocleitis	Tendon that inserts on the inner side of the arm

“The inflammation, if not treated immediately, then tends over time to evolve into a tendinosis, ie a degenerative disease of the tendons,” adds the doctor.

At the root of the problem

Tennis elbow is considered a functional overload syndrome, i.e. a consequence of microtraumas and micro-injuries repeated over time that weaken and / or damage some tendon fibers, determining the inflammatory state first and then the degenerative state.

“Microtraumas are a consequence of the repetition over time of incorrect movements that engage the extensor muscles incorrectly. For this reason, the problem often concerns manual workers struggling with repetitive tasks: this is the case, for example, of those who use the computer mouse a lot, but also of housewives and craftsmen who use vibratory tools that subject the tendon to improper stress» explains Andrea Grasso. “There are also cases, although they are less frequent, in which epicondylitis is the consequence of a single direct trauma.”

In sports, amateur sportsmen are more easily affected, who more easily make inaccurate and incorrect technical gestures than professionals and, despite the name of the pathology, not necessarily only those who play tennis are involved; Epicondylitis, in fact, can also affect those who practice other sports, such as baseball, volleyball, basketball, fencing, athletics throws.

Symptoms of epicondylitis

The typical manifestation of this condition is always pain, which generally concentrates in a precise point of the joint: on the external lateral protrusion of the elbow, where the muscles that are used to rotate the arm clockwise are inserted.

“Since the tendon and the muscles involved are those involved in the extension and torsion of the wrist, in the extension of the hand, fingers and forearm, the pain can then radiate to the hand and become more acute when lifting a load, bending the arm, when holding and handling even small objects and when twisting the wrist, For example, to turn the key in a lock,” describes the orthopedist.

If initially you may feel only a weakness of the arm and a loss of strength, which passes or tends to decrease with rest (so for example after a night of sleep you wake up without discomfort), over time, in the absence of adequate treatment, the pain may worsen until it is such as to prevent movement.

How to diagnose

A clinical examination of the patient may be sufficient for the doctor’s expert eye to make a correct diagnosis of tennis elbow, but usually some further tests are used.

“In particular, an X-ray examination or an ultrasound of the elbow is generally prescribed not only to confirm the pathology, but also to verify the presence or absence of calcifications of the tendon, which are a rather frequent eventuality,” explains Andrea Grasso.

«If, then, the problem lasts for a long time and a degenerative tendinosis may therefore have occurred, a nuclear magnetic resonance may also be appropriate to evaluate the quality of the tendon tissue».

How do we cure it

“The first treatment of epicondylitis generally involves rest understood as the suspension of those incorrect movements that have contributed to inflaming the tendon and contracting the muscles,” explains the specialist.

It is also important to resort to the application of an ice bag (instant ice bags found in pharmacies are also fine) for about 10-15 minutes, three times a day, because the cold helps reduce the pain associated with inflammation (causing a narrowing of blood vessels).

Anti-inflammatory drugs (by mouth or ointment, to be applied topically) can be useful at first to counteract a particularly strong painful symptom, but their intake should not be prolonged for a long time (usually for no more than 5-6 days).

“In addition to completely resting the elbow, it is also important to follow a specific physiotherapy suggested by the orthopedist or physiotherapist, which consists in performing certain stretching exercises that loosen the contracted epicondyloid muscles, combined with other movements that are instead intended to strengthen the epitrochlear muscles, antagonist of the contracted one”, underlines the specialist.

In this way, on the one hand muscle strength and endurance are increased in the arm and forearm, stabilizing the joint, and on the other hand you learn to perform movements correctly, thus also implementing a strategy of prevention and reduction of the risk of future recurrences of epicondylitis.

“From the onset of symptoms, as long as you feel pain and also for the duration of physiotherapy, you can also help yourself by wearing a specific brace for epicondylitis,” highlights the orthopedist. “It is a sort of bracelet in semi-rigid fabric equipped with a kind of gel ball that acts as a presser: worn just before the elbow, the pressor discharges the vibrations and stresses of the movements, preventing them from further inflaming the tendon”.

The physiotherapy described above is generally combined with instrumental physical therapy, i.e. physiotherapy sessions that use special machinery to obtain a decontracting and anti-inflammatory action.

In these cases, laser therapy or tecar therapy can be used, for example. “The election strategy that proves particularly effective, however, is the one with shock waves, because these can be precisely directed to the point affected by epicondylitis,” underlines Andrea Grasso.

“Shock waves act on tissues and cells, stimulating the production of anti-inflammatory substances and also promoting tissue regeneration.” Generally it starts with a cycle consisting of about ten sessions lasting about 15 minutes each, repeatable if necessary.

Epicondylitis: what is done in the most complex cases

In chronic cases and in those that do not produce substantial improvements with the options described above, it is possible to resort to local infiltration.

“In many cases some infiltration of cortisone drugs is used, but, if on the one hand they are effective, on the other hand they do not fail to record many side effects so as to damage and weaken the tissues” highlights the specialist.

“The most scientifically valid and advisable alternative today is represented by the use of PRP infiltrations, already used for some time, for example, also for tendon and intra-articular pathologies of the shoulder and other joints. PRP stands for platelet rich plasma, i.e. platelet-enriched plasma: it is a gel that is obtained from the centrifugation of blood (coming from the same patient in which it is infiltrated) and the subsequent separation of platelets from the other components. In practice, in this way a concentrate, injectable, is obtained, particularly rich in platelets that release growth factors: thus, once infiltrated, it is effective in modulating inflammatory processes and inducing regenerative processes in the affected tendon».

In general, 2-3 infiltrations are enough to obtain the desired improvements and the disappearance of pain.

In those very few patients in whom none of the solutions indicated so far proves effective, the last option remains the use of surgery. Generally we proceed with an operation performed in a day hospital and with a loco-regional anesthesia, an intervention that, if you have the opportunity to evaluate any associated lesions, can also be performed in arthroscopy. It is a procedure that allows you to operate inside the joint using microincisions through which to insert small surgical instruments and an arthroscope, that is a camera that allows you to view the part to be operated.

Otherwise, an “open” operation is carried out: “By incising at the level of the epicondyle, the inflamed tendon is disengaged from the muscles of the forearm, then it is incised and cleaned of the degenerative tissue that has covered it due to inflammation, and then proceed to reposition it correctly by reinserting it into the bone”, explains the orthopedist.

Usually the intervention is decisive, even if it requires a personalized rehabilitation path before being able to return to normal daily activities.