Epicondylitis is a degenerative inflammatory lesion of tissues in the area of the elbow joint. It develops at the sites of attachment of the tendons of the inner and outer surfaces of the forearm to, respectively, the inner and outer condyles of the humerus. Pathology develops gradually, manifested by pain in the elbow joint, which increases with extension (with external epicondylitis) and with grasping (with internal epicondylitis). Treatment is usually conservative: correction of the load on the joint, immobilization, physiotherapy, physical therapy.
Epicondylitis is a degenerative–dystrophic process in the area of attachment of the tendons of the forearm muscles to the condyles of the humerus and the tissues surrounding these tendons. Depending on the localization, it is manifested by local pain on the outer or inner surface of the elbow joint. Develops as a result of chronic overload of the forearm muscles. The diagnosis of epicondylitis is made on the basis of characteristic clinical data. The treatment is conservative, the prognosis is favorable.
Epicondylitis of the elbow joint is one of the most common diseases of the musculoskeletal system. At the same time, it is not possible to accurately estimate the incidence rate, since a large number of patients do not go to doctors due to poorly expressed symptoms. The disease usually develops at the age of 40-60 years, while right–handed people are more likely to be affected by the right, and left-handed people – the left hand.
The lesion in the area of the external (lateral) condyle is called the elbow of a tennis player, since this disease is often observed in tennis players. However, much more often the disease develops in connection with professional activity. The cause of epicondylitis is stereotypical, constantly repeating movements – the extension of the forearm and its rotation outward. External epicondylitis often affects massage therapists, construction workers (painters, carpenters, bricklayers), tractor drivers, milkmaids, handymen. The disease develops more often in men.
Internal (medial) epicondylitis, which is also called golfer’s elbow, occurs with repetitive movements of low intensity and develops mainly in people engaged in light physical labor – seamstresses, typists, etc. The disease is more often observed in women.
As a result of chronic overload and repeated microtrauma, a degenerative process develops in the tendon tissue, accompanied by inflammation of the surrounding tissues. Small scars are formed, which further weaken the resistance of the tendon to loads, which, in turn, contributes to an increase in the number of micro-injuries. In some cases, the symptoms of epicondylitis occur after a direct injury. Congenital weakness of the ligamentous apparatus increases the risk of developing this disease and causes its more severe course.
With lateral epicondylitis, there is clearly localized pain on the outer surface of the elbow joint, which occurs when the hand is extended and rotated outward. In the study of muscle strength, the weakening of the muscles on the diseased side is determined when the hand rotates outward and resists capture. The text of the coffee cup (pain when trying to lift a cup filled with liquid from the table) is usually positive. When pressing on the lateral condyle, obvious, but not acute soreness is determined.
With medial epicondylitis, the pain is localized along the inner surface of the elbow joint. In the study of muscle strength, there is a weakening of the muscles on the sick side when grasping. There is an increase in pain when pronating at right angles and bending the forearm with resistance. Palpation determines soreness and tightness in the lower part of the medial condyle. The milking test (increased pain during simulated milking) is positive.
The diagnosis of epicondylitis is made on the basis of patient complaints and external examination data. Additional research is usually not required. Differential diagnosis of epicondylitis is carried out with diseases of the elbow joint itself (aseptic necrosis of articular surfaces, arthritis) and tunnel syndromes: (cubital canal syndrome – infringement of the ulnar nerve and circular pronator syndrome – infringement of the median nerve). Usually, the diagnosis does not cause difficulties.
With arthritis, pain occurs in the area of the elbow joint itself, and not in the area of the condyle, while it is more “blurred”, and not localized in a well-defined area. Flexion contracture of the elbow joint may develop. When the nerves are pinched, neuritis and neurological symptoms characteristic of it are observed – there are sensitivity disorders in the innervation zone and a decrease in the strength of the innervated muscles.
If epicondylitis develops in young people, joint hypermobility syndrome (HMS), caused by congenital weakness of connective tissue, should be excluded. To do this, the doctor studies the history of life, paying attention to the frequency of sprains, tendinitis, acute and chronic arthralgia and back pain. In addition, the presence of HMS can be indicated by longitudinal and transverse flat feet, as well as an increase in joint mobility.
Additional research methods for the diagnosis of epicondylitis are usually not used. In some cases, radiography is performed to exclude traumatic damage (fracture of the condyle). If differential diagnosis between epicondylitis and tunnel syndrome is difficult, an MRI may be prescribed. If inflammatory diseases of the joints are suspected, a blood test is performed to exclude signs of acute inflammation.
Treatment is carried out on an outpatient basis by an orthopedic traumatologist. The scheme and methods of treatment of epicondylitis are determined taking into account the severity of functional disorders, the duration of the disease, as well as changes in the muscles and tendons. The main goals of treatment:
- Elimination of pain syndrome.
- Restoration of blood circulation in the affected area (to ensure favorable conditions for the restoration of damaged areas).
- Restoration of the full range of movements.
- Restoring the strength of the forearm muscles, preventing their atrophy.
If the pain syndrome in epicondylitis is not clearly expressed, and the patient goes to the doctor mainly in order to find out the cause of unpleasant sensations in the elbow joint, it will be enough to recommend the patient to observe a protective regime – that is, to closely monitor his own feelings and exclude movements in which pain appears.
If a patient with epicondylitis is engaged in sports or his work is associated with heavy physical exertion on the muscles of the forearm, it is necessary to ensure rest of the affected area for a while. The patient is given a sick leave or recommended to temporarily stop training. After the pain disappears, the load can be resumed, starting with a minimum and gradually increasing. In addition, the patient is recommended to find out and eliminate the cause of overload: revise the sports regime, use more convenient tools, change the technique of performing certain movements, etc. With a chronic course of epicondylitis with frequent exacerbations, patients are advised to stop playing sports or switch to another job, limiting the load on the forearm muscles.
With severe pain syndrome in the acute stage of epicondylitis, short-term immobilization is necessary. A light plaster or plastic splint is applied to the elbow joint for a period of 7-10 days, fixing the bent elbow joint at an angle of 80 degrees and hanging the arm on a kerchief bandage. In the chronic course of epicondylitis, the patient is recommended to fix the elbow joint and the forearm area with an elastic bandage during the day. At night, the bandage must be removed.
If the symptoms of epicondylitis appeared after the injury, cold should be applied to the affected area during the first days (an ice bubble wrapped in a towel). Patients suffering from epicondylitis in the acute period are prescribed physiotherapy: ultrasound, phonophoresis (ultrasound with hydrocortisone), paraffin, ozokerite and Bernard currents.
At the end of the acute phase of epicondylitis, the patient is prescribed electrophoresis with potassium iodide, novocaine or acetylcholine, UHF and warming compresses on the affected area. In addition, starting from this moment, the patient with epicondylitis is shown therapeutic gymnastics – repeated short-term overextension of the hand. Such movements help to increase the elasticity of connective tissue structures and reduce the likelihood of subsequent microtrauma. In the recovery period, massage and mud therapy are prescribed to restore the volume of movements and prevent muscle atrophy.
Pain syndrome in epicondylitis is caused by an inflammatory process in soft tissues, therefore, nonsteroidal anti-inflammatory drugs have a certain effect in this disease. NSAIDs are used topically, in the form of ointments and gels, since inflammation in epicondylitis is local. Administration of nonsteroidal anti-inflammatory drugs orally or intramuscularly in modern traumatology and orthopedics in epicondylitis is not practiced due to their insufficient effectiveness and unjustified risk of side effects.
With persistent pain that does not weaken for 1-2 weeks, therapeutic blockades with glucocorticosteroids are performed: betamethasone, methylprednisolone or hydrocortisone. It should be borne in mind that when using methylprendisolone and hydrocortisone during the first day, there will be an increase in pain due to the reaction of tissues to these drugs.
A glucocorticosteroid drug is mixed with an anesthetic (usually lidocaine) and injected into the area of maximum soreness. With external epicondylitis, the choice of the injection site is not difficult, the blockade can be carried out in the patient’s position both sitting and lying down. In case of internal epicondylitis, the patient is placed on a couch face down with his arms stretched out along the body to carry out the blockade. This position ensures the accessibility of the area of the internal condyle and, unlike the sitting position, eliminates accidental damage to the ulnar nerve during the procedure.
With conservative therapy without the use of glucocorticosteroids, the pain syndrome in epicondylitis is usually completely eliminated within 2-3 weeks, during blockades – within 1-3 days. In rare cases, persistent pain is observed, which does not disappear even after injections of glucocorticosteroid drugs. The probability of such a course increases with chronic epicondylitis with frequent relapses, joint hypermobility syndrome and bilateral epicondylitis.
If the pain syndrome persists for 3-4 months, surgical treatment is indicated – excision of the affected areas of the tendon in the area of its attachment to the bone. The operation is performed as planned under general anesthesia or conduction anesthesia. In the postoperative period, a splint is applied, the stitches are removed after 10 days. Subsequently, rehabilitation therapy is prescribed, including physical therapy, massage and physiotherapy procedures.