Lateral epicondylitis, or 'tennis elbow', is a common condition that usually affects patients between 35 and 55 years of age. It is generally self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment.
In the United Kingdom it affects between 1% and 3% of the population, mainly those aged from 35 to 55 years, with an equal gender distribution. It is generally self limiting, and most cases require no more than treatment with simple analgesia.
Tennis elbow is a common cause of chronic elbow pain. Injection treatment should be considered in patients who do not respond to conservative management. Steroid injections can provide good pain relief in these patients. Platelet rich plasma therapy has also been used with success in management of patients with tennis elbow. However it is important to note that in some cases injection treatment may not provide the desired results or the pain relief may not be sustained. At Pain Spa Dr Krishna is very experienced in interventional treatments. Dr Krishna always performs injections under ultrasound guidance or fluoroscopy for greater accuracy and improved safety. Ultrasound gives the added advantage of targeting the surrounding tendons and muscles, which can be contributory to pain.
At Pain Spa Dr Krishna is very experienced in interventional treatments. Dr Krishna always performs injections under ultrasound guidance or fluoroscopy for greater accuracy and improved safety. Ultrasound gives the added advantage of targeting the surrounding tendons and muscles, which can be contributory to pain.
In most cases of lateral epicondylitis no obvious underlying cause can be identified. However, any activity that involves overuse of the wrist extensor or supinator muscles may be incriminated. The most commonly affected muscle is the extensor carpi radialis brevis (ECRB).
Although popularly associated with tennis, lateral epicondylitis may develop from a variety of activities that involve excessive and repetitive use of the forearm extensors, such as typing, playing the piano and various types of manual work. When affected, any movement that puts force on the extended wrist may be painful, as it increases the load on the diseased common extensor tendon.
Lateral epicondylitis was previously considered to be a tendinitis, arising as inflammation of the tendon. However, it has been shown histopathologically to have a paucity of inflammatory cells such as macrophages and neutrophils. The condition is therefore now considered to be a tendinosis, which is defined as a degenerative process.
Patients most often complain of pain at or around the bony prominence of the lateral epicondyle that often radiates down the forearm in line with the common extensor muscle mass and occasionally proximally into the upper arm. This pain is usually triggered or exacerbated by contraction of the common extensor mass in response to a variety of activities. The intensity of the pain can range from intermittent and mild to constant and severe, affecting all daily activities, and even occur at night causing a disturbance in sleep.
Plain elbow radiographs can be helpful to exclude bony pathologies, including loose bodies, osteoarthritis and osteochondritis dissecans. In some cases patchy calcification in the overlying soft tissue may be seen on plain radiographs at the attachment of the common extensor tendon.
Ultrasound imaging can be useful by identifying structural changes in the affected tendons, including thickening or thinning, hypoechogenic foci indicating intra-substance degenerative areas, tendon tears, calcification, bony irregularity or calcific deposits. Doppler ultrasound is able to detect neovascularisation. The absence of this and of grey-scale changes have been shown to rule out lateral epicondylitis.
MRI can demonstrate other intra-articular pathology, confirm the presence of degenerative tissue and tears within the tendon and underlying capsule.
Local injection of corticosteroids is a commonly used treatment in management of tennis elbow. The exact mechanism of action in a tendinopathic condition such as lateral epicondylitis is poorly understood, as the effects of corticosteroid are predominantly anti-inflammatory. Corticosteroids have been found to be superior to NSAIDs at four weeks, but no long-term differences were noted between steroid injections and NSAID treatment.
Injections may be administered using a single-injection technique or peppered injections into multiple areas of the tendon. This is thought to stimulate local blood flow. A randomized trial compared single versus peppered injections of corticosteroids and found slightly better improvements in the peppered injection group in terms of Disabilities of the Arm, Shoulder and Hand (DASH) score, visual analogue scale (VAS) for pain and grip strength. However, corticosteroids have been associated with local skin atrophy, depigmentation and muscle wasting, resulting in an increase in the bony prominence of the lateral epicondyle.
Botulinum toxin affects the neuromuscular junction by reducing resting muscle tone. By effectively reducing the resting tension at the ECRB insertion it may potentially reduce pain. At present there is no consensus on the use of botulinum toxin in lateral epicondylitis.
Platelet-rich plasma (PRP) is a concentrate of platelets derived from the patient’s own blood and is known to contain a high content of growth factors that have the potential to enhance the healing process of the tendon. A blood sample is taken and centrifuged to extract the plasma content, and the blood is then re-injected around the lateral epicondyle. A number of RCTs have shown that PRP is superior to autologous blood and bupivacaine injections. However there is a great variation in the way that different commercial systems prepare and activate the PRP, and hence it is difficult to draw clear conclusions on the efficacy of PRP.
Injections are generally avoided in patients with systemic infection or skin infection over puncture site, bleeding disorders or coagulopathy, allergy to local anaesthetics or any of the medications to be administered.
The procedure is usually done on an outpatient basis. The procedure is performed under ultrasound guidance to ensure accuracy of needle placement. Patients need to be aware that the outcome of the procedure is variable and they may not receive the desired benefits. Similarly, they must be aware of the transient nature of the therapeutic benefits and that there may need repeated injections.
Generally a mixture of local anaesthetic and steroid is injected. The local anaesthetic agent within the injectate may act on the nociceptive fibres , whereas corticosteroids may reduce inflammation. The anaesthetic is probably responsible for immediate pain relief, whereas steroids are believed to be responsible for pain relief 2–6 days after their administration.
Complications are rare, particularly if the injections are performed using a precise needle-positioning technique. Possible complications include bruising, infection, hematoma, nerve injury and reaction to the injectates. Infection can be avoided with appropriate aseptic precautions. Severe allergic reactions to local anaesthetics are uncommon. Steroid injections may produce local reactions, occurring most often immediately after injection. These local reactions last for 24 to 48 hours, and are relieved by application of ice packs. Post-procedural pain flare-up may occasionally occur, and may be treated with pain killers. Neurological complications including paraesthesias and numbness have been described but are extremely rare. In addition corticosteroids have been associated with local skin atrophy, depigmentation and muscle wasting, resulting in an increase in the bony prominence of the lateral epicondyle.