11-Lateral and medial epichondylitis "Tennis, Golfer's and Little Leaguer's Elbow"

Lateral epicondylitis

Otherwise known as "tennis elbow", this condition is characterized by pain and weakness along the muscles and tendons on the outside of the elbow (extensor mechanism) right by the bony protrusion (lateral epicondyle). This injury is seen in many sports such as tennis or golf, as well as any activity or work which requires repetitive grasping or gripping. Chronic stress to the extensor carpi radialis brevis and extensor carpi radialis longus results in swelling and microtearing of the tissue, which in extreme cases causes a creaking of the tendon as it is being flexed and extended. Very chronic cases can have capsular restrictions as well.

Diagnosis:--

First, a careful history of the injury is obtained--paying close attention to subtle clues such as morning pain, an increase in keyboard use at work, or changes in golf grip. Demonstration of tennis, golf, or hammer gripping technique or stance position (i.e. open vs. closed in tennis) can help spot clues on mechanical predisposition. Palpation will reveal pain along the anterior inferior aspect of the lateral epicondyle, made worse with active grasping. It is also important to rule out any other conditions such as a cervical problem, thoracic outlet condition or nerve entrapment. Special tests such pain with manual resisted wrist extension with the hand in a fist helps to confirm the diagnosis. An MRI is helpful to clarify the pathology and to rule out associated lesions.

Treatment:--

Initial care consists of ice and ice massage to the area 3-5 times a day for 10-15 minutes to control the swelling of the tissue and pain. The use of anti-inflammatories for the first couple of weeks as prescribed your physician is also effective in controlling the inflammation. Depending on the extent of the symptoms, we have found the use a wrist splint very effective. Treatment should consist of soft tissue treatments to reduce the adhesions, passive stretching of the extensors, eccentric training of the flexors, a postural program, and modification of aggravating factors. It is also important to treat any shoulder conditions such as instability or significant rotator cuff weakness. An appointment with the local club pro can improve mechanical contributing factors, as well as equipment related problems such as grip size or string tension. A sample home program can be viewed at Lateral Epicondylitis Home Program.

Medial epicondylitis

The extreme forceful contraction of the wrist flexors as in a golf swing or baseball pitch can cause an overuse injury to the inside of the elbow. Sometimes referred to as "golfer's elbow", or "Little Leaguer's elbow" in adolescents, this injury involves the pronator teres, flexor carpi radialis, and sometimes the flexor carpi ulnaris (the tendons on the inside of the forearm leading to the elbow.) Unlike lateral epicondylitis which most often happens as the result of repetitive mechanical and postural flaws, medial epicondylitis is usually a true overuse syndrome or as the result of one forceful contraction such as a baseball pitch which set off the symptoms.

Diagnosis:--

A detailed history of the injury is important to discover the most likely cause or mechanism of injury. Again, rule out more insidious conditions which may be manifesting themselves in the elbow. Point tenderness is found at the medial aspect of the elbow right at the attachment of the flexor mechanism of the wrist and hand. Pain with resisted wrist flexion also aids in confirming the diagnosis. An MRI is helpful to identify the pathology.

Treatment:--

Icing or ice massage 3-5 times a day for 10-15 minutes along with anti-inflammatories will aid in controlling the swelling and inflammation. Passive stretching of the flexors coupled with soft tissue mobilization is effective in improving elbow mechanics. Shoulder and postural program, wrist splint, and modification of aggravating factors are all effective initial treatment plans. Once the initial symptoms are reduced, a progressive strengthening program of the flexor mechanism beginning with resisted isometrics in neutral position and advancing to eccentrics as comfortable is introduced.