The elbow is a synovial hinge joint between the distal humerus and the proximal end of the ulna and radius. Every upper and lower arm muscle crosses or attaches to one of the articulations. Tendons are the connective tissues that bind the muscles with bones. The inflammation of the tendons that attach arm muscles to the elbow is called elbow tendonitis.
Elbow tendonitis is of two types: lateral and medial epicondylitis. Lateral epicondylitis is the inflammation of the common extensor tendon at the origin of the extensor carpi radialis brevis (ECRB) tendon. Medial epicondylitis is the inflammation of the medial common flexor tendon.
Additionally, persistent stress on the elbow through a range of motion in the wrist and fist leads to elbow tendonitis. It affects their daily activities, rendering them dependent on another person.
Causes of Elbow Tendonitis
There are various causes of elbow tendonitis, which are discussed below.
- Repetitive Motions
Repetitive wrist extension, radial deviation, and forearm supination are the primary causes of lateral epicondylitis. Athletes’ engines in sports like tennis, squash, and badminton commonly suffer from this.
Chronic concentric and eccentric load on the wrist flexors and pronator teres causes minor tears in the associated tendons leading to medial epicondylitis.
In golfers, the stress occurs during the movement from the top of the backswing to just before the impact on the ball. It is common in people from professions such as carpentry, plumbing, and construction.
- Overuse of the Elbow Joint
Overuse of elbow joints exhausts the muscles attached to the joint, necessitating them to apply a higher force that engages tendons and causes minor tears. It results in inflammation.
- Age-Related Wear and Tear
Tendons lose their flexibility with age, becoming brittle and prone to injuries. It is due to age-related changes in the composition and distribution of its components. They include decreased collagen synthesis, the proportion of thick fibrils, and cellular activity.
- Sports-Related Injuries
Tennis elbow occurs when a person gripping an object, such as a racquet, loses control over its movement, causing radial deviation, wrist extension, and forearm supination. They twist the hand at the wrist with greater force and tear the tendons.
In contrast, a golfer’s elbow occurs when a sportsperson moves his arm overhead. The high energy valgus force during the late cocking and acceleration phase tears the medial common flexor tendon.
Symptoms of Elbow Tendonitis
- Pain and Tenderness
Patients with golfer’s elbow complain of aches on the medial or the ulnar side of the elbow, radiating down into the forearm and wrist. The muscles 5 to 10 millimetres distal and anterior to the medial epicondyle appear tender or sensitive to touch.
Patients with tennis elbow experience pain in the lateral elbow, which worsens with movement. The intensity may increase, so the patient cannot pick and hold a cup of coffee.
- Swelling and Stiffness
In patients with tennis elbow, arm muscles become stiff across the region of ulnar nerve distribution.
Patients may present swelling, erythema, or warmth in acute cases.
- Weakness and Loss of Grip Strength
Patients with golfer’s elbows feel weak in their arm muscles innervated by ulnar nerves.
- Numbness and Tingling
Numbness and tingling sensations are common in the ulnar nerve distribution.
Diagnosis of Elbow Tendonitis
- Physical Examination
Golfer’s Elbow Test: This test is divided into active and passive components.
In the passive component, the examiner palpates the medial epicondyle and supports the elbow in one hand. The other hand supinates the patient’s forearm and straightens the arm extending the elbow. If the patient experiences pain in the region of the medial epicondyle, the test is positive.
In the active component, an examiner resists the active flexion and pronation of the forearm and wrist. Pain in the medial epicondyle region indicates inflammation.
A distal location about 1 to 2 cm from the lateral epicondyle in the tennis elbow appears tender upon palpation. The muscles connected to the tendon exhibit tightness.
Patients with tennis elbow experience pain during wrist extension with stretched elbow and pronated forearm. Further, the examiner may check if the patient feels pain during resisted extension of the middle finger with the elbow extended and increased stress placed on the tendon.
- Imaging Tests
Tennis elbow does not require imaging tests. However, doctors suggest MRI or ultrasound scans when patients do not respond to non-operative management modalities.
The purpose of imaging tests on patients with golfer’s elbow is differential diagnosis to rule out the other causes of the pain. Radiography, ultrasound, and MRI scan are the tests used to look for any abnormal observations.
Treatment Options for Elbow Tendonitis
- Rest and immobilisation
Cessation of offending activities is the initial management. It includes reducing the volume, frequency, and intensity of elbow activities.
- Physical Therapy
Physical therapy is the first-line treatment for elbow tendonitis. However, the combination of modalities varies between medial and lateral epicondylitis.
Occupational or physical therapy for tennis elbow focuses on stretching and strengthening the forearm. With improvement, eccentric muscle strengthening of the common extensor tendon can help further.
Physical therapy for a golfer’s elbow comprises multiple modalities, including dry needling, extracorporeal shock wave therapy, electrical stimulation, iontophoresis, phonophoresis, and ultrasonography. Soft tissue and manipulation techniques offer better and faster recovery from the elbow tendonitis symptoms.
- Topical or oral NSAIDs help reduce pain allowing elbow movement.
- Topical nitrates are the elbow tendonitis treatment options when a patient does not respond to conservative methods.
- NSAIDs and acetaminophen provide an analgesic effect.
- Topical nitro-glycerine patches help treat tendinopathies.
Injections effective in elbow tendonitis treatment are as follows.
- Ultrasound- or palpation-guided corticosteroid
- Platelet-rich plasma
- Dextrose prolotherapy
Surgical intervention is the last resort for the treatment of elbow tendonitis. The options for the procedure are as follows.
- Release the affected tendon at the corresponding epicondyle and debridement of pathological tissue
- Mini-open muscle resection to remove degenerative tissue
- Fascial elevation and tendon origin resection.
Elbow tendonitis primarily occurs due to the assault of tendons in the elbow due to repetitive movements and a high workload. The elbow plays a vital role in daily life activities, and its fitness is crucial for the independence of others.
Since it is one of the most complex joints, a detailed examination is necessary to differentiate tendonitis from other ailments. Treatment options range from minimally-invasive therapy to invasive pharmacotherapy and surgical interventions.
It allows us to make strategies to minimise side effects. Research is underway to develop new medications that specifically target the inflammatory factors in the elbow.