An Unusual Cause For Refractory Lateral Elbow Pain

What Is a Tennis Elbow?

Tennis elbow or lateral epicondylitis is a painful condition of the elbow. It arises from the tedious stress of the extensor muscles and tendons during repetitive movements of the forearm and the wrist. These kinds of repetitive movements result in fatigue of the forearm, which leads to overloading of the tendon. This, in turn, causes pain and inflammation of the tendon called tendonitis. Further, it leads to a degenerative condition called tendinosis, which altogether results in tendon tearing.

Who Is Prone to Get Tennis Elbow or Lateral Epicondylitis?

Despite its name, this condition is more commonly associated with work-related repetitive elbow and wrist movements like washing clothes, wringing clothes, hammering, and carpentry than in tennis players. It is seen in people who vigorously do repetitive actions that use the forearm, hands, or wrist. The following are the group of people who are predisposed to tennis elbow:

• Fencers.

• Golfers.

• Baseball players.

• Squash players.

• Bowlers.

• Racquetball and pickleball players.

• Butchers.

• Manicurists.

• Chefs.

• Cleaners.

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  An Unusual Cause For Refractory Lateral Elbow Pain

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• Carpenters.

• Musicians.

• Gardeners.

• Plumbers.

• Auto mechanics.

• Assembly line workers.

What Are the Symptoms of Tennis Elbow or Lateral Epicondylitis?

• Burning sensation or pain in the outer elbow, which radiates to the wrist.

• Twisting or bending the arm causes pain.

• Weakening of grip.

• Pain and stiffness during arm extension.

• Swollen and tender elbow joint.

How Is Lateral Epicondylitis or Tennis Elbow Diagnosed?

• X-rays.

• Electromyography to assess nerve compression.

• Imaging tests like ultrasound, computed tomography, and magnetic resonance imaging detect damage in the muscles and nerves.

How Is Tennis Elbow or Lateral Epicondylitis Treated?

In its early stages, the condition responds well to rest, ice packs, analgesics, and anti-inflammatory drugs. However, later stages usually require intervention in the form of steroid injection and then surgical treatment.

1. Rest: Giving adequate rest to the tendons aids in healing.

2. Medications: Non-steroidal anti-inflammatory drugs like Naproxen and Ibuprofen help in reducing the pain and inflammation associated with lateral epicondylitis.

3. Steroid Injections: Corticosteroids are injected into the site of pain, which helps in relieving pain and inflammation. Ultrasound-guided steroid injections are given to a few individuals to determine the exact location of the injection site.

4. Braces: A counterforce brace can be worn to relieve the tension exerted on the muscles and tendons.

5. Physical Therapy: Physiotherapy exercises help in strengthening the muscles of the forearm and help in enhancing the grip. Ultrasound, massage, and muscle-stimulation techniques help reduce pain and inflammation and improve function.

6. Extracorporeal Shock Wave Therapy: With the help of this therapy, the scar tissue is broken down, leading to improved blood flow to the area of damage.

7. Platelet-Rich Plasma Therapy: In this therapy, a little amount of blood is taken with the help of PRP injection, platelets are removed, and the concentrated platelets are injected with the help of an ultrasound.

8. Minimally Invasive Tenotomy: It is a minimally invasive procedure in which the degenerative tendon tissue is hydro-resected with the help of a needle device.

If the non-surgical therapies do not help, arthroscopic surgery, tendon repair, or tendon debridement is recommended. It takes around four to six months to recover from surgery.

How Is the Prognosis of Lateral Epicondylitis?

Lateral epicondylitis is usually treated by non-surgical therapies in about 95% of people, and the symptoms typically subside in a period of six to 18 months. However, few might require surgery. After surgery, recovery of symptoms usually occurs in one year

How Can We Prevent Lateral Epicondylitis or Tennis Elbow?

• Warm-up before starting work by stretching wrists and arms.

• Wear elbow braces.

• Do not push hard with pain.

• Strengthen wrist and forearm muscles by lifting weights.

At times, certain unusual conditions of the lateral aspect of the elbow can mimic or co-exist with a tennis elbow and can cause refractory pain.

Chronic Non-responsive Lateral Elbow Pain:

The use of Duloxetine, a selective serotonin and norepinephrine reuptake inhibitor in chronic refractory elbow pain, which does not respond to any other non-surgical and surgical therapies, is under study.

Here is a case report of a young female who had chronic non-responsive lateral elbow pain.

• A 32-year old female, who is a household worker, presented with chronic pain in the lateral aspect of the left elbow that had not responded to repeated attempts at conservative treatment (rest, ice, and analgesics) and steroid injections.

• Her clinical examination, which included 10 degrees of flexion deformity (difficulty to straighten elbow fully), raised suspicion of intra-articular (joint) pathology.

• An MRI of the elbow revealed soft tissue growth in the humeroradial joint (elbow joint).

• A minor incision surgery was performed to expose the humeroradial joint through the Kocher approach.

• Humeroradial synovial plica (extension of the synovial fold) was identified and excised.

• A release of the extensor muscle origin was also performed to address the tennis elbow.

• The postoperative recovery of the patient was terrific, and her pain and movements improved.

This report describes an unusual cause of lateral elbow pain that could be missed during the management of refractory tennis elbow.

This stresses the need for clinical suspicion and adequate assessment in such refractory patients to provide early functional improvement and pain relief.

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