SPORTS MEDICINE

Dr. Patricia Baumann

TENNIS ELBOW presents with pain on the lateral (outside) part of the elbow over the bony region known as the lateral epicondyle.  The epicondyle is the place of origin of the extensor tendons of the wrist.  When there is chronic overuse of these tendons, the tendon degenerates and pain persists.   Most patients are between the ages of 30 and 50, however tennis elbow may occur in any age group.  Most patients with tennis elbow do not play racquet sports, but do participate in repetitive activities at work or play that require vigorous use of their forearm muscles.

Most patients present to the orthopedic office with complaints of severe, burning pain on the outside portion of their elbow.  Usually the pain progressively worsens over time and becomes worse with certain activities, such as carrying and lifting heavy items, or even lifting light items.  Diagnostic examination involves direct palpation or pressing firmly on the lateral epicondyle which, if tennis elbow is present, reproduces the patient’s pain.  The pain can be exacerbated by resisting extension of the wrist by the examining physician with the elbow flexed.  Radiographs (xrays) rarely show any changes, as the injury is associated with tendon, not bone.

A TENNIS ELBOW brace is designed to apply pressure over the muscle belly of the extensor muscles, which is why it is worn below the elbow and not over the elbow. The brace is designed to “trick” the tendon origin as the tendon now acts as though it starts at the brace and not at the elbow.

• In most cases (85-90 percent) non-surgical treatment will lead to resolution of the symptoms.  Pain relief is the initial goal followed by decreasing the inflammation so the tendon can heal. Non-steroidal anti-inflammatories (NSAIDS), such as Ibuprofen, are effective in both decreasing pain and inflammation.  If NSAIDs are contraindicated due to reflux disease, a history of stomach ulcers or anti-coagulation therapy, acetaminophen (Tylenol) may be taken instead.  Ice to the elbow will decease inflammation and decrease pain.  A tennis elbow brace may be beneficial.  This brace is designed to apply pressure over the muscle belly of the extensor muscles, which is why it is worn below the elbow and not over the elbow.  The brace is designed to “trick” the tendon origin as the tendon now acts as though it starts at the brace and not at the elbow.  This allows the extensor muscles and the tendon to rest.  A wrist brace may be worn to prevent extension of the wrist, again allowing the extensor tendons to rest.
• Physical therapy in conjunction with bracing is frequently recommended, and many modalities such as ultrasound can be used to decrease inflammation at the tendon origin.  The therapist will also work on stretching the extensor tendons to relieve the pain at the elbow.
• A corticosteroid injection may also be used at the lateral epicondyle to allow for local decrease in inflammation. Corticosteroid injections should be limited in their numbers because too many injections into the tendon can cause degeneration and rupture of the tendon.  (Usually, the maximum number of injections is 2-3).
• Casting to rest both the elbow and the wrist may be used to further avoid surgery – as a last resort.
• • Activity modification is essential.  A tennis player would need to rest from tennis while completing the course of physical therapy.  Returning to sports should be worked in gradually upon resolution of the symptoms.
• Surgical treatment is reserved for cases that have failed all non-surgical treatment options and the symptoms have persisted beyond six months.  The surgery is an outpatient procedure, meaning the patient goes home on the day of surgery.  The surgery consists of cleaning (debriding) the degenerated tendon and reattaching the fresh edges of the tendon to the epicondyle.  The patient is placed in a splint that holds the elbow at 90 degrees for 1-3 weeks.  After the splinting, the patient is again placed in physical therapy to first work to regain range of motion of the elbow then strengthening of the arm begins about 6-8 weeks after the surgery.  If the patient participates in tennis, they are allowed to return to their sport 4-6 months after surgery.  Tennis elbow surgery is successful about 80 percent of the time.

UNLIKE TENNIS ELBOW, Golfer’s elbow is painful on the medial epicondyle (inside of the elbow). The medial epicondyle is the origin of the flexor muscle of the wrist. Golfer’s elbow is caused by the pull of the flexor tendons of the wrist on the origin of the tendon at the elbow.

Golfer’s Elbow (medial epicondylitis)
Golfer’s elbow presents with pain on the medial epicondyle (inside of the elbow).  The medial epicondyle is the origin of the flexor muscle of the wrist. Golfer’s elbow is caused by the pull of the flexor tendons of the wrist on the origin of the tendon at the elbow.  Golfer’s elbow is also caused by repetitive motion of the arm, specifically with wrist flexion.  Golfer’s elbow is less common than tennis elbow.

Most patients will present to the orthopedic office with complaints of pain on the inside portion of their elbow.  The orthopedic surgeon will examine the patient and the pain is usually reproduced when the doctor palpates (presses on) the inside bony area of the elbow.  The pain is also reproduced when the doctor resists flexion of the wrist with the elbow flexed (bent) at 90 degrees.  Radiographs most commonly are negative for boney abnormalities.

The treatments are very similar to tennis elbow.  Most cases of golfer’s elbow will resolve without surgery.  NSAIDS can be prescribed for those patients who do not have any contra-indications for the medicine.  Physical therapy to stretch the flexor muscles combined with modalities such as ultrasound are effective.   A tennis elbow brace may also be used but the brace would be placed over the flexor muscles, again designed to trick the tendon and relieve the inflammation.  Corticosteroid injections are rarely used in this area due to the close proximity of the ulna nerve on the inside portion of the elbow.

Activity modification is essential.  Golfers must take a break from the game in order to allow the tendon to rest and heal.  Once resolution of symptoms occurs, returning to the game is done gradually. Surgery is rarely considered in golfer’s elbow due to the 95-100 percent resolution of symptoms with non-surgical treatments.

Dr. Baumann is fellowship trained in adult reconstructive total joint replacements, which is a subspecialty of orthopedic surgery.  She is Board Certified.  Her practice, Premier Orthopedics is located in Port St. John and she is on staff at Parrish Medical Center and Cape Canaveral Hospital. Please call 321-433-1439 for information.

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