Traumatic and overuse injuries of the elbow occur with equal propensity in sports, work, and home environments. Most will respond to conservative treatment but accurate diagnosis is required to determine the most appropriate course of management. The experiences and skills of a sports medicine physician reflect the principles of simple, sound practice of orthopaedics essential to the treatment of all elbow problems.
When surgery is necessary, often it can be performed arthroscopically. The advantages are clear. Less invasive techniques result in less postoperative pain and often quicker and easier recovery. While many orthopaedic surgeons perform knee and shoulder arthroscopy, few possess the necessary skills for performing this procedure in the elbow. Dr. Byrd is among those who have studied and developed this technique, expanding its role in providing a less invasive approach when surgery is needed. This includes the management of such conditions as chronic tennis elbow, loose bodies, bone spurs, select cases of arthritis, and even some fracture care.
Dr. Byrd has lectured and published scientific articles on various aspects of these techniques. He has trained other orthopaedic surgeons and participated in instructional programs, nationally and internationally.
Lateral Epicondylitis (Tennis Elbow)
Lateral epicondylitis is a tendonitis problem around the elbow. Tendinitis is inflammation of the tendon. Inflammation is the body’s response to injury, whether it is an acute strain or in this case more commonly a repetitive overuse injury.
The muscles on the backside of the forearm originate from a small tendon that attaches on the bony prominence along the outside edge of the elbow called the lateral epicondyle. The injury or inflammation is localized to this area, thus the name “lateral epicondylitis”. These muscles are actually more responsible for wrist motion. Thus, it is often wrist activities that worsen the pain more than use of the elbow. A whole group of tendons attach to the epicondyle, but the one most clearly responsible for epicondylitis is that of the extensor carpi radialis brevis (ECRB) that lies deepest on the bone and closest to the joint.
Lateral epicondylitis actually exists as a spectrum of injury, ranging from varying degrees of inflammation to partial tendon injury. Approximately 98% of all epicondylitis will respond successfully to conservative treatment. Since the injury exists on a spectrum, the treatment does also.
Mild inflammation may resolve spontaneously. Simply avoiding painful activities and a course of over the counter anti-inflammatory medication may be sufficient. Applying ice to the area of soreness for 20 or 30 minutes may help subside acute symptoms.
More stubborn cases may require medical attention. Examination will reveal point tenderness over the bony prominence. Pain is typically elicited when the patient is instructed to cock their wrist up against resistance by the examiner. This causes pain over the epicondyle because of tension created on the tendon when the forearm muscles contract to move the wrist. X-rays are usually unrevealing, but still useful to rule out arthritis, bone spurs, calcium deposits, or other unexpected findings.
Prescription anti-inflammatory medication may be more effective than over the counter products. Additionally, a counter force brace, which is a strap worn around the forearm, can help reduce tension on the tendon with normal use. Sometimes a wrist splint may help since it rests the involved forearm muscles. It becomes more important to identify the activities that trigger the onset of symptoms and modify these to avoid provoking pain, allowing the injury to heal. Once the problem develops, pain can be triggered by even the simplest of activities such as shaking hands, using a pencil, and even lifting a coffee cup.
Therapy can be helpful to instruct patients on how to gently stretch the muscle groups, maintaining flexibility as well as providing instruction on when best to use ice or heat. Strengthening can be helpful to protect the elbow for future use, but cannot be implemented when it is acutely inflamed. The therapists can also apply treatment modalities that reduce the localized inflammation and help with discomfort.
The most stubborn cases can sometimes benefit from a small cortisone injection into the area of involvement. This typically provides a reliable period of relief. However, if cortisone is used without trying to address the causative factors it is less likely to provide a permanent solution. With judicious use, cortisone injections can actually be used two or three times if necessary. The goal of the cortisone is to reduce the painful inflammation while allowing the injury to heal.
Instead of inflammation, sometimes the injury may include partial deterioration to the tendon adjacent to bone. Given adequate treatment and time these partial injuries have an excellent capacity to heal. For these circumstances the cortisone simply reduces the associated painful inflammation while allowing the healing process to occur. Occasionally, the tendon breakdown may exceed the body’s healing capacity. Thus, if two or three injections have not resulted in long-term resolution, repeated injections are unlikely to be of further benefit and in fact can inhibit the healing process.
For cases that continue to recur despite conservative treatment, an MRI (magnetic resonance imaging) can be helpful. This is a sophisticated non-radiation imaging technique that allows visualization of the tendon and can help to substantiate the extent of tendon injury. This is rarely necessary in the early course of treatment, because even if a partial tendon injury is identified these will predictably heal in the majority of cases.
Surgery is indicated in only 1 to 2% of all cases of lateral epicondylitis and is considered only after an appropriate trial of conservative treatment. Traditionally, this has been described using a 1.5-2 inch incision over the outside edge of the elbow. The healthy overlying tendon is taken down to debride the damaged portion underneath and the adjacent bone is scraped to stimulate the healing process.
More recently, arthroscopic techniques have been developed for addressing this problem. The most evident advantage is its less invasive nature. The tendon involved is the ECRB which lies deepest underneath the healthy overlying tendon adjacent to the joint. Arthroscopically, the damaged tendon can be debrided. Aided by the magnification provided by the arthroscope, the diseased tissue can be selectively resected without violating the overlying healthy tissue. The adjacent bone is selectively decorticated, stimulating the necessary healing response. The advantages of this less invasive approach are that there is less post-surgical pain, the patient can immediately return to light normal daily activities, and return to full unrestricted activities is quicker since the diseased tissue is addressed without having to violate any of the healthy structures. Therapy is generally less intense and the patient can anticipate a quicker return to both work and recreational activities. Another advantage of the arthroscopic method is the ability to thoroughly assess the elbow joint. About a quarter of cases will have associated joint damage that can be addressed simultaneously. The arthroscopic technique is more technically demanding and necessitates a surgeon knowledgeable in elbow arthroscopy. In our experience, we have had virtually 100% success in regards to patient satisfaction and no complications. However, potentially serious complications can occur with any of these type procedures.