Epicondylitis : Elbow tendonitis

Diagnosis of an epicondylitis

This term describes an inflammation of the tendons inserting at the lateral edge of the elbow at the humerus. Often called « Tennis - Elbow » this condition is not exclusive to sports-players, but also occurs after a shock or over-exertion of the elbow and can be occasional or chronic. This lesion can cause disabling pain which can last for several months, or even years and if left untreated, result in a necessary change of job or the inability to continue practising sports.

Diagnosis is made essentially during the examination when the pain is reproduced by exerting pressure at the insertion of the tendons on the lateral aspect of the elbow.

X-rays or an MRI may be requested where there is the possibility that the cause is the initial stage of a rupture of the tendons or the associated lesions.

Treatment of an elbow tendonitis

Treatment is difficult, long, and not always entirely efficient.

It is firstly medical, involving the discontinuation of the activities responsible, an analgesic and anti inflammatory treatment. Specific physical therapy is also very useful. Infiltrations may also be realised.

Extra-corporal shock wave sessions performed by a specialised practitioner may also be proposed.

Where the operation has failed, it is possible to envisage further surgery after several months of treatment.

This is carried out at the request of the patient when several months of treatment have proven to be ineffective and the patient wishes to improve his condition.

Surgery consists in making a lateral incision to distend the irritated tendons at the point of bone insertion, removing fragments of bone or degenerative tendons, and possibly freeing the compressed nerves at their point of contact.

It may be required for the patient to stop work for several months at the decline of treatment, and improvement is unfortunately not always complete or sufficient.

Nevertheless, when all other possibilities have been exhausted, surgery remains the only solution to improve symptoms.

Surgical procedure to treat epicondylitis

• Length of hospital stay: outpatient or two days depending on the individual case
• Anaesthetic: Regional. Only the arm is put to sleep
• Immobilisation: arm in a sling for 8 to 10 days

The procedure is carried out under regional anaesthetic, only the arm is put to sleep and a tourniquet is placed at the root of the limb so as to prevent bleeding. A 4 to 5cm incision is made on the side of the elbow.

Several different techniques may be used. Personally I often first opt to distend the muscles by sectioning the aponevrosis, i.e. the envelopes surrounding the different muscles, and freeing the motor branch of the radial nerve which is in contact with them. Secondly, I distend the tendons at their insertion point on the humerus, and remove all of the degenerative tendinous or osseuses zones. The joint is not opened systematically. A Redon, i.e. a tube to aspirate blood, is left in place for 24 hours during the hospital stay.

The skin is sutured using an intra-dermic surjet i.e. in the thickness of the tissues, in order to limit visible scarring. The arm is kept immobile using a scarf for one week and physical therapy is commenced two weeks after surgery.

Sports activities using the affected arm are not generally to be envisaged before 2 months. The functional result can be excellent, but pain or functional discomfort may persist after surgery and constitute a handicap for the patient.

Complications

• The main complication is the persistence of pain or functional discomfort.
• Infection, haematoma, are rare but remain possible, and require antibiotic treatment or further surgery.
• Lesions of the nerves or tendons are also a possibility.
• Stiffening of the elbow, with swelling and pain may last for several months.
• Algoneurodystrophy with stiffness, swelling and pain may develop over several months. Unfortunately this condition is unpredictable prior to the operation and treatment is difficult and long and often involves functional after-effects with loss of mobility as a result.
• In spite of surgery, it may become indispensable for the patient to stop sports activities or even adapt his work activities for several months. This is, of course, due to the initial medical problem and not caused by the surgery itself.