Demystifying epicondylitis

Medial and lateral epicondylitis are elbow pathologies frequently encountered by healthcare professionals.  Although the patient presents with recent symptoms, epicondylitis is a chronic tendinosis rather than an acute inflammatory phenomenon. Most often, it’s a tendon injury secondary to work or repeated practice of a sport. In fact, it’s important to question the activities of a patient with elbow pain. Repeated pronation and supination movements, as well as repetitive gripping and twisting movements, can be identified in the history. Diagnosis is essentially clinical, hence the importance of mastering certain anatomical notions and the key maneuvers to be performed during the physical examination. Examination of the cervical spine is necessary to rule out referred pain. A differential diagnosis must be made to rule out any other pathology. Initial management of epicondylitis is primarily conservative : relative rest, anti-inflammatories, ice and physiotherapy. Rehabilitation and a gradual return to activity should not be neglected, as the prognosis will depend on it. Rarely, investigations such as X-ray, ultrasound or MRI will be necessary to clarify the diagnosis when the course is unfavorable. Many therapeutic options have been explored in recent years, for example, platelet-rich plasma (PRP) injection and the nitroglycerin patch for refractory cases. Referral to orthopaedics is reserved for patients who have undergone at least six months’ adequate conservative treatment, with surgery remaining the exception.  Written by Carolanne ForguesFamily Medicine Resident   Choose the right interventions! It’s important to understand that in the presence of epicondylitis, the treatment approach must be individualized, and that the opposite could have deleterious effects on the patient. For example, the use of ice in subjects with central tenderness is likely to lead to an increase in pain (3-4). It is not uncommon for these patients to suffer from cold hyperalgesia, which is an unfavorable prognostic factor (4). It is therefore inadvisable to use ice as a treatment for them. Similarly, anti-inflammatory drugs are of little use if the patient is in the tendinosis phase, rather than in the acute inflammatory phase (3). As mentioned above, tendinosis is more common. Cortisone injections should be avoided. It may reduce symptoms in the short term, but is not very effective in long-term treatment, and is associated with a high risk of recurrence (1). The physiotherapy approach produces the best short- and long-term results (1). Strengthening the muscles of the forearm and the whole upper body is a priority. The introduction of eccentric exercise appears to be effective, but may exacerbate symptoms in the reactive inflammatory phase (3). All in all, you need to be patient, as about two-thirds of cases will improve after six weeks of exercise and physiotherapy treatment. After one year, 91% of cases have satisfactory results with this approach (1).   Written by  Maxime Provencher M. Physiotherapy References :

1. Coombes BK & al. Effect of corticosteroid injestion, physiotherapy or both on clinical outcomes in patients with unilateral lateral epicondylalgia. A randosized controlled trial. American medical association (2013). JAMA. 2013 Feb 6;309(5):461-9
2. Bisset LM & Vicenzino B. Physiotherapy management of lateral epicondylalgia. Journal of physiotherapy (2015) 61:174-181
3. Coombes BK & al. Management of lateral elbow tendinopathy: One size does not fit all. J Orthop Sports Phys Ther.(2015) Nov;45(11):938-49
4. Coombes BK & al. Cold hyperalgesia associated with poorer prognosis in lateral epicondylalgia: a 1-year prognostic study of physical and psychological factors. Clin J Pain. (2015) Jan;31(1):30-5
5. Jayanthi, Neeru.  Epicondylitis (tennis and golf elbow), Uptodate, October 2018.
6. Le médecin du Québec, July 1988; April 1999