Contents
What is epicondylitis
Epicondylitis – This is a lesion of tissues in the area of the elbow joint, which is inflammatory and degenerative in nature. The disease begins to develop in the places of attachment of the tendons of the forearm to the epicondyles of the humerus, on the outer or inner surface of the joint. Its main cause is chronic overload of the muscles of the forearm.
With epicondylitis, the pathological process affects the bone, periosteum, tendon attached to the epicondyle, and its vagina. In addition to the external and internal condyle, the styloid process of the radius is affected, which leads to the development of styloiditis and pain at the site of attachment of the tendons of the muscles that abduct and extend the thumb.
Epicondylitis of the elbow joint is a very common disease of the musculoskeletal system, however, there is no exact incidence statistics, since the disease often proceeds in a fairly mild form, and most potential patients do not go to medical institutions.
According to localization epicondylitis is divided into external (lateral) and internal (medial). Lateral epicondylitis occurs 8-10 times more often than medial epicondylitis, and predominantly in men. In this case, right-handed people mainly suffer from the right hand, and left-handed people have the left hand.
The age range in which this disease is observed is 40-60 years. The risk group includes people whose occupation is associated with the constant repetition of the same monotonous movements (drivers, athletes, pianists, etc.).
Causes of epicondylitis
In the development of the disease, degenerative changes in the joint precede the inflammatory process.
The provoking factors in this case are:
The nature of the main work;
Regular microtraumas or direct injuries of the elbow joint;
Chronic overload of the joint;
Disturbances of local blood circulation;
The presence of osteochondrosis of the cervical or thoracic spine, humeroscapular periarthritis, osteoporosis.
Epicondylitis is often diagnosed in people whose main activities involve repetitive hand movements: pronation (turning the forearm inward and palm down) and supination (turning outward with the palm up).
The risk group includes:
agricultural workers (tractor drivers, milkmaids);
builders (masons, plasterers-painters);
athletes (boxers, weightlifters);
doctors (surgeons, massage therapists);
musicians (pianists, violinists);
service workers (hairdressers, ironers, typists), etc.
By themselves, these professional activities do not cause epicondylitis. The disease occurs when the muscles of the forearm are overloaded, when systematic microtraumas of the periarticular tissues occur against its background. As a result, an inflammatory process begins to develop, small scars appear, which further reduces the resistance of tendons to loads and high muscle tension and leads to an increase in the number of microtraumas.
In some cases, epicondylitis occurs due to:
Received direct injury;
Congenital weakness of the ligamentous apparatus in the area of the elbow joint;
Single intense muscle strain.
As mentioned above, there is a connection between epicondylitis and diseases such as:
Osteochondrosis of the cervical or thoracic spine;
Shoulder-shoulder periarthritis;
Connective tissue dysplasia;
Circulatory disorders;
Osteoporosis.
The role of local circulatory disorders and degenerative phenomena in the onset of the disease is evidenced by the often diagnosed bilateral nature of the lesion and the slow, gradual development of the disease.
Symptoms of epicondylitis
Common symptoms of epicondylitis include:
Spontaneous intense, sometimes burning pain in the elbow joint, which over time can become dull, aching in nature;
Increased pain during physical exertion on the elbow or with tension in the muscles of the forearm;
Gradual loss of muscle strength in the arm.
With lateral epicondylitis, pain spreads along the outer surface of the elbow joint. It increases with wrist extension, resistance to passive flexion and outward rotation of the wrist. In the latter case, there is also weakness of the muscles on the outside of the elbow. The “coffee cup” test is positive (pain worsens when trying to pick up a cup filled with liquid from a table). The intensity of the pain syndrome increases with supination (turning outward) of the forearm from the extreme point of pronation.
With medial epicondylitis, pain is localized on the inner surface of the elbow joint, aggravated by flexion of the forearm and resistance to passive extension of the wrist. The pain may radiate down along the internal muscles of the forearm towards the hand. There is a sharp limitation of the range of motion in the joint.
There are acute, subacute and chronic stages of the disease. First, the pain syndrome accompanies a sharp or prolonged muscle tension, then the pain becomes constant, and rapid fatigue of the muscles of the hand appears. In the subacute stage, the intensity of pain decreases again, at rest they disappear. They say about the chronic course of the disease when the periodic alternation of remissions and relapses lasts from 3 to 6 months.
Types of epicondylitis
Depending on the localization, epicondylitis is divided into two main types: external, or external, which affects the tendons attached to the external epicondyle, and internal, in which the tendons coming from the internal epicondyle become inflamed.
Lateral (external) epicondylitis
In this case, the place of attachment of the muscle tendons to the lateral epicondyle of the bone becomes inflamed. External epicondylitis is often referred to as “tennis elbow” because the problem is common among people who play tennis. When playing tennis, there is an overstrain of the extensor muscles located on the outside of the forearm. A similar excess load on specific muscles and tendons is also observed in such monotonous work as sawing firewood, painting walls, etc.
Lateral epicondylitis is detected by a screening test called the handshake symptom. The usual handshake in this case causes pain. Also, pain may appear when the hand is turned palm up, when the forearm is extended.
Medial (internal) epicondylitis
With internal epicondylitis, the place of attachment of the muscle tendons to the medial epicondyle of the bone is affected. Other names for this type of disease are epitrochleitis and “golfer’s elbow”, which indicates its prevalence among golfers. Also, sports such as throws, shot throwing lead to medial epicondylitis.
Unlike lateral, this type of epicondylitis is more common with lighter loads, therefore it is observed mainly in women (typists, dressmakers, etc.). The monotonous stereotypical movements that they perform are made by the wrist flexor muscles, which are attached by tendons to the medial epicondyle of the humerus.
Usually in this case, pain occurs when pressure is applied to the inner epicondyle, increases with flexion and pronation of the forearm, and also radiates along its inner edge. In most cases, the patient can accurately determine the localization of pain. For internal epicondylitis, a chronic course is especially characteristic, as well as involvement in the process of the ulnar nerve.
Traumatic epicondylitis
Traumatic epicondylitis refers to systematic minor traumatization in the process of constant performance of the same type of actions. Usually it is accompanied by deforming arthrosis of the elbow joint, damage to the ulnar nerve and cervical osteochondrosis. At the age of over 40, the ability of tissues to regenerate decreases, and the disturbed structures are gradually replaced by connective tissue.
Post-traumatic epicondylitis
This type of epicondylitis develops as a result of sprains or dislocations of the joint, with poor adherence to medical recommendations during the rehabilitation period and too hasty transition to intensive joint work.
Chronic epicondylitis
The chronic course is very characteristic of a disease such as epicondylitis. For a long time, when exacerbations are replaced by relapses, the pain gradually acquires a weak, aching character, and the muscles lose strength, to the point that a person cannot sometimes write or simply take something in his hand.
Diagnosis of epicondylitis
The diagnosis is made on the basis of a patient interview, anamnesis data and visual examination. The difference between epicondylitis and other destructive lesions of the elbow joint is determined by the specifics of the pain syndrome. With this disease, pain in the joint appears only with independent physical activity. If the doctor himself makes various movements with the patient’s hand without the participation of his muscles (passive flexion and extension), pain does not occur. This is the difference between epicondylitis and arthritis or arthrosis.
Additionally, tests for Thomson’s and Welt’s symptoms are carried out. The Thomson test is as follows: the patient must clench the hand in the back position into a fist. At the same time, it quickly unfolds, moving into a position with the palm up. When identifying a symptom of Welt, you need to keep your forearms at the level of the chin, and at the same time unbend and bend your arms. Both actions performed by the diseased hand are noticeably behind the actions performed by the healthy hand. These tests are accompanied by severe pain. Also, this disease is characterized by pain in the area of the articular tendons when the arm is abducted behind the lower back.
Epicondylitis must be differentiated from:
Joint hypermobility syndrome;
Soft tissue bruises;
Fracture of the epicondyle;
Fissures of the styloid process;
Aseptic necrosis;
Arthritis;
Bursitis;
Tunnel syndromes (infringement of the ulnar or median nerve);
Rheumatoid joint disease;
Symptoms of cervical osteochondrosis.
With a fracture of the epicondyle, there is swelling of the soft tissues in the joint area, which is not the case with epicondylitis. In arthritis, pain occurs in the joint itself, rather than in the epicondyle, and it is more vague, rather than clearly localized.
When the nerves are pinched, characteristic neurological symptoms are noted – a violation of sensitivity in the zone of innervation.
Joint hypermobility syndrome (if we are talking about young patients) is caused by congenital weakness of the connective tissue. To identify it, the frequency of sprains, the presence of excessive joint mobility, and flat feet are analyzed.
Additional research methods in the diagnosis of epicondylitis are usually not used. For differentiation with a fracture of the epicondyle, an x-ray is done, with tunnel syndromes – magnetic resonance imaging, with an acute inflammatory process – a biochemical blood test.
Radiography with epicondylitis is informative only in the case of a long chronic course of the disease. In this case, foci of osteoporosis, osteophyte growths, thickening of the ends of the tendons and bone tissue are found.
How to treat epicondylitis?
Treatment is carried out on an outpatient basis. Therapeutic tactics is determined depending on the duration of the disease, the degree of functional disorders in the joint and pathological changes in muscles and tendons.
The main tasks are:
Termination of pain in the lesion;
Restoration of local blood circulation;
Restoration of the full range of motion in the elbow joint;
Prevention of atrophy of the muscles of the forearm.
With mild pain, it is recommended to observe a protective regimen and try to exclude movements that cause pain. If work or sports are associated with a large load on the muscles of the forearm, you should temporarily provide rest to the elbow joint, as well as find out and eliminate the causes of overload: change the technique for performing specific movements, etc. After the disappearance of pain, you need to start with a minimum load and increase it gradually .
In the chronic course of the disease and frequent relapses, it is recommended to change the type of activity or stop practicing this sport.
With severe pain in the acute stage, a short-term immobilization of the joint is carried out with the help of a plaster or plastic splint for about a week. After removing the splint, you can do warming compresses with camphor alcohol or vodka. In the chronic stage, it is recommended to fix the joint and forearm with an elastic bandage during the day, removing it at night.
Use of NSAIDs
Since the cause of pain in epicondylitis is an inflammatory process, topical non-steroidal anti-inflammatory drugs are prescribed in the form of ointments: Diclofenac, Nurofen, Indomethacin, Nimesil, Ketonal, Nise, etc. Oral intake of NSAIDs in this case is little justified.
With very strong, unrelenting pain, corticosteroid blockades are carried out, which are injected into the area of inflammation: hydrocortisone or metiprednisolone. However, it must be borne in mind that during the first day this will cause increased pain. Glucocorticosteroid is mixed with an anesthetic (Lidocaine, Novocaine). Usually 2-4 injections are given with an interval of 3-7 days.
With conservative treatment without the use of glucocorticosteroids, the pain syndrome is usually removed within 2-3 weeks, with drug blockades – within 1-3 days.
Additionally, Nikoshpan, Aspirin, Butadion can be prescribed. To change tissue trophism, blockades with bidistilled water can be carried out; they are quite painful, but effective. In the chronic course of the disease, Milgamma injections are prescribed.
Physiotherapy
For the treatment of epicondylitis, almost the entire list of possible physiotherapy procedures is used.
In the acute period can be carried out:
High-intensity magnetotherapy in a course of 5-8 sessions;
Diadynamic therapy, a course of 6-7 sessions;
Infrared laser radiation, duration of exposure 5-8 minutes, course 10-15 procedures;
At the end of the acute stage appoint:
Extracorporeal shock wave therapy;
Phonophoresis from a mixture of hydrocortisone and anesthetic;
Electrophoresis with novocaine, acetylcholine or potassium iodide;
Toki Bernarda;
Paraffin-ozocerite and naphtholone applications;
Dry air cryotherapy.
Paraffin applications can be done approximately 3-4 weeks after joint immobilization and novocaine blockade. In shock wave therapy, the acoustic wave should be directed to the area of the joint and not spread to the ulnar, median, radial nerves and blood vessels.
To prevent muscle atrophy and restore joint functions, massage, mud therapy, wet and dry air baths and exercise therapy are prescribed. There are good reviews about acupuncture.
In rare cases, with chronic bilateral epicondylitis with frequent exacerbations, progressive muscle atrophy or nerve root compression, even injections of glucocorticosteroid drugs do not help. In such a situation, surgical intervention is indicated.
Operative intervention
If, with conservative treatment, pain does not stop within 3-4 months, this is an indication for surgical excision of the tendons at the sites of their attachment to the bone.
The so-called Hochmann operation is performed in a planned manner using conduction anesthesia or under general anesthesia. In the original version, the tendons were excised at the points of their connection with the extensor muscles.
Currently, excision is carried out in the area of attachment of the tendon to the bone itself. At the same time, a small horseshoe-shaped incision of about 3 cm is made in the region of the external epicondyle, the epicondyle is exposed, and a 1-2 cm incision of the tendon fibers is made in front of it, without affecting the bone. All extensor attachments are not disturbed, but the source of pain on the anterior surface of the epicondyle is released from muscle traction. The risk of damage to blood vessels and nerve channels is excluded. After the operation, superficial sutures and plaster are applied, the sutures are removed after 10-14 days.
[Video] Doctor Egorov – elbow hurts, treatment options: