Elbow Epicondylitis (elbow Joint) - Types, Symptoms, Modern Methods Of Treatment

2024 Author: Josephine Shorter | [email protected]. Last modified: 2023-12-16 21:43

Elbow epicondylitis (elbow joint)

What is epicondylitis

Epicondylitis is an inflammatory-degenerative tissue damage in the area of the elbow joint. The disease begins to develop at the points of attachment of the tendons of the forearm to the epicondyle of the humerus, on the outer or inner surface of the joint. Its main cause is chronic overload of the forearm muscles.

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 the occurrence of 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, but there is no exact incidence statistics, since the disease is often mild enough, and most potential patients do not go to medical institutions.

By localization, epicondylitis is divided into external (lateral) and internal (medial). Lateral epicondylitis occurs 8-10 times more often than medial, and mainly in men. At the same time, right-handers mainly suffer from the right hand, and left-handers - the left.

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.).

Content:

• Epicondylitis causes
• Epicondylitis symptoms
• Types of epicondylitis
• Diagnosis of epicondylitis
• How is epicondylitis treated?
• Exercises for epicondylitis
• Prevention of epicondylitis and prognosis

Epicondylitis causes

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 job;
• Regular microtrauma or direct trauma to the elbow joint;
• Chronic overload of the joint;
• Local circulatory disorders;
• Presence of osteochondrosis of the cervical or thoracic spine, humeroscapular periarthritis, osteoporosis.

Epicondylitis is often diagnosed in people whose main activity is associated with repetitive hand movements: pronation (turning the forearm inward and palm down) and supination (turning outward, palm up).

The risk group includes:

• agricultural workers (tractor drivers, milkmaids);
• builders (bricklayers, plasterers, painters);
• athletes (boxers, weightlifters);
• doctors (surgeons, masseurs);
• musicians (pianists, violinists);
• service workers (hairdressers, ironers, typists), etc.

By themselves, these professional activities do not cause epicondylitis. The disease occurs with excessive overload of the muscles of the forearm, when systematic microtraumas of the periarticular tissues occur against its background. As a result, the inflammatory process begins to develop, small scars appear, which further reduces the resistance of the tendons to stress 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;
• A 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-scapular 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.

Epicondylitis symptoms

Common symptoms of epicondylitis include:

• Spontaneous intense, sometimes burning pain in the elbow joint, which over time can become dull, aching;
• Increased pain during physical exertion on the elbow or when the muscles of the forearm are strained;
• Gradual loss of muscle strength in the arm.

With lateral epicondylitis, pain spreads over the outer surface of the elbow joint. It increases with the extension of the wrist, with resistance to its passive flexion and rotation of the wrist outward. In the latter case, there is also muscle weakness on the outside of the elbow. The coffee cup test is positive (pain worsens when trying to lift a cup filled with liquid off the table). The intensity of the pain syndrome increases with supination (turning outward) of the forearm from the extreme point of pronation.

With medial epicondylitis, the pain is localized on the inner surface of the elbow joint, aggravated by flexion of the forearm and by resistance to passive extension of the wrist. Pain can radiate down the internal muscles of the forearm towards the hand. There is a sharp limitation in the range of motion in the joint.

Distinguish between acute, subacute and chronic stages of the disease. At first, the pain syndrome is accompanied by a sharp or prolonged muscle tension, then the pain becomes constant, and rapid fatigue of the arm muscles appears. In the subacute stage, the intensity of pain sensations decreases again, at rest they disappear. The chronic course of the disease is said to be when the periodic alternation of remission and relapse lasts from 3 to 6 months.

Types of epicondylitis

Depending on the location, epicondylitis is divided into two main types: external, or external, which affects the tendons that attach to the external epicondyle, and internal, in which the tendons coming from the internal epicondyle become inflamed.

Lateral (external) epicondylitis

In this case, the site of attachment of muscle tendons to the lateral epicondyle of the bone becomes inflamed. External epicondylitis is often referred to as "tennis elbow" because this problem is typical for people who are fond of this sport. When playing tennis, the extensor muscles on the outside of the forearm are overstrained. A similar excessive load on specific muscles and tendons is also observed during such monotonous work as sawing wood, painting walls, etc.

Lateral epicondylitis is diagnosed with a screening test called the handshake symptom. The usual handshake is painful. Also, pain can appear when the hand is turned with the palm up, when the forearm is extended.

Medial (internal) epicondylitis

With internal epicondylitis, the site of attachment of 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 throwing, throwing the nucleus lead to medial epicondylitis.

Unlike lateral epicondylitis, this type of epicondylitis is more common with lighter loads, therefore, it is observed mainly in women (typists, dressmakers, etc.). The monotonous stereotyped movements that they perform are done by the flexor muscles of the wrist, 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 location of pain. For internal epicondylitis, a chronic course is especially characteristic, as well as involvement of the ulnar nerve in the process.

Traumatic epicondylitis

Traumatic epicondylitis includes systematic minor trauma in the process of constantly performing 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 damaged structures are gradually replaced by connective tissue.

Post-traumatic epicondylitis

This type of epicondylitis develops as a result of the resulting sprains or dislocations of the joint, with poor adherence to medical recommendations during the rehabilitation period and a 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 give way to relapses, the pain gradually acquires a weak, aching character, and the muscles lose strength, to the point that a person sometimes cannot write or just take something in his hand.

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Diagnosis of epicondylitis

The diagnosis is made on the basis of patient interviewing, history 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 arise. This is the difference between epicondylitis and arthritis or arthrosis.

Additionally, tests for Thomson's and Welt's symptoms are performed. Thomson's test is as follows: the patient must clench the hand in the back position into a fist. At the same time, it turns around rather quickly, moving to the position with the palm up. When Velta's symptom is detected, 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 lag significantly 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;
• Contusions of soft tissues;
• Epicondyle fracture;
• Cracked styloid process;
• Aseptic necrosis;
• Arthritis;
• Bursitis;
• Tunnel syndromes (infringement of the ulnar or median nerve);
• Rheumatoid joint damage;
• Symptoms of cervical osteochondrosis.

With a fracture of the epicondyle, swelling of the soft tissues in the joint area is observed, which is not the case with epicondylitis. With arthritis, pain occurs in the joint itself, and not in the epicondyle, while it is more vague, rather than clearly localized.

When nerves are pinched, characteristic neurological symptoms are noted - a violation of sensitivity in the innervation zone.

Syndrome of hypermobility of joints (when it comes to 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. To differentiate with a fracture of the epicondyle, X-rays are taken, 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 prolonged chronic course of the disease. In this case, foci of osteoporosis, osteophytic growths, compaction of the ends of the tendons and bone tissue are found.

How is epicondylitis treated?

Treatment is carried out on an outpatient basis. Therapeutic tactics are 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 syndrome in the lesion focus;
• Restoration of local blood circulation;
• Restoration of the full range of motion in the elbow joint;
• Prevention of forearm muscle atrophy.

In case of mild pain, it is recommended to observe a protective regime 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 ensure peace of the elbow joint, as well as find out and eliminate the causes of overload: change the technique for performing specific movements, etc. After the pain disappears, you need to start with a minimum load and increase it gradually …

In case of a chronic course of the disease and frequent relapses, it is recommended to change the type of activity or stop practicing this sport.

In case of severe pain in the acute stage, a short-term immobilization of the joint is carried out using a plaster cast or a plastic splint for about a week. After removing the splint, you can make 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, non-steroidal anti-inflammatory drugs for topical use in the form of ointments are prescribed: Diclofenac, Nurofen, Indomethacin, Nimesil, Ketonal, Nise, etc. Oral administration of NSAIDs in this case is little justified.

With very strong, unrelenting pain, blockages are performed with corticosteroids, which are injected into the area of inflammation: hydrocortisone or metiprednisolone. However, it should be borne in mind that during the first day this will cause increased pain. A 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 relieved within 2-3 weeks, with drug blockades - within 1-3 days.

Additionally, Nikoshpan, Aspirin, Butadion can be assigned. To change the trophism of tissues, 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.

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Physiotherapy

Almost the entire possible list of physiotherapy procedures is used to treat epicondylitis.

In the acute period, the following can be carried out:

• High-intensity magnetic therapy with a course of 5-8 sessions;
• Diadynamic therapy, a course of 6-7 sessions;
• Infrared laser radiation, duration of exposure 5-8 minutes, course of 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;
• Bernard's currents;
• Paraffin-ozokerite and naphtholone applications;
• Dry air cryotherapy.

Paraffin applications can be done approximately 3-4 weeks after joint immobilization and novocaine blockade. With shock wave therapy, the acoustic wave should be directed to the joint area and not propagate 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, in chronic bilateral epicondylitis with frequent exacerbations, progressive muscle atrophy or compression of nerve roots, even injections of glucocorticosteroid drugs do not help. In such a situation, surgical intervention is indicated.

Operative intervention

If, with conservative treatment, the pain does not stop within 3-4 months, this is an indication for surgical excision of the tendons in the places of their attachment to the bone.

The so-called Hohman operation is performed routinely using conductive anesthesia or under general anesthesia. In the original version, the tendons were excised at their junction with the extensor muscles.

Currently, excision is performed in the area of attachment of the tendon to the bone itself. In this case, in the area of the external epicondyle, a small horseshoe-shaped incision of about 3 cm is made, 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 intact, but the source of pain on the anterior surface of the epicondyle is freed 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.

Exercises for epicondylitis

Therapeutic exercises help restore the functionality of the joint. You can start it only after the extinction of the acute stage of the disease. The exercise therapy complex should be compiled by the attending physician. Basic exercises focus on stretching and relaxing muscles and tendons.

When doing gymnastics, you must adhere to the following rules:

• Increase the load and duration of classes gradually;
• Stop exercising immediately when acute pain occurs, since they should not cause pain;
• Exercise daily.

Exercise therapy exercises improve blood circulation, stimulate lymph flow and the secretion of synovial fluid, increase the elasticity of ligaments and strengthen muscles, which generally increases the endurance of the elbow joint.

The exercises recommended for epicondylitis are divided into active and passive movements performed with the other, healthy hand.

Passive movements:

• Grasp the other hand with your good hand and slowly bend it until a feeling of tension appears in the elbow area, trying to ensure that the angle between the hand and the forearm is 90 ° C. Linger at the extreme point for 10-15 seconds. Do two approaches 7-10 times. Repeat the same exercise, unbending the brush (that is, pulling it up).
• While standing, put both palms in front of you on the table. Lean forward slightly so that the palms are at a right angle with the forearms.
• Put your hands on the table with the back surface (palms up), while fingers are directed towards you, elbows are slightly bent. Also try to create a right angle between the hands and forearms by leaning slightly off the table.

After the stretching exercises stop causing any discomfort, you can move on to exercises aimed at strengthening the muscles and ligaments.

Active movements:

• Alternately transfer the free hand to the position of pronation and supination, while the palm first looks down, then up;
• Consistently bend and unbend the forearm, while the shoulder remains motionless;
• Bend your arm at the elbow, alternately clench and unclench your fist;
• Connect the hands in a lock, bend and unbend both arms at the elbows;
• Rotate your shoulders back and forth, then perform circular movements with your forearms;
• Raise straight arms in front of you and alternately wind one after the other ("scissors").
• Take a thick rubber cord and wind the ends around your hands. Put the wrist of the healthy hand on the table, place the wrist of the sore hand over it, palm down. Perform slow extension and flexion of the wrist of the sore arm, while stretching the cord, which will provide resistance. Then turn your hand palm up and repeat the exercise.
• Stand straight, feet shoulder-width apart, back straight, in an outstretched hand in front of you, a gymnastic stick, located vertically. Slowly turn the stick to parallel to the floor (the palm goes down), and also slowly return the hand to its original position. Then again turn the stick to a horizontal position, only the palm now looks up. Continue twisting the stick, pausing at the extreme positions. Do 2-3 sets of 20 times.

Then you can move on to strength exercises with minimal stress, for example, working with a wrist expander, but at the same time avoiding muscle strain.

Some exercises:

• Pick up a hammer or any other heavy object that is comfortable to hold; the hand is turned with the back surface up, the angle at the elbow joint is 90-120 ° C. Supinate (unbend) the brush and return to its previous position. Do 2 sets of 10 repetitions, with a break of 2-3 minutes.
• Take the hammer in the same way, only with the back facing down (palm up). Flex and unbend the wrist. Do 2 sets of 10 repetitions, with a break of 2-3 minutes.

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Prevention of epicondylitis and prognosis

Prevention is divided into primary (prevention of disease) and secondary (prevention of exacerbations). In both cases, it is necessary to observe the established regime of work and rest.

Among the specific recommendations are the following:

• When playing sports, you should observe the correct technique for performing exercises and correctly select sports equipment;
• Try to avoid stereotypical monotonous movements that load the joint;
• Before any kind of physical activity, warm up the joints, warming up the muscles and tendons;
• During exacerbations and during heavy physical exertion, fix the elbow joints using an elastic bandage or elbow pads;
• Take breaks from work with prolonged monotonous movements.

Drug prophylaxis consists in the regular intake of vitamin preparations, as well as the timely treatment of any foci of inflammation in the body.

The prognosis for epicondylitis is favorable; if preventive measures are taken, a stable remission can be achieved.

Author of the article: Kaplan Alexander Sergeevich | Orthopedist

Education: diploma in the specialty "General Medicine" received in 2009 at the Medical Academy. I. M. Sechenov. In 2012 completed postgraduate studies in Traumatology and Orthopedics at the City Clinical Hospital named after Botkin at the Department of Traumatology, Orthopedics and Disaster Surgery.