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Epicondylitis

Dr. Paul A. Reilly

“Epicondylitis” of the elbow is a common condition in clinical practice. Standard textbooks contain conventional wisdom and references to appropriate studies, and the audience is well advised to consult these books. This talk will discuss the epidemiology, aetiology, pathogenesis and management of lateral and medial epicondylitis from the perspective of a Rheumatologist who also suffers from the former.

As with much of soft-tissue rheumatism the terminology is poor. So-called “tennis elbow” (lateral epicondylitis) was first described well over a century ago, but only a small minority of sufferers are raquet sportsmen, and the condition is as likely in a doctor as a docker. Medial epicondylitis (or “golfers’ elbow”) is 15 times less common than tennis elbow, and seems rare even in golfers unless their right hand grip is too strong (leading to a habitual slice.!)

The epidemiology of epicondylitis is interesting. It is not a problem in childhood or among teenagers, and is rare in those in their 20s, even if such individuals play daily tennis or golf. As an “overuse injury”, at least in a sporting context, it is not associated with youth. Epicondylitis therefore seems to be related to advancing years. A visit to any tennis, badminton or squash club will illustrate that Neoprene and other supports are worn mainly by the active middle-aged. These occasional sportsmen and women are not only older, but are, relatively speaking, unused to to vigorous physical activity involving their dominant limb. Since professional raquet sportsmen (even on the Seniors Tour), who play every day, are rarely seen wearing elbow clasps, we can perhaps deduce that regular vigorous activity is less likely to cause epicondylitis than intermittent, unaccustomed activity. Ergo, epicondylitis occurs in ageing individuals who do occasional vigorous exercise.

And what is the pathological basis? There are numerous postulated pathologies for epicondylar pain. Age-related changes are obvious in skin and hair, but similar changes occur in most tissues, including tendons, ligaments, and intervertebral discs. There is evidence that epicondylitis is related to natural age-related degeneration in tendon fibres, perhaps at areas of relative ischaemia, and that these changes are brought to our attention by unaccustomed activities: tennis, badminton, gardening, and other DIY pursuits. Does work cause epicondylitis, or merely bring degenerate tendons to our attention? There is little evidence that use of a keyboard, no matter how intense, can actually damage an intact enthesis at the elbow. There is no requirement for rapid, forceful pronation and supination of the forearm. Depression of computer keys relies upon activity in the introsseous and lumbrical muscles, not the power grip muscles of the forearm. We all have anecdotal recollections of bricklayers who have developed tennis elbow on their non-dominant side due to frequent, rapid and forceful supination of the hand, or carpenters who have dominant limb pain, but in my own experience I have injected many more patients with epicondylitis who did white-collar work than manual work, and this is borne out by formal epidemiological research.

Is epicondylitis an occupational disorder? Rarely. Is it a recreational disorder? Partly. Is it an age-related phenomenon? Probably. How should it be managed? Physiotherapy is often disappointing, while injection of corticosteroids usually brings relief which is sometimes prolonged, but more often temporary. Splints are often equally unhelpful. As a last resort lateral release may help, but not in all cases. The management of ageing soft-tissues is difficult indeed.

A presentation will soon be avilable to accompany this abstract

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