What exactly hurts: not a joint or inflammation
On the outside of the elbow there is a bony protrusion - the lateral epicondyle of the humerus. The muscles that extend the hand and fingers are attached to it by a short common tendon. Every time a person extends their wrist, holds an object, turns a key, or makes a fist, this tendon places stress on a small area of bone. With monotonous, often repeated work, microdamages in the tendon accumulate faster than they can be restored, and the tissue is rebuilt: collagen fibers lose their correct structure, blood vessels and nerve endings grow in them, and areas of degeneration appear.
This is an important finding that has changed the approach to treatment over the past twenty years. The ending “-itis” implies inflammation, but when examining the tissue, classical inflammation is not found there—degenerative changes are discovered. This is why anti-inflammatory drugs provide only temporary pain relief and do not solve the problem, and this is why treatment is based on gradual loading of the tendon, which triggers its restructuring in the opposite direction. The tendon tissue is rebuilt only in response to load - but the load is dosed and correct.
- External epicondylitis - pain on the outside of the elbow, the extensors of the hand are affected, it is much more common
- Internal epicondylitis, "golfer's elbow" - pain on the inside, the wrist flexors are affected
- The basis of the changes is not inflammation, but degenerative restructuring of the tendon tissue
- The tendon most commonly affected is the extensor carpi radialis brevis tendon.
- Typical age is from 35 to 55 years, about the same for men and women
- As a rule, the dominant hand is affected, but there is also a bilateral process
Who is really sick?
The name stuck at the end of the nineteenth century, when tennis was popular among wealthy people, and doctors described the characteristic pain among players. Since then, the ratio has changed radically: today athletes make up a minority of patients. The bulk are people with monotonous household and professional loads on the hand, where the hand does not work with a lot of weight, but with a large number of repetitions and in an uncomfortable position.
- Working with a computer mouse and keyboard on an awkwardly located desk
- Professions with hand tools: electricians, plumbers, mechanics, builders, carpenters
- Hairdressers, manicurists, massage therapists, dentists - constantly work with a brush in a fixed position
- Cooks and pastry chefs: kneading, cutting, carrying heavy pans at arm's length
- Musicians, especially string players and pianists
- Parents of small children: lifting the child with outstretched arms dozens of times a day
- A sharp increase in unusual load: renovation, moving, summer season, new workout
- Sports with a racket - if the hitting technique is incorrect, the strings are too tight or the handle size is inappropriate
Pay attention to the common denominator: in almost all cases we are talking about a load with an outstretched or half-bent arm with simultaneous extension and rotation of the hand. A classic everyday example is turning a key in a tight lock, wrung out a rag, lifting a full cup by the handle. If such movements have become painful, and in the first days the pain appeared only in the evening, but now it appears immediately, the process is already underway, and there is no need to wait.
Symptoms and simple tests
The pain is localized very precisely: a person can show it with one finger - on the bony protrusion on the outside of the elbow or just below it. It intensifies with extension of the hand, with grip and rotation of the forearm, and often radiates down the outer surface of the forearm. Externally, the elbow looks normal: there is no swelling or redness, and the range of motion in the joint itself is completely preserved - which is why patients do not take the problem seriously for a long time.
- Point pain when pressing on the external epicondyle
- Pain when lifting an object with your palm down, while it is easier to lift the same object with your palm up
- Pain when turning a key, wrung out a rag, shaking hands, holding a cup by the handle
- Weakening grip strength: a cup or phone begins to fall out of your hand
- Pain when trying to straighten the wrist against resistance
- The joint is externally unchanged, movements in the elbow are complete
- In the later stages - aching pain at rest and at night
A simple home test: take a cup from the table, first with your palm down, and then with the same hand, but with your palm facing up. With external epicondylitis, the first option causes pain, the second almost not - because in the first case it is the extensors of the hand that work. Another test is to stretch your hand forward, clench your fist and straighten your wrist, overcoming the resistance of the other hand. A sharp pain at the outer point of the elbow during this movement is very characteristic.
Examination and what it is confused with
- Осмотр и нагрузочные пробы — в большинстве случаев диагноз ставится клинически, без дополнительных исследований.
- Ультразвуковое исследование — показывает утолщение и неоднородность сухожилия, кальцинаты, признаки частичного разрыва. Метод доступен и информативен.
- Рентген локтевого сустава — не для подтверждения эпикондилита, а для исключения артроза, отложений кальция и последствий травмы.
- МРТ — при нетипичной картине, при подозрении на разрыв сухожилия и при боли, не поддающейся лечению более полугода.
- Осмотр шейного отдела позвоночника — отражённая боль of шеи очень часто маскируется под эпикондилит.
- Проверка чувствительности и силы кисти — чтобы не пропустить сдавление нервов предплечья.
The most common diagnostic pitfall is radial nerve compression syndrome in the forearm. It gives pain in almost the same place, but a little lower, feels like a deep, aching pain, often bothers you at night and is accompanied by a feeling of weakness when straightening your fingers. The second source of confusion is the cervical spine: pain from the spine radiates along the outside of the arm and intensifies when turning the head. The third is instability or arthrosis of the elbow joint itself. If standard treatment does not produce an effect for months, most often the matter is not that it is ineffective, but that the cause of the pain is different.
Treatment: why there is little rest and what eccentric exercises are
The first step is not complete rest, but a change in load. Completely immobilizing the arm is harmful: without load, the tendon loses strength, the muscles weaken, and returning to normal life after a month of inactivity results in a new exacerbation. The correct strategy is to eliminate movements that cause acute pain and replace them with measured, controlled work. They understand the workplace: the height of the table and chair, the position of the elbow and wrist when working with the mouse, the size of the tool handle. Sometimes this setting solves half the problem.
The basis of treatment is exercises, primarily eccentric ones. Their meaning is that the muscle works by lengthening, not contracting: the weight is lifted with the healthy hand, and lowered slowly with the sick one, controlling the movement. This load stimulates the restructuring of collagen fibers in the tendon. Start with minimal weight, perform the movement slowly, moderate pain during the exercise is acceptable and is not a reason to quit. You need to exercise daily or every other day, and the first noticeable improvements appear no earlier than after 4–6 weeks. This is the most difficult part of the treatment - not in technique, but in patience.
- Correcting the workplace and movement technique is a mandatory first step
- Eccentric wrist extensor exercises are the main method with proven benefits.
- Stretching the forearm extensors before and after exercises
- Strengthening the muscles of the shoulder and shoulder blade - if the shoulder girdle is weak, the load shifts to the forearm
- Orthosis with a pressure pad on the forearm below the elbow - reduces pain during work, but does not replace exercise
- Cold after exercise, short-term painkillers - as auxiliary measures
- Complete inactivity and prolonged immobilization are not recommended
Injections, shock wave therapy and surgery
Injection of glucocorticoids into a painful point is probably the most controversial intervention for this disease. It does provide quick and noticeable relief in the first weeks, which is why it remains popular. The problem is what happens next. Studies comparing patients after a year showed an unexpected result: those who received hormonal injections felt worse by this time, and they had relapses more often than those who did not receive injections and exercised or simply waited. The explanation is in the nature of the drug itself: it suppresses inflammation, which is almost absent here, and at the same time inhibits the recovery processes in the tendon tissue.
- Hormonal injection - quick relief for 4-8 weeks, but worsening long-term results after about a year
- Repeated injections at one point increase the risk of thinning of the tendon and subcutaneous fat tissue
- Shock wave therapy is a method with moderate benefit in long-term processes
- Platelet-rich plasma - results are contradictory, the method is discussed individually
- Physiotherapy and manual techniques are supportive and work in combination with exercises
- Forearm brace - makes work easier, but does not replace an exercise program
Surgery is rarely considered for persistent pain that persists for more than six to twelve months despite comprehensive conservative treatment, including exercises. The point of the intervention is to remove the degenerated section of the tendon and stimulate recovery; it is performed openly or arthroscopically. It is important that surgery for this disease is not a shortcut: recovery after it also requires several months of exercise, so skipping the stage of conservative treatment still will not work. If the pain cannot be treated, it is better to first double-check the diagnosis rather than rush to the operating room.