Dr Louis M Adler answers four questions about epicondylitis.

[Related information can be found in the Orthopaedia chapter, Lateral and medial epicondylitis of the elbow]

ORTHOPAEDIA: One common treatment for epicondylitis is some form of immobilization. Often if not always, a splint is recommended. Why isn’t casting used more, as that would certainly help with compliance?

LOUIS M ADLER: First, it’s important to always recall the burdens our treatments may impose. Having a cast on can be a serious hassle—and that alone may be worth the price of a little less compliance. But here, it goes deeper than that. Immobilization is not used to cure epicondylitis, but rather only to relieve symptoms. If you have lateral epicondylitis, and you don’t actively extend your wrist, you won’t hurt, but you won’t be doing much toward resolving the underlying problem. The real therapeutic treatment is gentle mobilization. We have to stimulate healing, and that needs motion. A cast would actually be a step in the wrong direction.

ORTHOPAEDIA: Refractory epicondylitis — that is, cases that don’t get better – are ultimately treated with surgical debridement: cutting out the diseased tissue. And it seems to work! In fact, the results from this surgery are far better than most “debridement” procedures elsewhere, such as in the knee. Thus, it’s likely that the mechanism of action is not simply cutting out the pain. How do you think this operation works?

LOUIS M ADLER: Let’s start at the beginning. In about 15% of cases, surgery doesn’t work. For that reason alone, I can’t be certain of the mechanism. One possibility is that the operation denervates the painful area: we may not cut out the pain, but we cut out the nerves that send the signal with the pain to the brain. Another possibility is that by debriding the area, we stimulate the formation of healthy tissue. Of course, it is possible that the pathological tissue (what Nirschl called “microangiopathic fibroplasia”) actually generates some chemical substance that is noxious. And we should not discount either the possibility of a placebo effect.

ORTHOPAEDIA: Students are taught about two conditions, medial epicondylitis and lateral epicondylitis. Are they different conditions? Or are they the same condition with just a different adjective in front to name the location? For instance, in the knee, a medial collateral ligament sprain is quite different from a lateral collateral ligament sprain as those ligaments do different things with regards to the biomechanics of the knee. On the other hand, a medial meniscus tear is quite similar (broadly speaking) to a lateral meniscus tear, except for the issue of location.

LOUIS M ADLER: In general, medial epicondylitis and lateral epicondylitis, are the same process: the tendon is pulled off, or avulsed, from its origin. Granted, the types of activities that provoke it are a little different, which is responsible for the two eponyms given: tennis elbow for the lateral side, and golfer’s elbow for the medial. Hitting a backhand while playing tennis is more likely to provoke lateral epicondylitis, whereas golf swings usually affect the flexor pronator mass on the medial side. Yet there are a few important distinctions to keep in mind. The first is if surgery is needed, medial side surgery is a bit trickier. On the lateral side, the pathology jumps right out at you, as the disease is on the superficial surface of the tendon. On the medial side, the diseased tissue is on the deep surface. The other issue is consideration of the nearby structures. There’s really not much going on laterally, but the ulnar nerve is right there medially. It’s therefore possible to have a combination of medial epicondylitis along with a compression neuropathy of the ulnar nerve of the elbow. It is therefore especially important when considering the diagnosis of medial epicondylitis to make sure that there isn’t a second diagnosis of lurking as well.

ORTHOPAEDIA: As you mentioned, surgery is chosen for epicondylitis that does not get better with other treatments. That of course implies that patients have to jump through a few hoops to get to the operating room. They have to try immobilization, therapy and possibly injections. Only if all of that fails do they come to surgery. Wouldn’t it be better if we could identify those cases at the outset and operate on them sooner?

LOUIS M ADLER: The tricky thing here is that the disease process of a patient who comes to surgery is not very different from the disease process of people who get well on their own. It’s not even that they necessarily have “worse” epicondylitis, but rather they have epicondylitis that doesn’t go away fast enough for them. The phrase “fast enough for them” also underscores another important point. That is, surgery is chosen because the patient says “I can’t take it anymore!” It’s hard for patients to know in advance what they can’t take without experiencing it a little bit. That said, you are right: if you get a sense that a patient is the impetuous, impatient sort, it may be reasonable to offer surgery more quickly. And I don’t know if I am getting impetuous and impatient myself, but as I am ending my 25th year of practice, I have become more open to the idea of operating sooner. My colleagues in spine surgery admit that most patients with disc herniations all get better eventually (independent of treatment), yet they say that waiting it out, in pain, may not be the best approach for all. I think that applies here too.