Medial and Lateral Epicondylitis
Pain on the Outside or Inside of the Elbow
(AKA Lateral or Medial Epicondylitis/Epicondylopathy and Tennis or Golfer’s Elbow)
When there is pain/tenderness on the outside or inside surfaces of the elbow without any underlying mechanical issues the most common diagnoses by far are lateral or medial epicondylitis. These conditions go by several different names but these are still the most commonly used names. These are very common but somewhat poorly understood conditions of the muscles/tendons that attach to the outside and inside surfaces of the elbow.
These conditions are so common that up to 50% or more of all people will experience symptoms at some point in their lives, such that many consider these to be a “rite of passage”. I have experienced this condition myself in both of my elbows. However, some patients are able to cope with this with minimal pain and dysfunction while others seem to be severely disabled. We don’t completely understand why there is such a difference in how people experience this nearly universal condition. What is also frustrating is that the condition can linger with off-an-on symptoms for up to 1-2 years or more! Some patients have severe symptoms and dysfunction from this process even after it would have been expected to resolve. Many of these patients do not get relief from any treatment interventions, including therapy, medicines, injection, and surgery. It is almost as if the pain lingers even after the process has resolved, analogous to a “phantom pain”. For some of these patients their underlying psychosocial situation can impact their symptoms significantly. For example, we know that people with broken bones who also have stress, anxiety, depression, or other significant psychosocial issues will continue to have pain and symptoms even after their broken bones have healed. They almost continue to feel as if the bone is still broken even though structurally it has healed. Therapy, medications, biofeedback, meditation, education, and other interventions to address these issues may be beneficial.
While an MRI is not usually needed or recommended for this condition, if you were to obtain an MRI sometimes it would show some changes in the affected area of the elbow and sometimes it wouldn’t; in other words the MRI pictures may not correlate with symptoms. Interestingly, studies have shown that the more torn the muscles/tendons are in these areas of the elbow the less painful and disabling the condition is for patients. In fact, if it is completely torn we usually do not recommend repair since a complete tear will typically resolve the symptoms spontaneously without any loss in strength unless they have some confounding mechanical or other issues.
If symptoms cannot be controlled by the patient on their own there are several options available. The best evidence we currently have is that time plus a home program with specific stretching and strengthening exercises and avoiding things that worsen the symptoms until resolved are the best long-term options and are what I used to help my symptoms. It is important that the exercises be explained by a healthcare professional since doing them incorrectly, such as with weight-lifting or other traditional exercise programs, can actually worsen the symptoms. Once explained and demonstrated most patients can perform the program on their own. I think it is important that the program be performed several times a day for at least 2 months. I recommend doing the program, which only takes a few minutes, when first waking up, with each meal, and right before bed. It is important to remember that this is like working out or going on a diet, you can’t expect results in just a few days or weeks! I think it is important to continue for at least 2 months initially. If at 2 months everything is resolved that’s great and it is ok to resume previous normal activities. If at 2 months symptoms are improved but not resolved I recommend continuing for another 2 months. If at 2 months there is no improvement, or even worsening, a re-evaluation is appropriate to make sure nothing else is happening. Using splints, straps, or other devices along with the program may help with symptoms but have not been shown to change the natural course of the condition. Therefore, it is ok to use these if they provide comfort but they should not take the place of the other recommendations.
Steroid and other injections were once thought to be a good treatment option for these conditions. Unfortunately all of our best and most recent evidence suggests that these injections at best can help symptoms in the short term but actually worsen symptoms in the long run and at worst are no better or may even be more harmful than placebo injections. Thus, I currently only offer injections if someone is having a severely terrible acute flare of pain that they cannot cope with, as long as they understand that the shot may help short term but may be more likely to cause the symptoms to return and be even worse in the future compared to if we hadn’t done the injection at all in the first place.
90% or more of people will eventually have resolution of their symptoms without surgery and it is generally recommended to avoid surgery unless all else fails. I do not offer surgery for patients if they have never had even temporary relief from some other interventions in the past. In those cases I think surgery is more likely to cause significant complications/risk without any added benefit for relieving symptoms. I think if patients at least had some temporary relief from some other intervention in the past that they are more likely to get longer-lasting relief from surgery but there is little evidence to support even this approach. Unfortunately, for patients who do undergo surgery, which typically involves removal of all of the degenerated tissue and repair of healthy tissue and removal of the nerves that transmit pain from this area to the brain, there are still a percentage of patients who will continue to have the same symptoms, or worse, after surgery. Again, as mentioned before, it is almost as if the pain and dysfunction symptoms have become permanently imprinted on the patient and “phantom symptoms” and dysfunction remain without any structural explanation. In these cases the only known options are to improve coping/pain management skills and consider addressing any psychosocial issues that could be contributing as previously mentioned. Hopefully some day we will have an easier answer for these very common and vexing processes about the elbow as we continue to study all aspects; we certainly wish there were a better answer!