Tennis elbow then, tennis elbow now

Excerpt, antique medical manuscript with pictorial depiction of the trials and tribulations of tennis elbow, in archaic times referred to as “lawn tennis arm” as seen in both right and left arm dominant individuals. Source: University of Texas San Antonio Health Center Library.

Lost to the annals of medical history, is the origin of the condition known colloquially as “tennis elbow” and medically as lateral epicondylitis.  It is rumored that a British orthopaedist by the name of Robert Symon Garden published a manuscript in 1961, in which he cites that a German physician by the name of F. Runga was first to describe the condition in 1873. Runga’s original citation however, has been lost.

The earliest surviving mention in a medical publication then, was by another British physician named Sir Henry Morris, as published in the elder statesman medical journal the Lancet circa 1882.  In true Masterpiece Theatre, he described the condition in genteel fashion as “lawn tennis arm,” a wonderfully quirky history of which can be found here. Sir Morris proposed that the nagging injury was caused by “repetitive backstrokes” leading to a sprain of the pronator radii teres muscle.*

*Side note: Yes, to confirm your suspicion, the action of the pronator radii teres (with the added efforts of the pronator quadratus muscle) allow one’s arm to do that supposedly intuitive pronating thing your coaches always stressed during serves. Yeah, you know I’m talking to you John Boytim in Houston, TX of King Daddy Sports.

This is a bit confusing as the pronator radii teres muscle actually originates from the medial epicondyle, which is the area associated with golfer’s elbow; while the lateral epicondyle is the area associated with tennis elbow.

Illustrative of the different muscles involved in Tennis elbow and Golfer’s elbow. Source: Rupert Health Center Inc., Priscilla Wan.

There was presumably some historical reason for the mixup, but if not, Sir Morris (pictured below) and his academic followers have likely emerged from the grave and are coming to politely, yet passionately debate this academic matter now.

Sir Henry Morris, captured with an expression of fatherly disdain, as if his anatomical description of “lawn tennis elbow” had been challenged. Source: U.S. National Library of Medicine.


Extensor Carpi Radialis Brevis (ECRB)

ECRB as labeled above. Other forearm muscles labeled as “Forearm muscles” presumably in an attempt to not detract from the ECRB’s known propensity for the pathophysiological limelight. Source: American Academy of Orthopedic Surgeons.

Ignoring the impending arrival of Sir Morris et al. for now, it’s important to note that the lateral epicondyle is home to the extensor carpi radialis brevis (ECRB) muscle. Tennis elbow is caused by microscopic damage and inflammation of the ECRB tendon. Typically caused by repetitive wrist extension, it presents with a pointed area of chronic pain on the lateral elbow +/- radiation down the arm lasting weeks to months. While Sir Morris may have been wrong about the muscle involved, he was right about the course:

“The symptoms soon disappear if the movements of pronation and supination are restricted for a few weeks and the forearm is enveloped in an elastic bandage or firm elastic webbing.”

— Sir Henry Morris

Yet immobilization for even a few weeks in athletes, plumbers, musicians, landscapers, professional arm wrestlers, mothers wringing out diapers, etc. was as impossible in 1882 as it is today.

Non-surgical treatments and the largest study on them to date

Thus spawned treatment modalities galore.  Listed in order from easily understandable to that-which-sounds-like-science-fiction or biohacking we can include: physical therapy, massage, splinting, forearm support banding, various types of surgical modification to the ECRB, acupuncture, dry needling, oral anti-inflammatories, corticosteroid/lidocaine/alcohol/carbolic acid/botulinum toxin/autologous blood injections, ultrasound tenotomy, low-level laser therapy, iontophoresis, phonophoresis.

Google if you wish.

On 10/31/2018, the largest systematic review and meta-analysis on placebo controlled non-surgical treatments to date for tennis elbow was published by Nazarian, A et al. from Harvard’s Beth Israel Deaconess Medical Center (BIDMC).  A bottom-line quote from the lead investigator if you will:

“All 11 treatment options provided only small pain relief, while increasing the odds of adverse events. More than 90 percent of the patients given placebo experienced pain resolution after four weeks.”

Ara Nazarian, PhD, Associate Professor of Orthopaedic Surgery at Harvard Medical School

Placebos, by the way did not mean no treatment.  It meant those individuals received either saline injections, ingested sugar pills similar in appearance to the actual medication, had false ultrasound procedures done, etc.  This is standard operating procedure in placebo based research studies which do so in an attempt to eliminate bias, making data more accurate. You can read more about the curiously intriguing power of the placebo here.

Now back to the study.

Of course, sufferers don’t want to hear that treatments don’t work. But negative findings are still important to consider, in an era where treatments and procedures are overprescribed, leading to exacerbation of our already overburdened healthcare system.

Was there anything positive about the study?

Yes. A few of the non-surgical treatments did help with the pain for the average individual with tennis elbow. But the treatments were only minimally helpful. To elaborate, we delve a little deeper into their results. They assessed study participants through three time-based categories and found that:

  • Within 4 weeks of diagnosis.
    • No treatments demonstrated statistically significant improvement in pain over placebo.
    • >90% of placebo patients reported improved pain after 4 weeks.
  • 5 – 26 weeks after diagnosis.
    • Those receiving laser therapy or botox injections had (small) statistically significant improvements in pain.
  • > 26 weeks after diagnosis.
    • 99% of patients on placebo reported minimal or no pain.
    • Steroid injections were associated with worse pain, than folks on placebo.
    • Shockwave therapy was the only therapy to show long-term statistical significance, but that too, was minimal.

Bottom line

The good news is that tennis elbow on average appears self-limiting with >90% placebo patients showing vast improvement in pain after only 4 weeks. Most importantly, Nazarian et al. showed that while there are numerous non-surgical treatments available, they aren’t much better than placebo, the risk of side effects are greater and in some cases (e.g. corticosteroid injections) treatments might actually worsen the pain.

What about surgery? That’s a topic for another day, but is typically a last resort when all else has failed. As we note from this study, the condition is (fortunately for the majority) a minor medical inconvenience. However, sufferers tend to forcefully mention again and again that this condition remains one in which the relentless Father Time could not be any more of a painful hinderance to the game.

Curse that tennis addiction.

Excerpt, superannuated metaphorical painting depicting the souls of the same two individuals shown at the beginning of this post, 3 weeks later, still awaiting pain resolution so they might return posthaste to their lawn tennis. Source: University of Texas San Antonio Health Center Library.

Miscellany:

  • The ECRB, by the way, is of such paramount importance in the medical field – as others have pointed out – that my 2005 edition of Gray’s Anatomy devotes a whole half a paragraph and two figures out of a 1,058 page text to it.
A tribute to the 80’s.

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