• Epicondylitis is a tendonitis of the tendons that insert into the epicondyles (bony protuberances) of the bone of the upper arm (the humerus)
• This is caused by microscopic tearing and damage in the tendons resulting in inflammation
• With time, this chronic damage leads to degenerative changes including calcifications, the formulation of granulation tissue, and loss of blood flow to the area.

• Tennis Elbow
  • If the inflammation is on the outside edge of the elbow, it is called lateral epicondylitis, or tennis elbow
  • This is caused by damage to the tendons of the muscles that straighten the fingers and the wrist and turn the palm up
• Golfer's Elbow
  • If the inflammation is on the inside edge of the elbow, it is called medial epicondylitis, or golfer's elbow
  • This is caused by damage to the tendons of the muscles that bend the fingers and wrist and turn the palm down
  • Golfer's elbow occurs only 10-20% as frequently as tennis elbow

SYMPTOMS

• Tenderness at the sides of the elbow over the bony protuberances
• In more severe cases, pain may radiate from the elbow down the forearm and into the upper arm
• Activity makes the pain worse 
  • Tennis elbow is aggravated by gripping with the wrist bent back 
  • Golfer's elbow is aggravated by gripping with the wrist bent forward
• Loss of elbow and wrist motion due to pain
• Weakness of the affected muscles due to pain
• Occasionally, the elbow will be swollen over the bony protuberances

OCCUPATIONAL CAUSES

• Repeated or forceful rotation of the forearm and bending or straightening of the wrist
• Using the arm for impact activity or jerky, throwing motions
• Awkward positioning of the mouse

PREVENTION & ERGONOMICS

• Avoid repetitive wrist bending and straightening
• Avoid repetitive forearm rotation (palm-up/palm down movements)
• Avoid repetitive strong gripping, especially with the elbow straight
• Avoid lifting with the palm down and the wrist held back (for example, holding suitcases or grocery bags)
• Use both hands while lifting to share the load between the arms
• Try to lift with the palms up (as if you are scooping up the object)
• Avoid forceful push and pull activities with the elbow held straight; Use your body weight to assist with pushing activity
• Minimize repetition; Periodically rest the arms briefly during repetitive or stressful activity; Stretch often during repetitive activity
• Slow down the activity
• Use the lightest grip possible on tools that still allows you to maintain good control
• Use the least amount of force necessary during the activity
• Use the appropriate tool for the job
• Use ergonomically designed tools if available (modified or padded handles, larger grips with good traction, handles with modified designs)
• Make sure that tools are in good condition and that cutting edges are sharp (reduces the force needed to use the tool)
• Use power tools when able (for example, a power screwdriver reduces the amount of repetitive forearm rotation needed to perform the job)
• Alternate work activities so the hands are not performing any one task repetitively for any length of time
• Use good ergonomic practices at work; Apply these tendon and nerve protection principles to daily and leisure activities as well.
• Practice good health habits

PREVENTION & EARLY TREATMENT

• Use of counterforce bracing (a tennis elbow strap)
• Splinting (custom made or pre-fabricated) with the wrist held slightly back for lateral epicondylitis or in neutral position or slightly bent towards the palm for medial epicondylitis
• Avoid the activities which cause pain; Modify those activities which cannot be avoided
• An ergonomic consultation to modify work environment stressors
• The use of ergonomic tools such as a power screwdriver or tools with modified handles
• Education in tendon and nerve protection techniques including modification of sleep and work habits
• Hand therapy techniques to improve circulation, decrease swelling and reduce pain
• A supervised exercise program to stretch tight muscles, strengthen weak muscles, promote postural balance;  the program should include forearm stretches, tendon and nerve gliding exercises
• A general conditioning program and progressive strengthening program to tolerance
• Ice massage
• Cross-friction massage
• The M.D. may prescribe anti-inflammatory medications such as naprosyn or ibuprofen;  if these medications cause stomach irritation, the M.D. may also prescribe a stomach calmer such as zantac
• The M.D. may recommend a cortisone injection into the painful area

SURGICAL PROCEDURE

• There are a variety of surgical procedures which can be used to clean out the damaged tissue and promote healing at the elbow.  The procedure chosen depends upon the severity of injury and upon M.D. preference and training

WHAT SHOULD I DO AFTER SURGERY?

• Keep the initial cast and incision clean and dry
• Once the cast is removed (usually in 2-4 weeks), change the bandages as needed, especially if saturated with blood
• Keep the fingers moving - make a gentle fist and hook fist, spread the fingers apart
• Avoid bending the wrist forward or back, depending up the area of surgery, for 4 weeks after surgery to let the muscles that insert onto the elbow heal;  the M.D. or therapist may provide a wrist support (custom or pre-fabricated) to be worn at all times
• Begin gently bending and straightening the elbow once the M.D. approves movement
• When the cast is removed, use your arm for light activity, as normally as possible, but respect pain
• Once the stitches and cast are removed, begin gently massaging the scar
• Use a silicone based scar bandage if the scar is thick, stuck, red or painful
• Gradually increase strength activities at 6 weeks post-surgery

POST-SURGICAL THERAPY

• Protective splinting with the wrist neutral (or slightly bent or slightly pulled back depending upon the type and location of surgery) and the elbow at a 90 degree angle for a short period of time immediately post-surgery
• Cleaning and dressing of the incision until healed
• The therapist or M.D. may provide a padded elbow sleeve to protect the healing area from re-injury and for comfort.  The inside edge of the elbow can remain tender for 3-4 months after this type of surgery
• Scar management including massage, the use of scar molds or silicone gel sheeting, ultrasound, hot packs
• Swelling reduction techniques including instruction in elevation of the arm, compression wraps, retrograde massage, cold packs
• Active motion including tendon and nerve gliding exercises as necessary at about 4 weeks after surgery
• Strengthening and work conditioning activities beginning at about 6 weeks after surgery to tolerance

WHAT CAN I EXPECT AFTER SURGERY?

• The pain that travels or radiates up and down the arm is often relieved almost immediately.  Pain becomes more centered around the surgical site while the arm is healing. 
• The surgical area of the elbow will likely be tender for 4-6 months after surgery.  
• There will be some amount of swelling over the surgical side of the elbow for months as well .