Many of you have heard of and know what tennis elbow is...Zac Lee's injury appears to be an offshoot of that.

Lateral Epicondylitis (Tennis Elbow) -

The lateral (outside part) elbow is a frequent site of work and sports-related overuse injury. Lateral epicondylitis is the most commonly encountered overuse syndrome in the elbow. This entity is seen in patients performing repetitive wrist extension, supination, heavy lifting, or excessive gripping. While lateral epicondylitis is overwhelmingly encountered in the workplace, it is popularly associated with tennis and is thus often referred to as "tennis elbow".

Lateral epicondylitis is a degenerative condition, which affects the extensor tendons of the hand and wrist at their origin. The extensor carpi radialis brevis tendon is almost always the primary site of tendon pathology with variable involvement of the other wrist extensors arising from the common extensor tendon.

The pathologic process in lateral epicondylitis is more appropriately termed a chronic tendinosis, since inflammatory cells are not a predominant histologic feature. The injury begins with angiofibrotic degeneration resulting in microscopic tears of the extensor tendons of the wrist and hand. With continued activity, the tendon may progress to macroscopic partial tearing at its undersurface and eventually to complete rupture.

Partial thickness tears almost always occur as an undersurface partial avulsion of the common extensor origin from the lateral epicondyle. Both complete and partial tears result from fluid filling the tendon defect.

So lets look at The Anatomy...

Tear of the Common Extensor Tendon of the Elbow

Tennis Elbow, also known as Lateral Epicondylitis, occurs when tendons that attach to the lateral epicondyle of the elbow are too tight or restricted, causing irritation. This bony attachment point is located on the top of the forearm (in line with the back of the hand) near the elbow. It is the bony point that can be felt about one inch away from and on top of the point of the elbow.

Several muscles attach to the lateral epicondyle.

Two of the major muscles that attach there are the Anconeus muscle and the Supinator muscle. These two muscles rotate the forearm to a palm-up position. A typical example of this motion would include twisting the forearm to carry a tray.

Another group of muscles that are implicated in cases of Tennis Elbow or Lateral Epicondylitis are some of the extensor muscles. The extensor muscles lift the fingers or wrist away from the palm toward the back of the hand. Constant bending of the wrist in this direction, especially when it is associated with strain of any kind, can often be responsible for the development of Tennis Elbow (Lateral Epicondylitis).

A common example of this type of stress is when a computer user rests their wrists on a wrist rest or on the desk as they type, allowing the wrists to sink toward the desktop.

From Brian Schiff

Injury Causes:

Inflammation of the Common Extensor Tendon of the Elbow

Overuse of the muscles and tendons of the forearm and elbow are the most common reason people develop tennis elbow. Repeating some types of activities over and over again can put too much strain on the elbow tendons. These activities are not necessarily high-level sports competition.

In an acute injury, the body undergoes an inflammatory response. Special inflammatory cells make their way to the injured tissues to help them heal. Conditions that involve inflammation are indicated by "-itis" on the end of the word. For example, inflammation in a tendon is called tendonitis. Inflammation around the lateral epicondyle is called lateral epicondylitis.

However, tennis elbow often does not involve inflammation. Rather, the problem is within the cells of the tendon. Doctors call this condition tendinosis. In tendinosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers.

Instead of inflammatory cells, the body produces a type of cells called fibroblasts. When this happens, the collagen loses its strength. It becomes fragile and can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue.

No one really knows exactly what causes tendinosis. Some doctors think that the forearm tendon develops small tears with too much activity. The tears try to heal, but constant strain and overuse keep re-injuring the tendon. After a while, the tendons stop trying to heal. The scar tissue never has a chance to fully heal, leaving the injured areas weakened and painful.

Symptoms and Diagnosis:

Tennis Elbow (Lateral Epicondylitis) symptoms involve pain when moving the hand, fingers or forearm. Pain is most apparent when bending the wrist or fingers away from the palm, or toward the back of the hand. Twisting the forearm to bring the hand into the palm-up position can also trigger painful symptoms. Pain is usually felt at the point of the lateral epicondyle which is the end of the humerus bone in the upper arm, at the elbow. There is no numbness typically associated with this condition.

A common test that doctors perform to identify Tennis Elbow, or Lateral Epicondylitis, is to have you hold your hand with the palm down, then bend your wrist so your fingers point towards the ceiling. If you experience pain near the elbow when performing this motion, chances are good that you have tennis elbow.

Two of the major muscles that attach to the lateral epicondyle are the Anconeus muscle and the Supinator muscle. These two muscles rotate the forearm to a palm-up position. Chronic contraction of these two muscles puts unusual strain on the tendons of those muscles as they attach to the lateral epicondyle. Irritation is the result and over time could lead to full blown tendonitis known as Tennis Elbow or Lateral Epicondylitis.

Activities that require the twisting of the forearm are known for creating the right conditions for Lateral Epicondylitis to develop. Carrying a tray, an armful of books or even an infant can cause the anconeus and supinator muscles to contract to the point of causing pain. Resting the wrists on a desk or tabletop will cause a contraction or shortening of the extensor muscles in the forearm and can also lead to symptoms.

Here is an undersurface partial thickness tear of the common extensor tendon (arrow) and an associated tear of the radial collateral ligament (arrowhead).

Treatment: From the American Academy of Orthopedic Surgeons

Non-Surgical: Approximately 80% to 95% of patients have success with nonsurgical treatment.

Rest. The first step toward recovery is to give your arm proper rest. This means that you will have to stop participation in sports or heavy work activities for several weeks.

Non-steroidal anti-inflammatory medicines. Drugs like aspirin or ibuprofen reduce pain and swelling.

Wrist stretching exercise with elbow extended.

Equipment check. If you participate in a racquet sport, your doctor may encourage you to have your equipment checked for proper fit. Stiffer racquets and looser-strung racquets often can reduce the stress on the forearm, which means that the forearm muscles do not have to work as hard. If you use an oversized racquet, changing to a smaller head may help prevent symptoms from recurring.

Physical therapy. Specific exercises are helpful for strengthening the muscles of the forearm. Your therapist may also perform ultrasound, ice massage, or muscle-stimulating techniques to improve muscle healing.

Brace. Using a brace centered over the back of your forearm may also help relieve symptoms of tennis elbow. This can reduce symptoms by resting the muscles and tendons.

Steroid injections. Steroids, such as cortisone, are very effective anti-inflammatory medicines. Your doctor may decide to inject your damaged muscle with a steroid to relieve your symptoms. Using steroids and other injections may enhance early recovery but could cause calcium deposits. Research shows with longer follow-up, results for patients treated with injections may be similar to patients who did not receive them.

Extracorporeal shock wave therapy. Shock wave therapy sends sound waves to the elbow. These sound waves create "microtrauma" that promote the body's natural healing processes.

Shock wave therapy is considered experimental by many doctors, but some sources show it can be effective.

Surgical:

Surgical Exposure of the Elbow - Robert Nirschl, MD

If your symptoms do not respond after 6 to 12 months of nonsurgical treatments, your doctor may recommend surgery.

Most surgical procedures for tennis elbow involve removing diseased muscle and reattaching healthy muscle back to bone.

The right surgical approach for you will depend on a range of factors. These include the scope of your injury, your general health, and your personal needs. Talk with your doctor about the options. Discuss the results your doctor has had, and any risks associated with each procedure.

Open surgery. The most common approach to tennis elbow repair is open surgery. This involves making an incision over the elbow.

Open surgery is usually performed as an outpatient surgery. It rarely requires an overnight stay at the hospital.

Arthroscopic surgery. Tennis elbow can also be repaired using tiny instruments and small incisions. Like open surgery, this is a same-day or outpatient procedure.

( Anatomical structures from the image...extensor carpi radialis brevis (ECRB), extensor digitorum communis (EDC), extensor carpi radialis longus (ECRL))

A closer look at Arthroscopic Repair of tennis elbow...

Endoscopic ECRB releases may also mitigate complications like nerve lacerations and injuries to the lateral ulnar collateral ligament (LUCL).

Special imaging is not typically needed for lateral epicondylitis or "tennis elbow." MRI is rarely indicated, especially if the classic signs are present: handshake weakness and tenderness over the ECRB insertion.

Surgery is indicated for patients who failed a comprehensive course of nonoperative treatment and have continued pain that interferes with daily activities.

Before surgery Ahmad suggested assessing compliance and motivation, which explain why a patient failed to respond to nonoperative treatment.

With either type of surgery, "We want to minimize any morbidity and complications with our surgical technique," he said.

During open lateral epicondylitis surgery, the extensor carpi-radialis brevis (ECRB) can readily be released and its origin resected.

Open tennis elbow treatment permits identification of the lateral epicondyle, and the split between the extensor carpi-radialis ligament (ECRL) and extensor aponeurosis. Also shown is the extensor digitorum communis (EDC). Images: Ahmad CS

Arthroscopy allows addressing articular pathology and is useful for diagnosing and treating radiocapitellar plicas and synovitis. It also meets the surgical goals of tissue resection if the ECRB release is done adequately and complications are avoided.

When surgery is required, surgeons should avoid common but critical nerve and ligament injuries. Before starting the arthroscopic procedure, he suggested they immediately identify the ulnar nerve by outlining the area around it and the bony landmarks and keep the nerve’s location in mind throughout surgery.

Frequently, the ulnar nerve subluxes, which is a contraindication for a standard medial portal. To avoid nerve injury in those cases dissect down, controlling the nerve and ensuring it is protected, Ahmad said.

To avoid injuring the LUCL, located just below the equator of the radial head, "make sure you don’t go below the equator" or release any tissues there, he noted, saying research by Cummins found a learning curve with arthroscopic releases.

Because it’s a limited procedure, you can be a little bit more aggressive. Active/passive range of motion can be done immediately postop to obtain full elbow extension. Formal physical therapy, including stretching and strengthening, should start a week later after the stitches are removed. Once patients regain strength they can return to full activity.

This way we will be addressing these injuries as we move forward. Rehab is quicker and more aggressive and there is less of a chance of nerve damage with the use of arthroscopy.

(Full Disclosure I have worked with both Dr. Nirschl and Dr. Ahmad in the past.)