Elbow Pain -- Lateral Epicondylitis - "Tennis Elbow"

Lateral epicondylitis is a condition that causes pain primarily at the outer or lateral aspect of the elbow in the area of the lateral epicondyle. Commonly called "Tennis elbow", the characteristic pain can extend down the forearm and can be quite significant, affecting almost all-upper extremity activity and compromising even simple chores such as picking up a coffee cup. Occurring, usually, in the fourth and fifth decades of life and most typically affecting the dominant arm, tennis elbow affects men and women equally.

The site of pathology is the lateral epicondyle of the humerus, which is the origin of a number of muscles that are involved in extension of the wrist and fingers. In tennis elbow, the origin of the Extensor carpi radialis brevis and to a lesser extent the Extensor carpi radialis longus are injured.. Overuse of these muscles, during activities such as tennis, use of hand tools, or any situation of constant hand use, can cause degeneration of the tendon origin. Current consensus is that inflammatory microtears, as well as granulation tissue, of the Extensor carpi radialis brevis tendon are the main cause of the symptoms.

Patients give a history of insidious onset, rather than a specific or acute event that they remember. The pain can be quite severe, although many patients may practice "trick maneuvers" in order to reduce their symptoms, altering otherwise coordinated activities of the shoulder and wrist. These modifications may put additional stress on areas remote from the elbow, causing secondary pain. Patients also experience severe tenderness at the tendon origin and at the lateral epicondyle. Range of motion of both the elbow and wrist is usually unaffected and the gross neurologic exam, including sensory testing, should be intact.

Diagnostically, x-rays are of little help, though a complete examination of the upper extremity, as well as the cervical spine, should be done in order to rule out any other condition or pathology.

Initial treatment consists of nonoperative, conservative measures -- reduction of the local repetitive trauma and relief of the inflammation, followed by a rehabilitation program. Cessation of the offending activity often brings inflammatory relief. Casting or splinting is usually not necessary. Ice and oral anti-inflammatory medications can be used to initially reduce the inflammation. Physical therapy, such as ultrasound treatment and range of motion exercise with strengthening of the surrounding musculature, can be successful.

If these simple measures do not bring relief, steroid injection can be employed, but care must be taken to avoid direct injection into the tendon, which might cause premature degeneration.

Only a small minority of patients will need to undergo surgical correction. Recurrences can be expected and approximately 10 percent of patients who originally do well following conservative treatment will have a recurrence of symptoms.

Heel Pain -- Plantar Fasciitis

A very common foot and ankle injury, especially in the very active population, is plantar fasciitis, a condition that causes heel pain. Although not the only cause of heel pain, it is probably the most frustrating because it is often difficult to treat. Presently, it is believed that there is a degeneration of the fascia from the take off site at the calcaneus. The pain can be quite debilitating, and it is difficult for many patients to stay off their feet in order to relieve the inflammation and repetitive trauma to the area, making this a frustrating clinical problem. Tension created in the relatively inelastic plantar fascia stabilizes the arch of the foot but also places great tensile force at the fascia - periosteal origin at the calcaneus. The tensile forces are maximal at the medial calcaneal tuberosity, the site most often symptomatic in this condition. Pathology studies reveal microtears of the fascia and angiofibroblastic hyperplasia consistent with the chronic degeneration and inflammation involved with repetitive stress.

Diagnosis

Various systemic inflammatory arthropathies, tumors, infections and calcaneal stress fractures may be the cause of such pain. Though involvement of the medial calcaneal nerve and the lateral plantar nerve is a possible cause of heel pain, as well as neuropathies secondary to diabetes and alcoholism, the diagnosis of plantar fasciitis should be straightforward. Patients will complain about pain after arising from bed or after a period of rest. Usually the pain will subside after a relatively brief period of ambulation and/or stretching. The pain is unmistakably located about the area of the medial tubercle of the calcaneus and direct palpation of this area will elicit pain, which may be exacerbated by dorsiflexion of the toes. Although a patient may also have a calcaneal bone spur, it is probably not a primary cause of the pain but rather a secondary traction spur that is the result of the chronic condition.

No single treatment stands out as the most efficacious, although most patients benefit from conservative measures. Physical therapy modalities, including ice and heat have been tried with some success. Stretching exercises, both during the day and evening, utilizing splints, are quite successful since they stretch the plantar fascia as well as the Achilles tendon. Nonsteroidal anti-inflammatory medications have also been successful, although there are significant populations of patients who do not improve on NSAIDs. Various heel cups and heel pads have been used but studies disagree as to the outcomes achieved. Injections of corticosteroids, limited to two per heel, have been used to reduce symptoms. However, plantar fascia ruptures, secondary to these injections, have been reported and can be quite debilitating.

If none of these treatments is successful, patients should undergo a regimen of casting in order to reduce pressure on the area as well as the irritation from daily pressure. Casting is avoided as an initial treatment because patients do not like to be so inconvenienced by a treatment for a situation they consider relatively minor. In addition, casting produces significant atrophy, thus compounding the problem. If everything fails, surgery is a final option.

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