Q: I am a 39 years old female suffering from acute pain in the right elbow, which has been diagnosed as tennis elbow. On consulting an orthopaedic surgeon, I was advised three injections at an interval of one month and the same were given in the elbow. Although, the injection was very painful, I got relief from pain for about a month after administration of the last injection. However, now the pain has started recurring. What should I do?

A:Lateral epicondylitis is a common overuse syndrome of the extensor tendons of the forearm. It is sometimes called tennis elbow, although it can occur with many activities, especially in rotating action in the forearm, like opening a door knob, grasping objects, opening a bottle cover etc. The condition affects men and women equally and is more common in persons 40 years or older. Xrays are not helpful in this condition as occasionally calcific tendinitis may be present. MRI demonstrated thickening of tendons with increased T1 and T2 signals, but generally is not indicated. I would advice a radiograph for the elbow if not done in your previous visit. MRI can be reserved and done later if needed in resistant times (severe pain, disturbing activities, not able to tolerate pain, weakness in elbow). The other conditions which may mimic like 'tennis elbow' are:

• radial tunnel syndrome (5%)
• osteochondritis dissecans of the capitellum
• elbow instability
• early elbow arthritis (rare)
Despite the prevalence of lateral epicondylitis (tennis elbow) and the numerous treatment strategies available, relatively few high-quality clinical trials support many of these treatment options; watchful waiting (no surgery) is a reasonable option. Cortico steroids injections to elbow cause complete and permanent pain relief in 40% of the patients. Since three such injections were given to you, I would advise you:
• not to be panic, as this problems settles with time, rest and support. Wear an elbow brace for this condition, which will be available in the market. Meanwhile, try ice or ultrasound therapy to the maximum pain area in the elbow and continue stretching, strengthening exercises under physiotherapist guidance.
• Remember watchful-waiting approach, avoidance of aggravating activities, pain killers for severe unbearable pain (Tab Voveran 50 mg thrice a day), support with splints/brace will give 95% of the patients permanent pain relief.
Surgery is often recommended when conservative (above mentioned) strategies fail to relieve lateral epicondylitis symptoms after six to 12 months. There are numerous surgical approaches, including open, percutaneous, and arthroscopic techniques. Most procedures excise abnormal tissue within the origin of the extensor carpi radialis brevis tendon at the lateral epicondyle or release the tendon altogether along with excision of the adventiious bursae and hypertrophied synovium. Patients will improve after the surgery within 3-4 months.