Angler’s elbow refers to the clinical spectrum of elbow pain often seen amongst avid fishing sportsman
It most commonly involves pain on the lateral aspect of the elbow (typically lateral epicondylitis) but can also be used to describe medial (inner) elbow pain, whether medial epicondylitis or perhaps cubital tunnel syndrome. These conditions will be defined and need to be understood by the sporting population so that early recognition, and treatment, an occur in order to avoid a chronic situation and frequent resultant surgery. Fortunately, the latter can now be done in a minimally invasive manner, hence allowing virtually painless, rapid return to sport and daily activities.
Lateral epicondylitis (tennis elbow) is an extremely common and painful condition that afflicts a variety of adults
Inflammation of the lateral epicondyle (outer aspect of the bony elbow prominence) is actually a form of tendonitis where the extensor tendon origin becomes inflamed at its point of origin off the bone. It is a similar process as the commonly known “shin splints” which often affects runners.
Many patients attribute this painful elbow condition to some activity they perform or to some overuse. Anglers often feel it is directly caused by vigorous fishing activity, but it should be thought of as more an aggravation. Although commonly attributed to tennis, the vast majority of people suffering with this “tennis elbow” have no involvement in racquet sports. Many tennis players also have never complained of tennis elbow so it is unfair to directly implicate a particular sport or even job activity to this common nuisance. It is known that people who tend to suffer from this will have pain from activities as simple as lifting a coffee cup, or reaching into the refrigerator. However, when anglers or other sportsmen are afflicted, the particular activity does greatly aggravate the pain and may hinder conservative recovery.
Medial epicondylitis or golfer’s elbow
Medial epicondylitis, often known as golfer’s elbow, is also commonly seen amongst anglers and can be severely aggravated during the reeling activity. There is no doubt that “battling the big one” will cause severe exacerbation of inner elbow pain due to the great force exerted by the forearm flexors (permit grip/squeezing). This less common form of epicondylitis is also considered part of the spectrum of “Anglers Elbow” and does require early recognition and appropriate treatment.
It should be noted that occasional medial (inner) elbow pain can result from other causes, the most common being compression of the ulnar nerve, known as cubital tunnel syndrome. The ulnar nerve, often called the “funny bone” by laypersons, is a commonly compressed or irritated peripheral nerve that runs in a groove behind the very prominent medial epicondyle, the bony prominence on the inner aspect of the elbow. While the pain may be confused with “golfers elbow”, it is more typically characterized by intermittent numbness of the small and ring finger, or shooting “parasethias” often described as electric shocks by the sufferer. Occasionally , this neurologic condition can occur in conjunction with medial epicondylitis and would be considered a particularly severe form of Angler’s Elbow.
A final cause of medial elbow pain in the fisherman is sprain or even tear of the elbow’s “medial collateral ligament”. Acute complete rupture of this critical ligament often occurs in pitchers or other throwing athletes, and often needs ligament reconstruction typically termed “Tommy John Surgery”. This complete tear is indeed rare in the Angler. Grade II and III sprains are common however, and can respond to period of rest/ice/NSAIDs.
Generally, epicondylitis is commonly seen in people who suffer from other inflammatory processes of the upper extremity such as shoulder bursitis, wrist tendonitis, trigger fingers and even carpal tunnel syndrome. This does argue for a hormonal and/or metabolic component where the membrane surrounding muscles and tendons may become inflamed and thickened due to fluid shifts in the body. Diabetics, hypothyroid patients and even perimenopausal women seem to have an increased incidence of this painful elbow condition. It is also common in laborers and this is probably because this type of activity can spur the condition in someone who tends to have this problem. It should not be seen as a direct causal relationship as we would be seeing a preponderance of heavy workers, or perhaps powerlifters, with lateral epicondylitis seeking treatment if that were the case.
The treatment of epicondylitis
The treatment is initially centered around reducing the inflammation at the lateral or medial epicondyle and the extensor/flexor surface of the forearm around the elbow. This may consist of ice, non-steroidal antinflammatories and activity modification. Stretching exercises and certain splints help in some patients. Physical or occupational therapy can help in some cases but may actually worsen symptoms in others. Most therapy should be directed at reducing the inflammation which can be done with ultrasound or steroid iontophoresis, where an anti-inflammatory cream is worked deep into the tissues with electric current. Most formal therapy can be avoided with specific protocols involving very accessible tools that are now being increasingly utilized by athletes, and manual workers, of all types. The first is the “elbow pressure strap” that is applied several inches below (distal to) the painful epicondyle. This effectively transfers the stress being experienced at the tendon/bone interface at the epicondyle, shifting this to the area where tendon/muscle interface are directly below the tight strap.
The EZ elbow system also contains a pouch within the strap that one can insert the “pressure spike plate” or the convenient hot/ice packs. Both adjunctive inserts are designed to increase blood flow to the region, thus helping the body heal the microtears within the tendinous origin.
Relieving stress AND augmenting the healing process is the goal of this easy to use conservative measure. This should be supplemented with stretching exercises as well as strengthening exercises designed to help the elbow absorb stress/shock while also stimulating blood flow for healing. An easy to use app is now available via OrthoNOW that can instruct the angler in how to perform these exercises, even setting up a schedule to facilitate compliance. Strengthening exercises are best done using the novel Xtensor device, a unique design hand based trainer that strengthens the extensor muscle/tendon units which originate at the elbow (lateral epicondyle) as discussed. While gripper exercises are also important, studies have shown there is often imbalance between forearm/hand flexor and extensor mechanisms and it is critical that the extensors be particularly trained. Nevertheless, a hand flexion gripper, commonly acquired, should be incorporated into both prevention and treatment regimens amongst anglers.
Pain and the inflammatory process, and utilizing an arthroscopic technique
Persistent pain and failed exercise treatment can be an indication for a corticosteroid injection directly into the lateral, or medial, epicondyle and around the extensor/flexor tendon sheaths. This directly reduces the inflammation and can be curative in some cases, assuming that the sportsman begins the exercise protocol within days when pain subsides. Recurrance of pain, often within 3-6 months, can occasionally be followed by a repeat injection in some athletes, particularly if an upcoming tournament or competition is pending. Many of the cases of epicondylitis will eventually disappear between 1 and 2 years and is therefore characterized as a “self limiting condition”. The inflammatory process simply burns itself out over time and treatment is hence directed at simply minimizing symptoms for the sufferer.
In relatively rare cases, the condition continues despite multiple attempts at conservative treatment as discussed. This is often an indication for surgical treatment which is directed at removing the inflammatory tissue from the tendon origin at the bony epicondyle. This can be done through an open incision, as traditionally performed, or minimally invasive technique.
Some years ago, I was utilizing an arthroscopic technique as it is minimally invasive, allows one to see any associated pathology inside the elbow joint, and allows for much more rapid recovery time. A small camera (arthroscope) is inserted into the inner aspect of the elbow joint allowing us to visualize the lateral (outer) capsule of the elbow joint where the inflammation lies. This capsule is resected and the tendon origin is released to minimize tension. This allows new, well vascularized scar tissue to come in and heal the pathology. The advantage is also rapid recovery with immediate use of the arm and elbow encouraged, and only a several week course of physical therapy prescribed. Although there are several encouraging reports in the orthopedic surgery literature, time will tell if this arthroscopic technique will largely replace the traditional open surgery as it has in the knee, shoulder and other joints.
The latest advance in epicondylitis treatment was previously termed “FAST Procedure” , an acronym for Fasciotomy And Subcutaneoust Tenotomy. The name was modified since confusing to the patient and the implication that it was “Fast” also led to issues amongst insurance carriers. It is now referred to as the Tenex Procedure, essentially an ultrasonic ablation of the common extensor, or flexor, from the epicondyle. This entails the insertion of a small probe, with ultrasound visualization, which will essentially remove the diseased/affected tissue and aspirates it out in order to allow the region to form a new healthy tendon/bone interface. It is done under local anesthesia, usually with very mild sedation, and is always done as an outpatient, occasionally even in an office environment. The post-op pain is minimal, often even absent, and allows immediate full use of the elbow. Vigorous activities such as intense angling, tennis or weightlifting are discouraged for a 2-4 week period. I have personally had elite tennis players return to vigorous hitting within 3 weeks.
Regardless of treatment, strengthening of the forearm flexor/extensor muscles is critical, and the Xtensor device amongst other protocols, is critical to allow maximum recovery and even avoid recurrence once the angler begins “reeling in the big one”…
Alejandro Badia, MD, FACS
Hand and Upper Extremity Surgeon
Badia Hand to Shoulder Center
Cofounder/Chief Med Officer, OrthoNOW orthopedic urgent care centers
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