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TENNIS ELBOW (LATERAL EPICONDYLITIS)

Introduction

Lateral epicondylitis is the most common disorder of the elbow among patients who seek medical attention for elbow symptoms. Lateral epicondylitis currents in 1-3% of the population (men=women) and most often between 35 and 50 years of age.  Lateral affects 50% of all recreational tennis players, and risk factors for developing the condition include a heavy racquet, improper grip size, high string tension and poor swing technique. The extensor carpi radialis brevis (ECRB) tendon is most commonly involved, and the pathoanatomy usually begins as a microtear at the origin of the ECRB. Microscopic evaluation reveals angiofibroblastic hyperplasia.

Related Anatomy

  • ECRB
  • Extensor carpi radialis longus
  • Extensor carpi ulnaris
  • Extensor digitorum
  • Extensor digiti minimi
  • Anconeus
  • Lateral ulnar collateral ligament

Pathophysiology

  • Mictrotrauma results in angiofibroblastic hyperplasia and disorganized collagen

Incidence and Related Conditions

  • Most common cause of elbow pain in patients presenting with symptoms
  • Up to 50% of all tennis players develop lateral epicondylitis
  • Radial tunnel syndrome is present in ~5% of cases

Differential Diagnosis

  • Radiocapitellar synovitis
  • Wartenburg’s syndrome
  • Radial tunnel syndrome
  • Pronator syndrome
Clinical Presentation Photos and Related Diagrams
  • Lateral Epicondylitis (Tennis Elbow) (Hover over right edge to see more images)
    Lateral Epicondylitis (Tennis Elbow) (Hover over right edge to see more images)
  • Lateral Epicondylitis (Tennis Elbow) - Epicondylar tenderness worse with resisted wrist extension
    Lateral Epicondylitis (Tennis Elbow) - Epicondylar tenderness worse with resisted wrist extension
  • Rule out Radial Tunnel Syndrome - Posterior Interosseous Nerve (PIN) tenderness aggravated by resisted long finger extension
    Rule out Radial Tunnel Syndrome - Posterior Interosseous Nerve (PIN) tenderness aggravated by resisted long finger extension
Symptoms
Aching pain and soreness outer part of elbow
Increasing elbow pain with lifting, e.g. milk bottle, shaking hands etc.
Night pain
Morning elbow stiffness
Weakened grip
Typical History

Patient is usually a middle aged individual with lateral elbow pain radiating into the proxiaml forearm. There is no specific history of trauma but a period of unusally heavy and repetitive use of the upper extremity may be reported. The patient will frequently complain of pain with gripping and lifting heavier objects. The patient localizes the pain to outside of the elbow.

Positive Tests, Exams or Signs
Lateral Epicondylitis Tenderness
Lateral Epicondylitis Tenderness with Resisted Wrist Extension
Tenderness
Work-up Options
Sonographic studies - Ultrasound
Magnetic resonance imaging - MRI without contrast
Radiology studies - X-ray
Images (X-Ray, MRI, etc.)
  • In tennis elbow the X-ray of the elbow is usually normal. Occasion calcifications of the extensor origin will be seen.
    In tennis elbow the X-ray of the elbow is usually normal. Occasion calcifications of the extensor origin will be seen. (Hover over right edge to see more images)
  • Normal elbow MRI
    Normal elbow MRI
  • Lateral epicondylitis with intrasubstance tear in the extensor origin(1) and plica(2).
    Lateral epicondylitis with intrasubstance tear in the extensor origin(1) and plica(2).
  • Lateral epicondylitis with intrasubstance degenerative tearing the ECRB.
    Lateral epicondylitis with intrasubstance degenerative tearing the ECRB.
Treatment Options
Conservative: 
  • First-line treatments: rest, ice, modification of activities, physical therapy, counterforce bracing, NSAIDS, ultrasound, corticosteroid injections and PRP injections.
  • Follow-up: Physical therapy is directed at extensor stretching and strengthening
  • Note: clinical trials have demonstrated not significant differences between extracorporeal shock wave therapy (ESWT) and placebo for improving function after 6 months of treatment. 
Operative: 
  • Indication: when pain limits function and interferes with daily activities/work; when conservative approaches for up to 6 months fail
  • Procedures:
    • open ECRB tendon release, removal of degenerated tendon with repair of remainder of the tendon
    • Arthroscopic release of ECRB tendon with intra-articular evaluation of the capsule and cartilage
Treatment Photos and Diagrams
  • Index finger on Lateral Epicondyle. Forearm band keeps tension off extensor origin by putting pressure on proximal extensors.
    Index finger on Lateral Epicondyle. Forearm band keeps tension off extensor origin by putting pressure on proximal extensors.
Complications
  • Iatrogenic lateral ulnar collateral ligament injury, iatrogenic neurovascular injury, missed concomitant radial nerve entrapment syndrome 
Outcomes
  • Surgical success rates are as high as 85%.
Key Educational Points
  • The lesion of lateral epicondylitis is typically found in the origin of the ECRB.
  • Differential diagnosis of lateral epicondylitis includes radial tunnel syndrome and radiocapitellar plica.
  • PA and lateral radiographs are usually normal.
  • Nonsurgical treatment is attempted initially and is usually effective.
  • The results of extracorporeal shock wave therapy is no different than placebo.
Practice and CME
References

New Articles

  1. Alberta F. CORR Insights(®): Does Nonsurgical Treatment Improve Longitudinal Outcomes of Lateral Epicondylitis Over No Treatment? A Meta-analysis. Clin Orthop Relat Res 2015;473(3):1108-10. PMID: 25472930
  2. Ruch DS, et al. A comparison of débridement with and without anconeus muscle flap for treatment of refractory lateral epicondylitis. J Shoulder Elbow Surg 2015;24(2):236-41. PMID: 25457781
  3. Faro F, Wolf JM. Lateral epicondylitis: Review and current concepts. J Hand Surg Am 2007;32(8):1271-1279. PMID: 17923315
  4. Inagaki K. Current concepts of elbow-joint disorders and their treatment.  J Orthop Sci 2013;18(1):1-7. PMID: 23306537

Reviews

  1. Sims SE, et al. Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand (NY) 2014;9(4):419-46. PMID: 25414603
  2. Ahmad Z, et al. The effect of platelet-rich plasma on clinical outcomes in lateral epicondylitis. Arthroscopy 2013;29(11):1851-62. PMID: 24060428

Classics

  1. Labelle H, et al. Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow. An attempted meta-analysis. J Bone Joint Surg Br 1992;74(5):646-51. PMID: 1388172
  2. Michelle AA, Krueger FJ. Lateral epicondylitis of the elbow treated by fasciotomy. Surgery 1956;39(2):277-84. PMID: 13298976
  3. 3. Nirschl RP,Pettrone FA.Tennis elbow.The surgical treatment of lateral epicondylitis. J Bone Joint Surg 1979;61A:832–839.