Lateral Epicondylitis
Craig C. Young
Bryant Walrod
BasicsDescription
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Lateral epicondylitis, or lateral elbow tendinosis, is an overuse injury of the forearm and wrist extensor muscles, which causes pain at the lateral elbow.
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Synonym(s): Tennis elbow
Epidemiology
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Accounts for ∼90% of elbow epicondylitis
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Precipitated by tennis and other activities that require repetitive wrist extension, radial deviation, and forearm supination
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Occurs in dominant arm 75% of the time
Risk Factors
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Age 40–60 yrs
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Improper equipment (eg, inappropriate grip size, overstrung racquet, inappropriate-weight racquet)
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Poor technique (eg, backhand with excessive wrist extension)
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Playing tennis for more than 2 hr per wk (1)
Commonly Associated Conditions
Posterior interosseous nerve entrapment (radial tunnel syndrome) may coexist in up to 15% of cases.
DiagnosisHistory
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Pain pattern: Patients typically report an insidious onset, but they will often relate a history of overuse without specific trauma. Pain can vary from mild (eg, present only with aggravating activities like tennis or the repeated use of a hand tool), or it can be severe (eg, holding a coffee cup will act as a trigger for the pain).
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Numbness or tingling: Radicular symptoms suggest nerve entrapment or radiculopathy.
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2-handed backhand: Most tennis players with lateral epicondylitis use a 1-handed backhand.
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Improper technique: Hitting late in the backhand or improper positioning when striking the ball
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Equipment used, location, and frequency of play: Many cases of lateral epicondylitis are associated with improper equipment, old or wet tennis balls, racquets that are strung too tightly or too heavy, and fast surfaces.
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Poor conditioning: Poor general conditioning leads to fatigue of the core and shoulder muscles, which puts an overemphasis on the extensor muscles of the forearm.
Physical Exam
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Pain at lateral elbow
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Pain with wrist and forearm movements
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Pain with gripping objects (“coffee cup sign”) and shaking hands (“politician's sign”)
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Localized tenderness over lateral epicondyle. Also pain just distal and anterior to lateral epicondyle ∼1–2 cm distal to the origin of the extensor carpi radialis brevis
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Tenderness with resisted wrist extension with wrist pronated and radially deviated
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Tenderness with resisted middle finger extension
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Tenderness with resisted supination
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Decreased internal rotation of ipsilateral shoulder causing compensatory excessive wrist flexion
Diagnostic Tests & Interpretation
Imaging
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Not usually needed for initial treatment
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Standard elbow radiography series (anteroposterior and lateral) should be obtained if other potential injuries are suspected (eg, fracture, tumor, degenerative joint disease) or if injury is not responding to appropriate treatment.
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Up to 25% of cases have associated calcification in extensor aponeurosis; however, presence of these deposits does not affect initial treatment.
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Consider additional imaging like MRI or US to evaluate for intrasubstance tears. MRIs are also helpful in diagnosing OCD lesions and stress fractures.
Diagnostic Procedures/Surgery
A local anesthetic block may lead to symptom resolution and confirmation of the diagnosis.
Pathological Findings
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Microscopic evaluation of the tendons does not show signs of inflammation, but rather angiofibroblastic degeneration and collagen disarray.
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Light microscopy reveals both an excess of fibroblasts and blood vessels that are consistent with neovessels or angiogenesis.
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The tendons are relatively hypovascular proximal to the tendon insertion. This hypovascularity may predispose the tendon to hypoxic tendon degeneration and has been implicated in the etiology of tendinopathies.
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These findings support a failed healing response rather than a true inflammatory process.
Differential Diagnosis
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Posterior interosseous nerve entrapment (radial tunnel syndrome)
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Osteoarthritis
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C7 radiculopathy
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Musculocutaneous nerve entrapment
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Chronic compartment syndrome of anconeus muscle
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Radiocapitellum OCD lesion
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Lateral collateral ligament strain
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Stress fracture
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Humeral fracture
Treatment-
Acute treatment:
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Ice after activity.
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Anti-inflammatory medications: Consider NSAIDS, either topical or by mouth. Corticosteroid injections have proven effectiveness for short-term relief of symptoms, but no major differences were seen at 1 yr compared to NSAID treatment (2).
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Modalities: Consider the use of US, phonophoresis, or iontophoresis. Some studies have shown them to be useful in returning an athlete to activity sooner, but they show no long-term benefit (3).
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Long-term treatment:
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Watchful waiting: 83% of patients symptom-free at 1 yr (2)
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Autologous blood, platelet-rich plasma, prolotherapy, topical nitrates, botulinum toxin have demonstrated effectiveness in small studies (4,5,6)
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Extracorporeal shock wave therapy and low-intensity laser therapy have not demonstrated effectiveness (2,7)
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Surgical intervention: 30 of 36 people reported improvement after surgery (8).
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Physical therapy consisting of forearm stretching and strengthening program with progression to eccentric muscle strengthening of the common extensor tendon
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A forearm counterforce brace during activities may help some patients; the use of a night wrist splint can be helpful for patients with morning pain.
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P.357
Additional Treatment
Referral
Consider referral for surgical debridement for individuals whose symptoms do not respond to a high-quality nonoperative treatment program.
Additional Therapies
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Technique modification: Lessons from a professional instructor or coach about proper serve and backhand techniques
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Improve ergonomics in the work environment.
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Equipment: Ensure athlete is using properly sized, weighted, and strung racquet.
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Stretching and strengthening: Ensure athlete is on appropriate conditioning program, preactivity warm-up, and postactivity cool-down programs.
Ongoing CareFollow-Up Recommendations
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Relative rest: Limit activities that cause pain
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Equipment modifications: Decrease racquet string tension; use only new, dry tennis balls; play on grass court if available.
References
1. Gruchow HW, Pelletier D. An epidemiologic study of tennis elbow. Incidence, recurrence, and effectiveness of prevention strategies. Am J Sports Med. 1979;7:234–238.
2. Smidt N, van der Windt DA, Assendelft WJ, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002;359:657–662.
3. Bisset L, Paungmali A, Vicenzino B, et al. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005;39:411–422; discussion 411–422.
4. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. 2006.
5. Paoloni JA, Appleyard RC, Nelson J, et al. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med. 2003;31:915–920.
6. Placzek R, Drescher W, Deuretzbacher G, et al. Treatment of chronic radial epicondylitis with botulinum toxin A. A double-blind, placebo-controlled, randomized multicenter study. J Bone Joint Surg Am. 2007;89:255–260.
7. Buchbinder R, Green SE, Youd JM, et al. Shock wave therapy for lateral elbow pain. Cochrane Database Syst Rev. 2005:CD003524
8. Grewal R, MacDermid JC, Shah P, et al. Functional outcome of arthroscopic extensor carpi radialis brevis tendon release in chronic lateral epicondylitis. J Hand Surg [Am]. 2009;34:849–857.
Additional Reading
Calfee RP, Patel A, Dasilva MF, et al. Management of lateral epicondylitis: current concepts. J Am Acad Orthop Surg. 2008;16:19–29.
Faro F, Wolf JM. Lateral epicondylitis: review and current concepts. J Hand Surg [Am]. 2007;32:1271–1279.
Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999;81:259–278.
Plancher KD, Halbrecht J, Lourie GM. Medial and lateral epicondylitis in the athlete. Clin Sports Med. 1996;15:283–305.
Thurston AJ. Conservative and surgical treatment of tennis elbow. Aust N ZJ Surg. 1998;68:568–572.
Walrod B, Young C. Lateral Epicondyitis. emedicine.com. July, 2009.
CodesICD9
726.32 Lateral epicondylitis
Clinical Pearls
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The lateral elbow serves as the origin of the forearm muscles and thus elbow pain may result
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Histologic biopsies of chronic lateral epicondylitis reveal no inflammation, but rather signs of poor and disordered healing, a term called angiofibroblastic degeneration. Chronic lateral epicondylosis is not an inflammatory condition. Consider other treatments such as physical therapy and proinflammatory modalities in this case.