Lateral Epicondylitis (Tendinosis)

By admin On Aug 6, 2023

Ovid: Master Techniques in Orthopaedic Surgery: The Elbow

Editors: Morrey, Bernard F.

Title: Master Techniques in Orthopaedic Surgery: The Elbow, 2nd Edition

> Table of Contents > Part III – Soft-Tissue Injury > 12 – Lateral Epicondylitis (Tendinosis)

Lateral Epicondylitis (Tendinosis)

Robert P. Nirschl M.D.¹

¹ Director Nirschl Orthopedic
Sports Medicine Clinic/Virginia Hospital Center Sports Medicine
Fellowship Program, Arlington, Virginia. Associate Clinical Professor,
Georgetown University Medical School Washington, D.C.

Epicondylitis (tendinosis) occurs at least five times
more commonly on the lateral than on the medial aspect of the joint.
The selection factors to determine the candidates for surgery are
similar for each process, yet there are some distinct features with
regard to the surgical technique. Thus medial epicondylitis is
discussed separately in Chapter 13.

Indications/Contraindications

Pain is the major indication for surgery of lateral
epicondylitis. There are three broad indications and a fourth feature
to consider (7).

Pain is of significant intensity as to limit function and interferes with daily activity or occupation.
Localization is precisely at the lateral epicondyle and origin of the ECRB and EDC to the epicondyle.
A legitimate period of nonoperative
management has been attempted. This typically includes at least 6
months of activity modification, forearm band, antiinflammatory agents,
and a quality rehabilitation program;
Failure of cortisone injections is no
longer considered an absolute necessity before offering surgical
intervention. However, if injections have been used and the patient is
no longer benefiting or has not benefited from them, then the patient
is a candidate for a surgical procedure.

The contraindications to surgical intervention include an inadequate nonoperative program (10)
and patients who have demonstrated lack of compliance with the
recommendations, particularly that of activity modification.
Individuals on worker’s compensation disability should be assessed on
several occasions to ensure that the preceding indications have been
met.

Figure 12-1. Arthroscopic identification of intraarticular pathology (A) was treated arthroscopically with relief of lateral epicondylitis symptoms (B).

P.206

Preoperative Planning

Physical findings include local tenderness to palpation
over the tendon origin at the epicondyle. Provocative tests of pain
with resisted wrist extension for lateral involvement are invariably
positive, especially with the elbow in full extension (5).
In some cases the symptoms may be aggravated by performing the test in
elbow extension. If forearm pain is a component, examine for posterior
interosseous nerve irritation. The most sensitive is pain on resistive
supination (13).

The most commonly involved tissue, the pathologic
process, and the principles of the surgical intervention should be
reviewed before undertaking the surgical procedure (7,8,9,11).

The hallmarks of good surgical concept and technique
include precise identification of the pathologic tissue, resection of
all involved pathology, maintenance of normal tissue attachments,
protection of normal tissue, enhancement of vascular supply, firm
repair of the operative site, and quality postoperative rehabilitation.

The extensor carpi radialis brevis (100%) and the
extensor communis (anterior edge) are the tissues most commonly
involved laterally (100% and 35%, respectively) (1,2,3,4,9).
Histologically, the pathologic tissue is devoid of inflammatory cells
but has a characteristic pattern of fibroblasts and vascular elements (6,12). Recent electron microscopic evidence reveals lack of extracellular cross-linkage (6).
Furthermore, approximately 20% of surgical cases have been noted to
have some form of bony exostosis at the lateral epicondyle. Less common
pathologic changes include calcification in the soft-tissue elements
(extensor communis and radial collateral ligament). Intraarticular
changes, including synovitis and orbicular ligament abnormality, are
being recognized with increasing frequency with the advent of elbow
arthroscopy as a therapeutic tool (Fig. 12-1).

Surgery

Lateral Epicondylitis

The described technique and illustrations apply for the
large majority of cases. It should be noted, however, that individual
variations can and do occur. In these instances, the pathologic
variations should be addressed as identified.

P.207

Arthroscopy

The data on arthroscopic debridement are incomplete at
this time to draw a conclusion or to recommend this treatment. The
topic is addressed in Chapter 2.

Technique

After anesthesia (general or arm block), the arm is draped free with a nonsterile tourniquet and placed on an arm board.

The incision extends from 1 to 2 cm proximal and just
anteromedial to the lateral epicondyle just to the level of the joint
(i.e., 1 cm distal to the epicondyle) (Fig. 12-3). The subcutaneous

P.208

P.209

tissue and superficial fascia are incised and retracted, locating the
interface between the extensor longus muscle and the firm anterior edge
of the extensor aponeurosis. A palpable crevice is present at this
interface as the fascia over the extensor longus is thin and the
anterior edge of the aponeurosis is firm and thick (Fig. 12-4).
A splitting incision 2 to 3 mm in depth is made between the extensor
longus and the extensor aponeurosis in the identified interface
extending from 1 to 2 cm proximal to the lateral epicondyle distally to
the level of the joint line. The extensor longus is released by scalpel
dissection and retracted anteromedially to 2 to 3 cm. This retraction
brings the extensor brevis into direct view (Fig. 12-5).

Figure 12-2. All illustrations are of a right elbow. The arm was draped with a nonsterile tourniquet and placed on an arm board.

Figure 12-3.
The skin incision extends from 1 to 2 cm proximal and just anterior to
the lateral epicondyle distally 1 cm just to the level of the elbow
joint (A). Circled area identifies lateral epicondyle (B).

Figure 12-4. Identification of tendons. Exposure of the lateral epicondyle and interface between extensor longus and extensor aponeurosis (A). Note that the extensor brevis is not visible as it is hidden under the extensor longus (B). Small asterisk, lateral epicondyle; large asterisk, extensor aponeurosis; arrow, extensor longus.

Technical note: A common
error in the incision at the extensor longus interface is to penetrate
too deeply by vertical dissection. As noted, the extensor longus is
only 2 to 3 mm thick at this level. Once the 2- to 3-mm depth is
reached, the dissection is primarily horizontal progressing medially.
This technical subtlety is important to avoid iatrogenic distortion as
well as to bypass the body of the extensor brevis tendon. Such
iatrogenic distortion can easily complicate the identification of the
pathologic regions.

Figure 12-5.
An incision in the extensor longus/extensor aponeurosis interface with
anteromedial retraction of extensor longus exposes the pathologic
origin of the extensor brevis (A). A key
technical point is not to incise too deeply but more medially as the
extensor longus is only 2 to 3 mm in depth at this level. Variations in
pathoanatomic damage include degeneration of the extensor brevis origin
(B) and a full avulsion rupture of the extensor brevis origin, as shown in a world-class tennis player (C). Small asterisk, lateral epicondyle; large asterisk, extensor aponeurosis; double asterisks, extensor longus; arrow, brevis tendinosis.

Figure 12-6. Resection of pathologic tissue. Resection of pathologic sections (histologically termed angiofibroblastic tendinosis) of extensor brevis origin. In this rendering, 100% of the origin is involved and a partial rupture is depicted (A).
In no circumstance is the extensor aponeurosis totally released from
the epicondyle. Surgical photograph of resection of pathologic extensor
brevis origin (B) shows major tendinosis
with an underside rupture. Note a small strip of normal tendon at the
edge of the extensor longus muscle. The remaining pathologic alteration
has a dull-grayish edematous gross appearance typical of
angiofibroblastic tendinosis. (Small asterisk, lateral epicondyle; below skin; large asterisk, extensor aponeurosis; arrow, tear.)

Figure 12-7. Completed resection of pathologic tissue. Resected pathologic section of the entire extensor brevis tendon (A). Surgical photograph depicting completed resection of the degenerated extensor brevis origin (B). Arrow, defect left after brevis resection; asterisk, healthy fascia over retracted longus.

P.210

P.211

With proper case selection and appropriate exposure, the
entire origin of the extensor brevis will be easily identified. The
gross appearance of the pathologic change is dull-grayish tissue, often
edematous and friable, and, on occasion, ruptured (Fig. 12-5).
Normal tissue in contrast is shiny, is firm, and has a slightly
yellowish-white hue. The pathologic tissue often encompasses the entire
origin of the extensor brevis, and in our series the anterior 10% edge
of the extensor aponeurosis is abnormal in approximately 35% of cases.

Excision of all pathologic tissue in the extensor brevis
origin is performed en bloc. This tissue block is somewhat triangular
in shape with the base distal (Fig. 12-6). The typical size of tissue is 2 з 1 cm (Fig. 12-6).
It should be noted that the brevis origin is released from the lateral
epicondyle and the anterior edge of the extensor aponeurosis. If the
anterior aponeurosis has pathologic alteration, the pathologic tissue
is also removed (but not normal tendon).

Pathologic tissue is easily identified by its visual
appearance and confirmed by the “Nirschl scratch test.” This makes use
of the friability of pathologic tissue, which easily peels off by
utilizing a scratching motion with the scalpel. When healthy tissue is
reached, it no longer peels off with the scratching motion. This
technique is especially helpful when removing the pathologic changes in
the anterior edge of the aponeurosis.

In the 20% of cases that present with an exostosis or
prominence of the lateral epicondyle, the proximal edge of the
aponeurosis is temporarily peeled off the epicondyle for adequate
exposure and the exostosis is removed by rongeur and smoothed by a rasp.

Once the pathologic tissue is adequately resected, a
defect is present in the prior area of the extensor brevis tendon
origin. The more distal aspect of the extensor brevis is still attached
to the orbicular ligament, distal anterior aponeurosis, and underside
of the extensor longus (Fig. 12-7). The brevis
therefore does not retract distally to any appreciable degree, thereby
maintaining an essentially normal working length of the entire extensor
brevis muscle-tendon unit (i.e., from elbow to wrist). If a segment of
the anterior edge of the extensor aponeurosis or a bone exostosis is
present on the lateral epicondyle, these abnormalities are resected at
this time. Firm repair of the aponeurosis is always undertaken in these
circumstances. The goal of the operation is resection of all pathologic
tissue, not tendon release.

A small synovial opening may be made at this time to
inspect the anterolateral joint compartment. Unless the patient
presents with clear intraarticular signs and symptoms preoperatively,
it is uncommon to find meaningful intraarticular changes.

To enhance vascular supply, two to three 5/64-inch holes
are drilled through cortical bone in the resected area. This technique
is theorized to encourage rapid replacement of this triangular tissue
void with healthy fibrotendinous tissue (Fig. 12-8).

Figure 12-8. A,B:
Enhancement of revascularization by cortical drilling. The cortical
bone is drilled with a 5/64-inch bit to enhance revascularization of
the area. (Asterisk, lateral epicondyle.)
Note: do not drill the tip area of the lateral epicondyle as bony
disturbance here causes increased post-op pain.

Figure 12-9. A,B:
Repair of tendon interface. In all cases the interface between the
extensor longus and the extensor aponeurosis is firmly closed. It is
theorized that blood clot transformed to biologically healthy fibrous
tissue (painless) replaces the proximal defect of the resected brevis
area further reinforcing the security of the ultimate brevis origin. Arrow, lateral epicondyle; asterisk, extensor longus.

P.212

The interface between the posterior edge of the extensor
longus and the remaining anterior edge of the extensor aponeurosis is
now firmly closed (Fig. 12-9). I use a simple
running stitch of No. 1 PDS. It is unnecessary to suture the distal
extensor brevis since a firm attachment is retained to the orbicular
ligament, distal aponeurosis, and underside of extensor longus
distally. The extensor aponeurosis is firmly repaired anteriorly, and
its proximal attachment is largely undisturbed; thus rapid mobilization
postoperatively is possible and encouraged. The skin is closed with 3-0
subcutaneous cat gut, subcuticular 3-0 Prolene and supporting
Steri-strips.

Figure 12-10.
Light elbow immobilizer with Velcro straps provides comfortable support
in the immediate postoperative period. Motion exercises are usually
started 48 hours postoperative but intermittent immobilizer protection
is usually maintained for 5 to 6 days. (Courtesy of Medical Sports,
Inc., Arlington, VA.)

P.213

Postoperative Management

The arm is placed in an elbow immobilizer with four Velcro straps (Fig. 12-10).
The joint is at 90 degrees flexion, the forearm is in neutral, and the
wrist and hand are free. I use full immobilization for 2 days. Motion
exercises are usually started within 48 hours following surgery (tendon
and/or tendon with nerve surgery when combined medial and lateral
surgery is done).

Intermittent immobilizer protection is usually
maintained for 5 to 6 days, at which time normal activities of daily
living are resumed. Counterforce support (forearm band) providing
protective function is utilized thereafter until full forearm strength
returns (usually 3 to 6 months). The brace is used at times of forearm
and shoulder rehabilitation exercise and more vigorous forearm
activities such as heavier household activities. A gradual return to
sports such as tennis and golf often is initiated at 8 to 10 weeks with
brace protection.

Results

After lateral surgery, approximately 85% to 90% of patients may be anticipated to expect full return of all prior activities (1,2,9).
In the remainder, improvement is usually seen, but not adequate to
allow the person to return to all sport activity levels. In less than
5% no improvement is observed, and in rare instances the patient’s
condition has deteriorated. Thus less than 5% of patients are
considered failures.

Complications

The most frequent complication after surgery for tennis
elbow is residual pain of varying degrees. This is not common in our
experience and occurs in fewer than 10% of patients. When pain after
surgery is present, a logical analysis is conducted and the following
determinations must be considered (7,11):

Has there been sufficient time and/or proper rehabilitation to allow adequate healing?
Did the proper diagnosis exist before the surgical intervention?

Figure 12-11. Arthrogram reveals extravasation of contrast material in forearm musculature after ill advised tennis elbow surgery technique.

P.214

Did something occur at the time of surgery to cause iatrogenic symptoms.
Was the true patho-anatomy adequately addressed?

An inadequate surgical excision leaving behind some of
the pathologic tendinosis tissue is implicated most commonly as the
cause of failure. In this case, a second surgical procedure should be
considered (7,11). Worker’s compensation may affect an individual’s motivation and should be considered during the rehabilitation phase.

An aggressive release of the common tendon from the
lateral or medial epicondyle can result in a release of the collateral
ligament and resulting joint instability (7,11).
Occasionally, instability is manifested as residual pain and not as
laxity. This is diagnosed by stress view radiographs and occasionally
by an arthrogram (Fig. 12-11). The treatment is collateral ligament repair or reconstruction.

Illustrative Case

A world-class tennis player had lateral epicondylitis
for 6 months. She had not responded to activity modification and
counterforce bracing. At surgery a complete rupture of the degenerated

P.215

brevis origin was identified and resected (Fig. 12-12).
Effectiveness was slightly altered but good enough to reach the
quarter-finals of the U.S. Open 9 months after surgery and to achieve a
ranking thereafter in the world’s top 10.

Figure 12-12. Complete rupture of brevis tendon in a professional tennis player (A). Histologic examination confirmed this to be a degenerative, rather than inflammatory, process (B). Asterisk, lateral epicondyle.