- 1 Other Names
- 2 Background
- 3 Pathophysiology
- 4 Risk Factors
- 5 Differential Diagnosis
- 6 Clinical Features
- 7 Evaluation
- 8 Classification
- 9 Management
- 10 Return to Play
- 11 Complications
- 12 See Also
- 13 References
- Tennis Elbow
- Lateral Epicondylosis
- Lateral Epicondylalgia
- Refers to overuse injury of the Common Extensor Tendon which attaches to the lateral epicondyle of the elbow
- The Extensor Carpi Radialis Brevis is the muscle group most commonly implicated
- Most common overuse injury of elbow (need citation)
- Affects up to 3% of the total adult population
- Initially considered to be a tendinitis and inflammatory condition
- Now considered a tendinosis or tendinopathy from chronic degenerative process
- Note that these terms are often used interchangeably
- Abnormal stress leads to increased cross-linkage, collagen deposition
- When the force loads exceed the tolerance of the tendon, micro-tears occur and the adaptive response leads to tendinosis
- Histological analysis demonstrates a paucity of inflammatory cells
- Stages of repetitive microtrauma
- Stage 1: acute inflammatory response
- Stage 2: sustained injury leads to angiofibroblastic hyperplasia (fibroblasts, hyperplasia, disorganied collagen)
- Stage 3: further pathological changes lead to structural failure with micro-tearing
- Stage 4: in addition to angiofibroblastic hyperplasia, fibrosis, calcification are seen
- The following muscles form the common extensor tendon along the lateral epicondyle
- Lateral supracondylar ridge
- Also potentially involved
- Etiology is often activity related or overuse related, although in some cases a cause can not be identified
- Almost universally, activities involve wrist extension, radial deviation or supination
- Racket sports
- Manual Labor
- Tobacco Use
- Dislocations & Instability
- Ligament Injuries
- Pediatric Considerations
- Patients complain of pain at or around lateral epicondyle
- The pain often radiates down forearm along extensor muscles
- Exacerbated by extension or supination activities
- Physical: Physical Exam Forearm
- Tenderness at the lateral epicondyle
- Range of motion typically intact
- Special Tests
- Standard Radiographs Elbow
- Not required to make the diagnosis
- Useful to exclude other causes of elbow pain
- Tendon may demonstrate:
- Thickening or thinning
- Hypoechogenic foci (intra-substance degenerative changes)
- Tendon tears
- Bony irregularity
- Calcific deposits
- Doppler: hypervascularity or neovascularization
- Absence of neovascularization, grey-scale changes helpful to exclude as a diagnosis
- Not necessary for diagnosis
- More reproducible, less inter-operator variability
- May demonstrate:
- Degenerative changes
- Tendon tears
- Edema of tendon
- In a blinded study, abnormal MRI did not correlate with patients symptoms
- In cases of unclear etiology, may be useful to exclude neurological causes
- Generally a self limiting condition if offending activities are discontinued
- 95% success rate with nonoperative treatment
- Discontinuation of offending activity
- In athletes, correction of mechanics and improper technique
- In workers, ergonomic changes or periods of rest may help reduce symptoms
- Ice after activity
- Physical Therapy
- May improve short term function
- One study found diclofenac superior to placebo, however naproxen was similar
- Corticosteroid Injection
- Often used to treat disease
- Superior to NSAIDS at 4 weeks, no long term differences were noted
- Studies show benefit early in treatment, but the long term efficacy has not been demonstrated
- At six weeks, treatment with corticosteroid injections was more effective than physiotherapy
- In this study, at 6 weeks, corticosteroid injections were superior, however long-term differences favored physical therapy
- Early local corticosteroid injection is effective for lateral epicondylitis.
- Extracorporeal Shock Wave Therapy
- 2007 systematic review attempt to summarize the research on SWT for lateral epicondylitis but was limited by significant heterogeneity among included studies.
- Nonetheless, they concluded there was evidence for effectiveness of shock wave treatment for tennis elbow
- One randomized, multicenter trial found no difference
- Low-level Laser Treatment (LLLT)
- Trinh et al found pain reduction at 2, 8 weeks
- Long term effects less clear
- Topical Nitroglycerin
- Useful for refractory tendinopathies
- Limited research but superior to placebo
- Autologous Blood Injection
- Platelet Rich Plasma
- Percutaneous Radiofrequency Thermocoagulation
- 85% of patients treated for lateral epicondyltis had a significant reduction in pain
- No reduction in thickness of origin of tendon was noted
- Iontophoresis and Phonophoresis
- Therapeutic Ultrasound
- Greater improvements in pain score, weight lifting, grip strength compared to placebo
- Dextrose Prolotherapy
- A double blind, randomized controlled trial demonstrated that dextrose prolotherapy was well tolerated and effective at reducing pain and improving strength testing in patients with lateral epicondylosis
- Needle Tenotomy
- Nearly 2/3 of patients reported improvement in pain up to 28 months 
- Sclerotherapy has a potential to reduce the tendon pain and increase grip strength, in patients with chronic painful tennis elbow.
- Chronic symptoms with failure of conservative management, typically 6-12 months or more
- Release of ECRB origin (tenotomy)
- Open vs arthroscopic
Return to Play
- Needs to be updated
- Chronic pain
- Inability to return to work, sport
- Sports Med Review Elbow Pain: https://www.sportsmedreview.com/by-joint/elbow/
- Smidt, Nynke, and Danielle AWM van der Windt. "Tennis elbow in primary care." (2006): 927-928.
- Image courtesy of orthobullets, "Tennis Elbow"
- 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-A:259–278.
- Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon: a controlled study of 891 patients. J Bone Joint Surg [Am] 1991;73-A:1507–1525.
- du Toit C, Stieler M, Saunders R, Bisset L, Vicenzino B. Diagnostic accuracy of power Doppler ultrasound in patients with chronic tennis elbow. Br J Sports Med 2008;42:872–876
- Savnik A, Jensen B, Nørregaard J, et al. Magnetic resonance imaging in the evaluation of treatment response of lateral epicondylitis of the elbow. Eur Radiol 2004;14:964–969.
- Degen RM, Conti MS, Camp CL, Altchek DW, Dines JS, Werner BC. Epidemiology and Disease Burden of Lateral Epicondylitis in the USA: Analysis of 85,318 Patients. HSS J. 2018 Feb;14(1):9-14.
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- McLauchlan GJ, Handoll HH. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Database Syst Rev. 2001:CD000232
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- Runeson L, Haker E. Iontophoresis with cortisone in the treatment of lateral epicondylalgia (tennis elbow)–a double-blind study. Scand J Med Sci Sports. 2002;12:136–142.
- Nirschl RP, Rodin DM, Ochiai DH, Maartmann-Moe C. Iontophoretic administration of dexamethasone sodium phosphate for acute epicondylitis. A randomized, double-blinded, placebo-controlled study. Am J Sports Med. 2003;31:189–195.
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- McShane, John M., Levon N. Nazarian, and Marc I. Harwood. "Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow." Journal of ultrasound in medicine 25.10 (2006): 1281-1289.
- Zeisig E, Ohberg L, Alfredson H. Sclerosing polidocanol injections in chronic painful tennis elbow-promising results in a pilot study. Knee Surg Sports Traumatol Arthrosc. 2006;14:1218–1224