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Lateral Epicondylitis

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Other Names

  • Tennis Elbow
  • Lateral Epicondylosis
  • Lateral Epicondylalgia

Background

Epidemiology

  • Most common overuse injury of elbow (need citation)
  • Affects up to 3% of the total adult population[1]

Pathophysiology

Illustration of the 4 muscles of the common extensor tendon[2]

Pathogenesis

  • 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[3]
  • When the force loads exceed the tolerance of the tendon, micro-tears occur and the adaptive response leads to tendinosis

Histopathology

  • Histological analysis demonstrates a paucity of inflammatory cells[4]
  • 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

Pathoanatomy

Etiology

  • 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

Associated Pathology

Risk Factors

  • Sports
    • Tennis
    • Squash
    • Badminton
    • Racket sports
  • Activities
    • Typing
    • Piano
  • Labor
    • Manual Labor
  • Obesity
  • Tobacco Use

Differential Diagnosis

Clinical Features

  • History
    • 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
    • Cozens Test: Patient is asked to supinate a pronated hand against resistance
    • Mills Test: Examiner passively pronates forearm, flexes wrist
    • Maudsleys Test: Patient extends middle finger against resistance
    • Chair Test: Patient is asked lift chair with forearm pronated

Evaluation

Radiographs

Ultrasound

  • Tendon may demonstrate:
    • Thickening or thinning
    • Hypoechogenic foci (intra-substance degenerative changes)
    • Tendon tears
    • Calcification
    • Bony irregularity
    • Calcific deposits
  • Doppler: hypervascularity or neovascularization
    • Absence of neovascularization, grey-scale changes helpful to exclude as a diagnosis[5]

MRI

  • 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[6]

EMG

  • In cases of unclear etiology, may be useful to exclude neurological causes

Classification

  • N/A

Management

  • Generally a self limiting condition if offending activities are discontinued
  • 95% success rate with nonoperative treatment[7]

Nonoperative

  • General
    • 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
    • Standard for management of lateral epicondylitis
    • Superior to compared to rest alone at 6 weeks[8]
    • Stretching
    • Eccentric Strengthening[9]
    • Rehabilitation at the shoulder, including periscapular, rotator cuff, etc[10]
  • Bracing
    • Elbow Counterforce Brace, often referred to as a strap brace, designed to offload the tendon
    • Superior compared to placebo, wrist splint[11]
    • Unclear if specific brace is superior to others[8]
    • Another study found wrist splints which block wrist extension, supination may be equal to or better[12]
  • NSAIDS
    • May improve short term function
    • One study found diclofenac superior to placebo, however naproxen was similar[13]
  • Corticosteroid Injection
    • Often used to treat disease
    • Superior to NSAIDS at 4 weeks, no long term differences were noted[13]
    • Studies show benefit early in treatment, but the long term efficacy has not been demonstrated[14]
    • At six weeks, treatment with corticosteroid injections was more effective than physiotherapy[15]
    • In this study, at 6 weeks, corticosteroid injections were superior, however long-term differences favored physical therapy[16]
    • Early local corticosteroid injection is effective for lateral epicondylitis.[17]
  • 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.[18]
    • Nonetheless, they concluded there was evidence for effectiveness of shock wave treatment for tennis elbow
    • One randomized, multicenter trial found no difference[19]
  • Low-level Laser Treatment (LLLT)
    • Four systematic reviews have addressed LLLT and all agreed the best current level of evidence does not support its use in the treatment of tendinopathy[20][21][22][23]
  • Acupuncture
    • Trinh et al found pain reduction at 2, 8 weeks[24]
    • Long term effects less clear
  • Botox
    • Currently no consensus on usefulness
    • Wong et al: pain reduction at 4, 12 weeks[25]
    • Hayton et al: No difference compared to placebo[26]
  • Topical Nitroglycerin
    • Useful for refractory tendinopathies[27]
    • Limited research but superior to placebo
  • Autologous Blood Injection
    • Limited research
    • Several small studies are favorable[28]
    • Kazemi et al: superior to CSI at 4, 8 weeks[29]
  • Platelet Rich Plasma
    • Very limited research
    • Several small studies showed PRP superior to autologous blood, bupivicaine[30][31]
    • Fitzpatrick et al: meta-analysis favors leukocyte rich (LR-PRP)[32]
  • Percutaneous Radiofrequency Thermocoagulation
    • 85% of patients treated for lateral epicondyltis had a significant reduction in pain[33]
    • No reduction in thickness of origin of tendon was noted
  • Iontophoresis and Phonophoresis
    • Two adequately powered studies showed no benefit[34][35]
  • Therapeutic Ultrasound
    • Greater improvements in pain score, weight lifting, grip strength compared to placebo[36]
  • 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[37]
  • Needle Tenotomy
    • Nearly 2/3 of patients reported improvement in pain up to 28 months [38]
  • Sclerotherapy
    • Sclerotherapy has a potential to reduce the tendon pain and increase grip strength, in patients with chronic painful tennis elbow.[39]

Operative

  • Indications
    • Chronic symptoms with failure of conservative management, typically 6-12 months or more
  • Technique
    • Release of ECRB origin (tenotomy)
    • Open vs arthroscopic

Return to Play

  • Needs to be updated

Complications

See Also

References

  1. ↑ Smidt, Nynke, and Danielle AWM van der Windt. "Tennis elbow in primary care." (2006): 927-928.
  2. ↑ Image courtesy of orthobullets, "Tennis Elbow"
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 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
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 8.0 8.1 Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med 2005;39:411–422.
  9. ↑ Croisier JL, Foidart-Dessalle M, Tinant F, Crielaard JM, Forthomme B. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br J Sports Med. 2007;41:269–275
  10. ↑ Kibler WB, Sciascia AD, Uhl TL, Tambay N, Cunningham T. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. Am J Sports Med 2008;36:1789–1798.
  11. ↑ Jafarian FS, Demneh ES, Tyson SF. The immediate effect of orthotic management on grip strength of patients with lateral epicondylosis. J Orthop Sports Phys Ther 2009;39:484–489.
  12. ↑ Garg R, Adamson GJ, Dawson PA, Shankwiler JA, Pink MM. A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis. J Shoulder Elbow Surg 2010;19:508–512.
  13. ↑ 13.0 13.1 Wolf JM, Ozer K, Scott F, Gordon MJ, Williams AE. Comparison of autologous blood, corticosteroid, and saline injection in the treatment of lateral epicondylitis: a prospective, randomized, controlled multicenter study. J Hand Surg Am 2011;36:1269–1272.
  14. ↑ Smidt N, Assendelft WJ, van der Windt DA, Hay EM, Buchbinder R, Bouter LM. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain. 2002;96:23–40.
  15. ↑ Verhaar JA, Walenkamp GH, van Mameren H, Kester AD, van der Linden AJ. Local corticosteroid injection versus Cyriax-type physiotherapy for tennis elbow. J Bone Joint Surg Br. 1996;78:128–132.
  16. ↑ Smidt N, van der Windt DA, Assendelft WJ, Deville WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002;359:657–662.
  17. ↑ Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. Bmj. 1999;319:964–968.
  18. ↑ Rompe, Jan D., and Nicola Maffulli. "Repetitive shock wave therapy for lateral elbow tendinopathy (tennis elbow): a systematic and qualitative analysis." British medical bulletin83.1 (2007): 355-378.
  19. ↑ Haake, M., et al. "Extracorporeal shock wave therapy in the treatment of lateral epicondylitis: a randomized multicenter trial." JBJS 84.11 (2002): 1982-1991.
  20. ↑ Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003:CD004258.
  21. ↑ McLauchlan GJ, Handoll HH. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Database Syst Rev. 2001:CD000232
  22. ↑ Stasinopoulos DI, Johnson MI. Effectiveness of low-level laser therapy for lateral elbow tendinopathy. Photomed Laser Surg. 2005;23:425–430.
  23. ↑ Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC. Rehabilitation for patients with lateral epicondylitis: a systematic review. J Hand Ther. 2004;17:243–266.
  24. ↑ Trinh KV, Phillips SD, Ho E, Damsma K. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology 2004;43:1085–1090.
  25. ↑ Wong SM, Hui AC, Tong PY, et al. Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial. Ann Intern Med 2005;143:793–797.
  26. ↑ Hayton MJ, Santini AJ, Hughes PJ, et al. Botulinum toxin injection in the treatment of tennis elbow: a double-blind, randomized, controlled, pilot study. J Bone Joint Surg [Am] 2005;87-A:503–507.
  27. ↑ Challoumas D, Kirwan PD, Borysov D, et al. Topical glyceryl trinitrate for the treatment of tendinopathies: a systematic review. British Journal of Sports Medicine 2019;53:251-262
  28. ↑ Edwards SG, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg Am 2003;28:272–278.
  29. ↑ Kazemi M, Azma K, Tavana B, Rezaiee Moghaddam F, Panahi A. Autologous blood versus corticosteroid local injection in the short-term treatment of lateral elbow tendinopathy: a randomized clinical trial of efficacy. Am J Phys Med Rehabil 2010;89:660–667.
  30. ↑ Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med 2006;34:1774–1778.
  31. ↑ Mishra A, Collado H, Fredericson M. Platelet-rich plasma compared with corticosteroid injection for chronic lateral elbow tendinosis. PMR 2009;1:366–370.
  32. ↑ <Fitzpatrick J, Bulsara M, Zheng MH. The Effectiveness of Platelet-Rich Plasma in the Treatment of Tendinopathy: A Meta-analysis of Randomized Controlled Clinical Trials. Am J Sports Med. 2017;45(1):226–233. doi: 10.1177/0363546516643716.
  33. ↑ Lin CL, Lee JS, Su WR, et al. Clinical and ultrasonographic results of ultrasonographically guided percutaneous radiofrequency lesioning in the treatment of recalcitrant lateral epicondylitis. Am J Sports Med 2011;39:2429–2435.
  34. ↑ 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.
  35. ↑ 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.
  36. ↑ Binder A, Hodge G, Greenwood AM, Hazleman BL, Page Thomas DP. Is therapeutic ultrasound effective in treating soft tissue lesions? Br Med J (Clin Res Ed). 1985;290:512–514.
  37. ↑ Scarpone, Michael, et al. "The efficacy of prolotherapy for lateral epicondylosis: a pilot study." Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine 18.3 (2008): 248.
  38. ↑ 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.
  39. ↑ 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
Created by:
John Kiel on 11 June 2019 01:32:57
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Last edited:
14 April 2023 18:50:34
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