http://upload.orthobullets.com/topic/3082/images/mri elbow.jpg
http://upload.orthobullets.com/topic/3082/images/tennis elbow.jpg
  • Overuse injury involving eccentric overload at origin of common extensor tendon  
    • leads to tendinosis and inflammation at origin of ECRB    
  • Epidemiology
    • incidence
      • most common cause for elbow symptoms in patients with elbow pain
      • affects 1-3% of adults annually
      • commonly in dominant arm
    • demographics
      • up to 50% of all tennis players develop 
        • risk factors
          • poor swing technique
          • heavy racket
          • incorrect grip size 
          • high string tension
      • common in laborers who utilize heavy tools
      • workers engaged in repetitive gripping or lifting tasks
      • most common between ages of 35 and 50 years old
      • men and women equally affected
  • Pathophysiology
    • mechanism
      • precipitated by repetitive wrist extension and forearm pronation
      • common in tennis players (backhand implicated)
    • pathoanatomy
      • usually begins as a microtear of the origin of ECRB 
      • may also involve microtears of ECRL and ECU
    • pathohistology
      • microscopic evaluation of the tissue reveals
        • angiofibroblastic hyperplasia  
        • disorganized collagen 
  • Associated conditions
    • radial tunnel syndrome 
      • is present in 5%
  • Prognosis
    • non-operative treatment effective in up to 95% of cases
  • Common extensor origin  
    • muscles that originate from lateral supracondylar ridge
      • extensor carpi radialis longus 
    • muscles that originate on lateral epicondyle
      • extensor carpi radialis brevis  
      • extensor carpi ulnaris 
      • extensor digitorum 
      • extensor digiti minimi 
      • anconeus 
        • shares same attachment site as ECRB 
  • Ligaments
    • lateral ulnar collateral ligament 
  • Nerves
    • posterior interosseus nerve (PIN) enters the supinator just distal to the radial head
      • compression can lead to radial tunnel syndrome (may co-exist with lateral epicondylitis)
  • Symptoms
    • pain with resisted wrist extension
    • pain with gripping activities
    • decreased grip strength
  • Physical exam
    • palpation & inspection
      • point tenderness at ECRB insertion into lateral epicondyle
        • few mm distal to tip of lateral epicondyle
    • neuromuscular
      • may have decreased grip strength
      • neurological exam helps to differentiate from entrapment syndromes
    • provocative tests 
      • the following maneuvers exacerbate pain at lateral epicondyle
        • resisted wrist extension with elbow fully extended
        • resisted extension of the long fingers
        • maximal flexion of the wrist
        • passive wrist flexion in pronation causes pain at the elbow
  • Radiographs 
    • recommended views
      • AP/Lateral of elbow
    • findings
      • usually normal
      • may reveal calcifications in the extensor muscle mass (up to 20% of patients)
      • may reveal signs of previous surgery
  • MRI 
    • not necessary for diagnosis
    • increased signal intensity at ECRB tendon origin may be seen (up to 50% of cases) 
      • thickening
      • edema
      • tendon degeneration
  • Ultrasonography
    • requires experienced operator (variable sensitivity/specificity)
      • most useful diagnostic tool in experienced operator hands
    • ECRB tendon appears thickened and hypoechoic

  • Histology
    • histopathological studies of the ECRB tendon tissue shows
      • fibroblast hypertrophy
      • disorganized collagen
      • vascular hyperplasia
  • Diagnosis
    • diagnosis is primarily based on symptoms and physical exam
  • Posterlateral plica
  • Posterlateral rotatory instability
  • Radial tunnel syndrome
    • palpation 3-4 cm distal and anterior to the lateral epicondyle
    • pain with resisted third-finger extension
    • pain with resisted forearm supination
  • Occult fracture
  • Cervical radiculopathy
  • Capitellar osteochondritis dissecans
  • Triceps tendinitis
  • Radiocapitellar osteoarthritis
  • Shingles
  • Nonoperative
    • activity modification, ice, NSAIDS, physical therapy, ultrasound
      • indications
        • first line of treatment
      • techniques
        • tennis modifications (slower playing surface, more flexible racquet, lower string tension, larger grip)
        • counter-force brace (strap)
        • steroid injections (up to three)  
        • physical therapy regimen 
        • acupuncture
        • iontophoresis/phonophoresis
        • extracoproeal shock wave therapy
      • outcomes
        • up to 95% success rate with nonoperative treatment, but patience is required
  • Operative
    • release and debridement of ECRB origin
      • indications
        • if prolonged nonoperative (6-12 months) fails
        • clear diagnosis (isolated lateral epicondylitis)
        • intra-articular pathology 
      • contraindications
        • inadequate trial of nonsurgical treatment
        • patient noncompliance with the recommended nonsurgical treatment
  • Release and debridement of ECRB origin 
    • open
      • incision is positioned over the common extensor origin
      • lift ECRL off of ECRB (located deep and posterior to ECRL)
      • excise degenerative tissue
      • decorticate epicondyle
      • repair capsule if breached
      • side-to-side closure of tendon
    • arthroscopic
      • advantages include visualization and ability to address and intraarticular pathology
      • resect lateral capsule anteriorly (do not pass midradial head to protect LUCL)
      • release ECRB from origin (where muscle tissue begins)
      • decorticate lateral epicondyle
  • Iatrogenic LUCL injury 
    • excessive resection of the LUCL
    • should not extend beyond equator of radial head
    • may lead to posterolateral rotatory instability (PLRI)
  • Missed radial nerve entrapment syndrome
    • common in up to 5% of patients with lateral epicondylitis  
  • Iatrogenic neurovascular injury
    • radial nerve injury
  • Heterotopic ossification
    • decrease risk with thorough irrigation following decortication
  • Infection
  • Missed concomitant pathology (i.e. PLRI, radial tunnel)

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Questions (3)

(OBQ09.107) Figure A shows the characteristic microscopic findings of lateral epicondylitis. Which of the following is the most appropriate term to describe the abnormal finding in the region marked with the two asterisks? Review Topic


Osteoblastic rimming




Reactive hyperemia




Localized hemorrhage with neutrophils proliferation




Angiofibroblastic dysplasia




Cystic degeneration with fatty infiltration



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The region marked by the asterix in Figure A demonstrates angiofibroblastic dysplasia, which is a term used to collectively describe the microscopic changes typically seen with lateral epicondylitis. These pathologic changes include fibroblast hypertrophy, disorganized collagen, and vascular hyperplasia.

Lateral epicondylitis or "tennis elbow" is a common condition resulting from repetitive wrist and elbow extension. It is most commonly located at the origin of the ECRB tendon with pain just distal to the lateral epicondyle.

Kraushaar et al describe the histology as "immature fibroblastic and vascular infiltration of the origin of the extensor carpi radialis brevis" and this description has been termed "angiofibroblastic dysplasia" (answer 4).

Nirschl et al reviewed nearly 1200 patients with lateral epicondylitis and only 88 required operative care with 97% reporting improvement and 85% returning to rigorous sport after surgery.

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(OBQ09.119) Which of the following structures shares the same origin site as the tendon that undergoes angiofibroplastic hyperplasia during the pathogenesis of tennis elbow? Review Topic










Annular ligament




Flexor carpi ulnaris




Palmaris longus



Select Answer to see Preferred Response


Lateral epidondylitis is classically thought to be caused by histopathologic angiofibroblastic hyperplasia at the origin of the extensor carpi radialis brevis. ECRB originates from the common extensor wad, that also includes ECRL, ED, ECU. The anconeus shares the same attachment site at the lateral epicondyle as the ECRB (as shown in Illustration A).

The classic Level 4 study by Nirschl reviewed 1,213 patients with tennis elbow of which 88 elbows underwent surgery. Immature fibroblastic and vascular infiltration of the origin of the ECRB was found, excised, and tendon repaired by Nirschl with an improvement rate of 97%.


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(OBQ08.194) A 50-year-old carpenter has chronic pain over the lateral aspect of the elbow. He notes pain when using a hammer. On exam, he has pain with resisted wrist extension while the elbow is fully extended. Which muscle attachment is likely to be involved? Review Topic


Distal biceps brachii








Extensor carpi radialis brevis




Extensor carpi radialis longus







Select Answer to see Preferred Response


The clinical presentation is consistent with lateral epicondylitis, which is caused from pathologic changes at the origin of the extensor carpi radialis brevis (ECRB).

Physical exam findings consistent with lateral epicondylitis include tenderness over the lateral epicondyle at the origin of the ECRB, and pain that is reproduced with gripping, resisted long finger extension, resisted wrist extension while the elbow is fully extended, and maximum passive wrist flexion. This should be distinguished with the pain with resisted supination with the arm and wrist in extension characteristically seen with radial tunnel syndrome.

Nirschl et al looked at their surgical cohort of patients with lateral epidondylitis that were treated with surgery. They found the lesion that was consistently identified at surgery was immature fibroblastic and vascular infiltration of the origin of the extensor carpi radialis brevis (ECRB). There was an over-all improvement rate of 97.7 per cent, and 85.2 per cent of the patients returned to full activity including rigorous sports following surgical treatment.

Morris et al used indwelling EMG to look at muscle activity about the elbow during tennis strokes in nine professional and collegiate level players. They concluded the predominant activity of the wrist extensors in all strokes may be one explanation for predisposition to injury.

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