http://upload.orthobullets.com/topic/3082/images/mri elbow.jpg
http://upload.orthobullets.com/topic/3082/images/tennis elbow.jpg
http://upload.orthobullets.com/topic/3082/images/lucl.jpg
Introduction
  • 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
    • demographics
      • up to 50% of all tennis players develop 
  • Pathophysiology
    • mechanism
      • occurs in activities with repetitive pronation and supination with elbow in extension
      • 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
Anatomy
  • 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 
Presentation
  • 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
  • Diagnosis
    • diagnosis is primarily based on symptoms and physical exam
Imaging
  • Radiographs 
    • recommended views
      • AP/Lateral of elbow
    • findings
      • usually normal
  • MRI 
    • increased signal intensity at ECRB tendon may be seen 
    • not necessary for diagnosis

Studies
  • 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
Treatment
  • 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) 
        • stretching of extensors
      • outcomes
        • up to 95% success rate with nonoperative treatment, but patience is required
  • Operative
    • release and debridement of ECRB origin
      • indications
        • if prolonged nonoperative (9-12 months) fails
Techniques
  • Release and debridement of ECRB origin 
    • can be done open or arthroscopic
    • radial tunnel release if coexistent radial tunnel syndrome
Complications
  • Iatrogenic LUCL injury 
    • excessive resection of the LUCL
    • should not extend beyond equator of radial head
    • may lead to posterolateral instability 
  • Missed radial nerve entrapment syndrome
    • common in up to 5% of patients with lateral epicondylitis  
  • Iatrogenic neurovascular injury
    • radial nerve injury
 

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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

QID:2920
FIGURES:
1

Osteoblastic rimming

3%

(19/697)

2

Reactive hyperemia

5%

(38/697)

3

Localized hemorrhage with neutrophils proliferation

8%

(57/697)

4

Angiofibroblastic dysplasia

82%

(574/697)

5

Cystic degeneration with fatty infiltration

1%

(7/697)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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

QID:2932
1

Brachioradialis

36%

(515/1419)

2

Anconeus

56%

(792/1419)

3

Annular ligament

3%

(49/1419)

4

Flexor carpi ulnaris

3%

(48/1419)

5

Palmaris longus

1%

(15/1419)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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%.

ILLUSTRATIONS:

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Question COMMENTS (7)

(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

QID:580
1

Distal biceps brachii

1%

(7/1282)

2

Brachioradialis

4%

(47/1282)

3

Extensor carpi radialis brevis

84%

(1080/1282)

4

Extensor carpi radialis longus

11%

(140/1282)

5

Supinator

1%

(7/1282)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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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