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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
      • 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
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 
  • 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)
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
        • passive wrist flexion in pronation causes pain at the elbow
Imaging
  • 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

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
Differential 
  • 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
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)  
        • 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
Techniques
  • 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
Complications
  • 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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