American Shoulder and Elbow Surgeons
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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?
Localized hemorrhage with neutrophils proliferation
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.
Kraushaar BS, Nirschl RP.
J Bone Joint Surg Am. 1999 Feb;81(2):259-78. PMID: 10073590 (Link to Abstract)
Nirschl RP, Pettrone FA.
J Bone Joint Surg Am. 1979 Sep;61(6A):832-9. PMID: 479229 (Link to Abstract)
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Which of the following structures shares the same origin site as the tendon that undergoes angiofibroplastic hyperplasia during the pathogenesis of tennis elbow?
Flexor carpi ulnaris
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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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?
Distal biceps brachii
Extensor carpi radialis brevis
Extensor carpi radialis longus
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.
Morris M, Jobe FW, Perry J, Pink M, Healy BS.
Am J Sports Med. 1989 Mar-Apr;17(2):241-7. PMID: 2757127 (Link to Abstract)
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