Updated: 12/28/2018

Lateral Epicondylitis (Tennis Elbow)

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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
      • tenodesis effect to optimize grip causes overuse of ECRB
      • 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 
  • Posterolateral plica
  • Posterolateral 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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(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
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1

Brachioradialis

34%

(962/2831)

2

Anconeus

57%

(1615/2831)

3

Annular ligament

4%

(105/2831)

4

Flexor carpi ulnaris

4%

(111/2831)

5

Palmaris longus

1%

(28/2831)

L 3

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(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:
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1

Osteoblastic rimming

2%

(33/1459)

2

Reactive hyperemia

4%

(52/1459)

3

Localized hemorrhage with neutrophils proliferation

6%

(85/1459)

4

Angiofibroblastic dysplasia

87%

(1272/1459)

5

Cystic degeneration with fatty infiltration

1%

(11/1459)

L 2

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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

QID: 580
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1

Distal biceps brachii

1%

(13/2270)

2

Brachioradialis

4%

(85/2270)

3

Extensor carpi radialis brevis

83%

(1895/2270)

4

Extensor carpi radialis longus

11%

(255/2270)

5

Supinator

1%

(14/2270)

L 2

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