Orthopaedic Surgery - Tennis Elbow

Basics

Tennis elbow, also called:

Lateral epicondylitis

is a degenerative tendinopathy involving the origin of the:

Extensor carpi radialis brevis

at the:

Lateral epicondyle of the humerus.

Despite the traditional term “epicondylitis,” the disorder is predominantly:

Degenerative rather than inflammatory.

Synonyms

Other terms include:

Lateral epicondylosis

Lateral epicondylalgia

Wrist extensor tendinosis

and

Tennis elbow.

Anatomy

The lateral epicondyle provides attachment for the:

Common extensor tendon.

Important contributing muscles include:

Extensor carpi radialis longus

Extensor carpi radialis brevis

Extensor digitorum communis

and

Extensor carpi ulnaris.

Extensor Carpi Radialis Brevis

The:

Extensor carpi radialis brevis, or ECRB

is the tendon most commonly involved.

It lies deep to the:

Extensor carpi radialis longus.

Function

The wrist extensors stabilize the wrist during:

Gripping

Lifting

and repetitive:

Forearm and hand activity.

They are also highly active during the:

Backhand stroke in tennis.

Clinical Setting

Although strongly associated with racket sports by name, lateral epicondylosis is actually more commonly encountered in patients performing repetitive:

Occupational

or

Daily-living activities.

It affects both:

Athletes

and

Nonathletes.

Typical Patient

The classic presentation is an adult in the:

Fourth or fifth decade

with overuse of the:

Dominant upper extremity.

Natural History

Lateral epicondylosis is generally:

Self-limited.

Symptoms may nevertheless persist for:

Many months

and occasionally longer before resolving.

Prevention

Prevention focuses on reducing excessive repetitive loading of the:

Wrist extensor origin.

Ergonomics

Patients performing repetitive occupational activity may benefit from:

Ergonomic assessment

and modification of their:

Workstation or tools.

This is particularly relevant for patients with prolonged:

Computer

Manual

or

Repetitive hand use.

Athletic Technique

Tennis players should be assessed for:

Racket grip size

Backhand technique

Racket weight

String tension

and training:

Volume.

Epidemiology

Lateral epicondylosis affects:

Men and women approximately equally.

Incidence

Peak incidence occurs during approximately the:

Fifth decade of life.

Lifetime Occurrence

Approximately:

1–3% of the population

develop lateral epicondylosis at some point.

Risk Factors

The condition is associated with activities involving repetitive:

Forearm pronation

Supination

Wrist extension

and

Gripping.

Elbow Position

Repetitive forearm rotation performed with the elbow near:

Full extension

may increase loading at the:

Common extensor origin.

Sports

Associated athletic activities include:

Tennis

Other racket sports

and

Fencing.

Occupational Activities

Occupations and activities associated with repetitive upper-extremity use include:

Plumbing

Painting

Knitting

Dentistry

and prolonged:

Computer work.

Tennis-Specific Factors

Potential contributing factors include:

Poor stroke mechanics

Incorrect racket grip size

Excessive racket weight

and inappropriate:

String tension.

Playing Surface

Harder court surfaces may increase force transmission through the:

Racket

and upper extremity, potentially increasing stress at the:

Lateral epicondyle.

Etiology

The disorder usually begins as repetitive microscopic injury to the:

ECRB origin.

Microtrauma

Repeated loading may produce:

Microscopic tendon tearing

that exceeds the tendon’s ability to:

Repair itself.

Other Involved Tendons

The:

Extensor carpi radialis longus

and

Extensor digitorum communis

may occasionally also demonstrate:

Degenerative involvement.

Failed Tendon Healing

An inadequate healing response leaves the tendon susceptible to repeated:

Microtrauma

and progressive:

Tendinosis.

Pathophysiology

The process is characterized more by:

Collagen degeneration

than by acute:

Inflammation.

This explains why the term:

Lateral epicondylosis

is often considered more pathologically accurate than “epicondylitis.”

Diagnosis

Diagnosis is usually:

Clinical.

The combination of characteristic:

Lateral elbow tenderness

and pain with resisted:

Wrist extension

is strongly suggestive.

Signs and Symptoms

Patients typically report a history of:

Repetitive upper-extremity activity.

Pain Location

Pain is centered around the:

Lateral epicondyle

and may radiate a short distance distally along the:

Proximal extensor muscle mass.

Activity-Related Pain

Symptoms generally worsen with:

Activity

and improve with:

Rest.

Gripping Pain

Patients commonly report pain while:

Gripping objects

Lifting a cup

Shaking hands

or

Carrying objects.

Resisted Wrist Extension

Pain is reproduced when the patient extends the wrist against:

Resistance.

Symptoms are often more pronounced when the elbow is:

Extended.

Range of Motion

Elbow range of motion is generally:

Preserved.

Loss of motion should raise concern for:

Alternative or additional pathology.

Physical Examination

The most characteristic finding is localized tenderness over the:

Common extensor origin

at or just distal to the:

Lateral epicondyle.

Distal Tenderness

Tenderness may extend several centimeters distally over the:

ECRB region.

Resisted Wrist Extension Test

The examiner stabilizes the forearm while the patient attempts:

Wrist extension against resistance.

Reproduction of lateral elbow pain supports the diagnosis.

Passive Wrist Flexion

Passive flexion of the wrist with the elbow:

Extended

stretches the common extensor origin and may reproduce:

Pain.

Grip Testing

Painful or reduced:

Grip strength

may be present because gripping requires stabilization by the:

Wrist extensors.

Radial Tunnel Examination

The clinician should evaluate for:

Radial tunnel syndrome.

Resisted Middle-Finger Extension

Pain reproduced with resisted:

Middle-finger extension

may suggest involvement of the:

Radial tunnel or posterior interosseous nerve region.

This finding should be interpreted with the remainder of the:

Clinical examination.

Cervical Spine Examination

A cervical spine examination is appropriate, especially when symptoms are:

Bilateral

Atypical

or accompanied by:

Neck pain or neurologic findings.

Imaging

Plain Radiographs

AP and lateral radiographs of the elbow may be obtained to exclude:

Fracture

Arthritis

Loose body

or other:

Bony pathology.

Typical Radiographic Findings

Plain radiographs are usually:

Normal.

Calcification

Historical studies report local soft-tissue calcification near the lateral epicondyle in approximately:

23% of patients.

Cervical Spine Imaging

Cervical radiographs may be considered when symptoms could originate from:

Cervical radiculopathy.

CT

CT is rarely needed for isolated tennis elbow.

It may be useful when evaluating:

Loose bodies

Arthritis

or other complex:

Intra-articular pathology.

MRI

MRI is not routinely required for the diagnosis.

Indications for MRI

MRI may be useful when symptoms are:

Persistent

Atypical

or when there is concern for:

Partial tendon tearing

or another:

Elbow disorder.

MRI Findings

Possible findings include:

Tendon thickening

Increased T1 and T2 signal

and

Partial tearing

at the common extensor origin.

Electrodiagnostic Testing

Electromyography and nerve-conduction studies are not usually required for isolated:

Lateral epicondylosis.

They may help when distinguishing it from:

Radial tunnel syndrome

or another:

Neuropathic disorder.

Pathological Findings

Microscopic examination demonstrates:

Degenerative tearing

within the substance of the:

ECRB tendon.

Histology

Characteristic changes include replacement of normal tendon collagen with:

Fibroblastic tissue

Abnormal vascular proliferation

and disorganized:

Collagen.

This has historically been termed:

Angiofibroblastic or angioblastic proliferation.

Inflammation

Importantly, significant acute inflammatory-cell infiltration is usually:

Absent.

The process therefore represents:

Tendinosis

rather than classic:

Tendinitis.

Differential Diagnosis

Important alternatives include:

Cervical radiculopathy

Radial tunnel syndrome

Olecranon bursitis

Medial epicondylitis

Ulnar collateral ligament injury

and

Intra-articular elbow disease.

Radial Tunnel Syndrome

Radial tunnel syndrome involves compression of the:

Posterior interosseous nerve

or radial nerve around the:

Supinator.

Coexisting Radial Tunnel Syndrome

Historical reports suggest that radial tunnel syndrome may coexist with lateral epicondylosis in approximately:

5% of patients.

Intra-Articular Disorders

Conditions such as:

Elbow arthritis

Capitellar osteochondritis dissecans

or a:

Loose body

may produce lateral elbow pain.

Treatment

Most patients are initially treated:

Nonoperatively.

General Measures

Treatment may include:

Activity modification

Relative rest

Ice or cryotherapy

NSAIDs

Physical therapy

Counterforce bracing

and occasionally:

Wrist splinting.

Activity Modification

Activities that reproduce pain should be:

Reduced or modified.

Complete inactivity is generally unnecessary.

Return to Activity

Normal activity can be resumed:

Gradually

as pain and strength:

Improve.

Ergonomic Correction

Work-related factors should be addressed through:

Tool modification

Workstation adjustment

and reduction of repetitive:

Grip or wrist-extension loading.

Athletic Modification

Athletes should optimize:

Stroke mechanics

Equipment

and

Training volume.

Counterforce Brace

A:

Counterforce strap

placed around the proximal forearm may reduce load transferred to the:

Common extensor origin.

Wrist Splint

Short-term use of a wrist splint, particularly at:

Night

or during aggravating activities, may reduce tension on the:

Extensor tendons.

Physical Therapy

Physical therapy is useful when symptoms persist.

Eccentric Exercise

A major component of rehabilitation is:

Eccentric strengthening of the wrist extensors.

Progressive Loading

Rehabilitation may gradually progress from:

Isometric exercises

to

Eccentric and concentric strengthening

as tolerated.

Stretching

Gentle stretching of the:

Wrist extensor musculature

may be incorporated into the program.

Soft-Tissue Treatment

Adjunctive techniques may include:

Friction massage

Soft-tissue mobilization

and other manual:

Therapies.

Therapeutic Modalities

Historically used modalities include:

Ultrasound

and

Iontophoresis.

Evidence for substantial additional benefit is:

Limited.

NSAIDs

NSAIDs may provide short-term:

Pain relief.

Because the underlying process is largely degenerative rather than inflammatory, they do not directly reverse:

Tendon degeneration.

Corticosteroid Injection

Corticosteroid injection may provide:

Short-term pain relief

in selected patients.

Limitations of Corticosteroid Injection

Benefits often diminish over time, and repeated injections may increase the risk of:

Tendon degeneration

or

Tendon rupture.

Therefore, repeated injections should be used:

Cautiously.

Nitroglycerin

Topical:

Nitroglycerin patches

have been studied as an adjunct to rehabilitation and may improve pain in some patients with:

Chronic tendinopathy.

Their role remains:

Selective rather than routine.

Shock-Wave Therapy

Extracorporeal shock-wave therapy has been investigated for:

Lateral epicondylosis.

Results across studies have been:

Variable

and it has not consistently demonstrated a large advantage over:

Placebo or standard rehabilitation.

Low-Level Laser Therapy

Low-level laser treatment has also been investigated, but evidence for a substantial clinically important benefit remains:

Limited.

Biologic Therapy

Autologous blood and:

Platelet-rich plasma

have been proposed to stimulate tendon healing by increasing local:

Growth factors.

PRP

PRP has shown benefit in some studies, particularly for:

Chronic symptoms.

However, results are inconsistent, and it has not consistently demonstrated superiority over:

Structured exercise-based treatment.

Nonoperative Success

Most patients improve without surgery.

Historical series report successful nonoperative treatment in approximately:

90–95% of patients.

Surgery

Surgery is rarely required.

Indications

Operative treatment may be considered after approximately:

6–12 months

of persistent symptoms despite appropriate:

Nonoperative management.

Surgical Principle

Traditional surgery involves removal of:

Degenerated ECRB tissue

from the:

Lateral epicondyle.

Open Débridement

Open surgery may include:

Débridement of the diseased ECRB origin

with repair or reattachment of:

Healthy tendon.

Radial Tunnel Release

If clinically significant coexisting:

Radial tunnel syndrome

is present, decompression may be considered during the same:

Procedure.

Arthroscopic Treatment

Arthroscopic treatment allows:

Débridement of the ECRB origin

while simultaneously evaluating:

Intra-articular pathology.

Open Versus Arthroscopic Surgery

Both open and arthroscopic procedures can provide:

Good outcomes.

Arthroscopy may allow somewhat faster:

Early recovery

in selected patients.

Follow-Up After Surgery

Postoperative rehabilitation is:

Progressive.

Early Period

A splint may be removed at approximately:

1 week

depending on the:

Procedure and wound.

Range of Motion

Gentle:

Elbow

and

Wrist range-of-motion exercises

are then initiated.

Strengthening

Once the wound has healed and motion is comfortable, progressive:

Strengthening

is added.

Activity

Pain-limited activities may be resumed as healing:

Progresses.

Full Activity

Return to unrestricted activity is often possible by approximately:

3 months

although timing varies according to:

Procedure

Occupation

and

Sport demands.

Prognosis

Lateral epicondylosis generally has a:

Good prognosis.

Chronic Course

Symptoms may fluctuate with periods of:

Exacerbation

and

Improvement.

Natural Resolution

Even without invasive treatment, many cases gradually improve because the disorder is often:

Self-limiting.

Nonoperative Outcome

Approximately:

90–95%

of patients can be managed successfully without:

Surgery.

Complications

Complications from conservative treatment are generally:

Uncommon.

Injection Complications

Potential complications of corticosteroid injection include:

Skin depigmentation

Subcutaneous fat atrophy

and

Tendon weakening or rupture.

Surgical Complications

Potential complications include:

Infection

Persistent pain

Recurrent tendon degeneration

Elbow stiffness

and reduced:

Range of motion.

Tendon Retear

The repaired or débrided extensor origin may rarely develop:

Recurrent tearing.

Patient Monitoring

Patients should be followed according to:

Symptoms

and response to:

Treatment.

Persistent Pain

If pain remains unexplained or persistent after several months, reassessment should consider:

Radial tunnel syndrome

Cervical radiculopathy

Arthritis

Loose body

or another:

Elbow diagnosis.

Repeat Imaging

Repeat radiographs or advanced imaging may be appropriate if symptoms remain persistent after approximately:

Several months

or if the clinical picture changes.

Key Principle

Tennis elbow is primarily a degenerative tendinopathy of the ECRB origin at the lateral epicondyle rather than a true inflammatory disorder.

Patients characteristically develop:

Lateral elbow pain with gripping and resisted wrist extension, while elbow range of motion is usually:

Normal.

Diagnosis is primarily:

Clinical, with imaging reserved for atypical, persistent, or diagnostically uncertain cases.

Most patients improve with:

Activity modification, ergonomic or technique correction, eccentric extensor strengthening, counterforce bracing, and time.

Injections may provide selective symptomatic relief, but repeated corticosteroid exposure should be used cautiously because of potential:

Tendon weakening.

Surgery is reserved for a small minority of patients with:

Persistent symptoms despite prolonged appropriate nonoperative treatment.