Lateral Epicondylitis

Introduction

Lateral epicondylitis and tennis elbow are the most commonly used terms to describe a condition that produces pain and tenderness at to origin of the origin of the extensor carpi radialis brevis muscle (lateral epicondyle of the humerus). Despite the term “epicondylitis”, the location of the pathology and point of maximal pain is just distal to the epicondyle.

Although the problem is often referred to as tennis elbow tendinitis, the process is not inflammatory but degenerative.  The degeneration involves fibroblasts and microvascular hyperplasia without actual inflammation. 

Compression of the posterior interosseus nerve at the elbow (radial tunnel syndrome) is often misdiagnosed as lateral epicondylitis. The posterior interosseus nerve has no sensory distribution but innervates the thumb and finger extensors and the extensor carpi unlaris. The posterior interosseus nerve is most commonly compressed by fibrous bands between the two heads of the supinator muscle in a region termed the radial tunnel. 

Medial epicondylitis, or golfer’s elbow, is similar to lateral epicondylitis in etiology and pathology and occurs in the origin of the flexor / pronator muscles just distal to the medial epicondyle. 

Lateral epicondylitis is much more common that radial tunnel syndrome and medial epicondylitis. 

Clinical Presentation

The typical patient with lateral epicondylitis is between 35 and 50 years old who reports the gradual onset of pain in the lateral elbow and forearm during activities involving wrist extension , such as lifting, turning a screwdriver, or hitting a backhand in tennis.  With time, the pain can become severe and eventually persists even when the aggravating activity has been discontinued. 

Age and duration of exposure to stressful repetitive forces influence the development of lateral and medial epicondylitis. In tennis players with over 2 hours of racquet time per week, the risk of developing lateral epicondylitis is 2 to 3.5 times greater than those playing less than 2 hour per week.  Players over the age of 40 years had a 4-fold increase in occurrence in males and a 2-fold increase in females. 

Ergonomics also impacts the incidence of lateral and medial epicondylitis. Many of the studies have examined the development of lateral epicondylitis in the tennis player.  Improper grip size, racquet weight, and racquet stringing generate higher loads in the lateral elbow muscle tendon unit and contribute to the development of lateral epicondylitis. 

Less commonly, the patient may report the onset of symptoms to an acute event, such as a direct blow to the elbow or a sudden maximal muscle contraction. 

Patients with radial tunnel syndrome present with similar symptoms but the pain is 4 to 5 cm more distal than lateral epicondylitis.  Because the posterior interosseus nerve contains only motor fibers, there is no numbness or tingling.  Obvious muscular weakness is rarely encountered until late in the disease process.

Medial epicondylitis typically occurs with active wrist flexion and forearm pronation, such as takes place with a golf swing, baseball pitching, or the pull-through strokes of swimming. 

Due to the large volume of work-related injuries seen in our practice, many of the patients treated present with lateral epicondylitis, medial epicondylitis, or radial tunnel syndrome that actually results from work activities.  There is an association between the performance of repetitive tasks and the development of these conditions.  Occupational activities that require forceful or repetitive forearm use, such as carpentry, plumbing and meat cutting, also have led to the development of lateral epicondylitis. 

Lateral epicondylitis is characterized by pain in the lateral epicondyle that radiates into the forearm.  It may also be associated with a sense of wrist and finger weakness with grasping. 

Medial epicondylitis is characterized by pain along the medial elbow that is worsened by resisted forearm pronation or wrist flexion.  Patients may also complain of vague tingling is the ring and little fingers if ulnar irritation has occurred.

In radial tunnel syndrome, symptoms include deep, dull proximal dorsal forearm ache, often with distal radiation. The pain is often described as a cramp, and night pain is a common complaint.

Physical Examination

The most consistent finding in lateral epicondylitis is localized tenderness over the common extensor origin 1 cm distal to the lateral epicondyle. During the examination it is best to have the patient’s elbow flexed to 90 degrees and the forearm supinated. Tapping lightly on the lateral epicondyle may be painful.

Pain is also reproduced with resisted extension of the wrist with the elbow in extension.  Grasping or pinching with the wrist in extension usually reproduces the pain. Resisted long finger extension often elicits the most severe pain. 

The area of tenderness with posterior interosseus nerve compression is directly over the radial tunnel, which is 4 - 5 cm distal and slightly anterior to the lateral epicondyle.  With radial tunnel syndrome, pain in the proximal forearm may be noted by extending the long finger against resistance (middle finger test). Pain may also be aggravated by resisted supination and extension, or repetitive forearm pronation with a flexed wrist.

Radial tunnel syndrome may be a major contributor to the symptoms in approximately 5% of cases of lateral epicondylitis.  Electrodiagnostic studies are rarely conclusive in diagnosing radial tunnel syndrome.

With medial epicondylitis, the area of tenderness is just distal to the medial epicondyle. The pain is exacerbated by pronating the forearm and flexing the wrist against resistance. 

X-rays

AP and lateral x-rays of the elbow are necessary to rule out arthritis or osteochondral loose bodies.  An area of calcification may be seen at the attachment of the extensor muscles to the lateral epicondyle (20-25% of cases).

Differential Diagnosis

Cubital tunnel syndrome

  • Compression of the ulnar nerve
  • Paresthesias in the little and ring fingers

Fracture of the radial head

  • Pain and tenderness over the radial head that is exacerbated by pronation and supination

Osteoarthritis of the radiocapitellar portion of the elbow joint

  • Similar to the exam for a radial head fracture but without a history of trauma

Osteochondral loose body

  • Medial or lateral joint line pain
  • Symptoms of locking

Synovitis of the elbow joint

  • Swelling, palpable fluid

Triceps tendinitis

  • Tenderness above the olecranon

Treatment

Modifying or eliminating the activities that cause symptoms is the most important step in treatment, such as changing to a lighter weight racquet or over wrapping the handle to make it slightly larger. For severe and long-standing cases, this activity modification may have to be permanent.

NSAIDs help during acute exacerbations.  If the patient’s medical condition allows, a 2-3 week course of an oral NSAID is generally suggested, followed by a period without medication.  If the symptoms recur, the medication is resumed for an additional 2-3 weeks. 

Tennis Elbow StrapUse of a commercial tennis elbow strap worn just below the lateral epicondyle during any and all activities that might cause pain is helpful. Never wear it to sleep.

Application of ice or heat (whichever works best) may relieve pain and inflammation. 

Once the pain has decreased, gentle stretching exercises can be initiated. 

If the symptoms persist or if they recur following the course of the NSAID, a corticosteroid injection into the area of maximum tenderness may be helpful with medial or lateral epicondylitis. Patients may experience increased pain for 1-2 days following the injection.  Occasionally it may take as long as 1 week for the corticosteroid to be maximally effective.

Care should be taken to instill the medication deep into the extensor carpi radialis brevis, anterior and distal to the lateral epicondyle, and into the fatty subaponeurotic recess. Injection of the mixture superficially may result in subcutaneous atrophy and intratendinous injection may lead to permanent changes within the tendon infrastructure. 

No more than 3 injections should be performed.  

Physical therapy modalities have limited success in treating lateral and medial epicondylitis. 

If the pain returns and the symptoms are severe, surgery should be considered.

Decompression of the radial tunnel is indicated for patients with radial tunnel syndrome who have significant discomfort.

Surgical Treatment

If nonsurgical treatments have not been successful, then surgery can be considered.  The procedure is usually performed with patients under a general anesthesia but a regional arm block can also be performed.

For lateral epicondylitis, a small incision is made over the lateral elbow and proximal common extensor tendon. The origin of the extensor carpi radialis brevis is identified and split longitudinally.  The area of degenerative and torn tendon is then meticulously sharply debrided.  The extensor tendon is then repaired. 

A bulky dressing is then applied for 7-10 days after surgery.  After this point, the dressing is removed and gentle passive and active elbow, wrist, and hand range of motion exercises are initiated. Lifting and resistance exercises of the wrist and fingers are avoided.

Light isometric exercises and then progressive strengthening exercises are started several weeks following surgery.

The results of lateral epicondylar release in the orthopedic literature is as follows:

Full activity without pain

85-90%

Improved with some pain during aggressive activity

10-12%

No improvement

2-3%

References

  • Greene, WB: Essentials of musculoskeletal care. AAOS, 2001.
  • Jobe, FW: Operative techniques in upper extremity sports injuries. Mosby, 1996.

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