Tennis Elbow – Lateral Epicondylitis

Discussion

• overuse syndrome or tendinosis involving the region of the lateral humeral epicondyle;
• most often the origin of the ECRB displays an abnormal vascular proliferation and focal hyaline degeneration;
  • ref: Anatomic Factors Related to the Cause of Tennis Elbow
• EDC may also be involved in some cases;
  • ref: The role of the extensor digitorum communis muscle in lateral epicondylitis.
• may or may not be associated w/ athletics;
• most common in 4th decade;

Microscopic Findings

• include hyaline degeneration and vascular proliferation in region of origin of ECRB tendon, w/o any evidence of chronic or acute inflammatory changes;
• ref: Microscopic histopathology of chronic refractory lateral epicondylitis.

Diff dx

• C6 or C7 cervical nerve root compression
• PIN syndrome: entrapment at arcade of Frohse is recognized in approx 5% of pts;
• radial head arthritis;
• posterolateral plica:
  • may accompany lateral epicondylitis;
  • remnant plicae may become inflamed because of repeated trauma and inflammation;
  • resultant plicae may become entrapped in the radiocapitellar joint;
• posterolateral instability;
• references:
  • Clinical presentation and radiographic findings of distal biceps tendon degeneration: a potentially forgotten cause of proximal radial forearm pain.
• Posterolateral Rotatory Instability of the Elbow in Association with Lateral Epicondylitis.

Exam

• ROM of Wrist and Elbow;
• motor strength of ECRL/ECRB, EDC;
• note any tenderness over radial head;
• Maudsley's test: pain in the region of the lateral epicondyle during resisted extension of the middle finger;

elicit tenderness:

• greatest tension is elicited w/ the elbow in extension, forearm in pronation, and wrist in flexion;
• note any tendnerness as the pronated forearm actively extends the fingers and wrist against resistance;
• pinching w/ the wrist in extension may elicit tenderness;

chair test:

• patient is asked to lift a chair with the shoulder adducted, the elbow extended, and the wrist pronated;

lidocaine injection test:

• lidocaine injection 4 finger breadths distal to the lateral epicondyle will result in temporary PIN palsy and, in the case of PIN syndrome, will result in temporary relief of pain;
• w/ lateral epicondylitis, the patient should note pain relief following injection at the origin of the ECRB tendon;

Radiographs / MRI

• rule out arthritis of the radial head;
• ref: Magnetic resonance imaging findings of refractory tennis elbows and their relationship to surgical treatment.

Non Operative Rx

• reduce stenuous activities for at least 6 weeks;
• attempt to grasp objects in supination as opposed to pronation;
• wrist splint: consider use of a wrist splint, especially if elbow tenderness is eccentuated by resisted wrist extension;

counter force strap

• applied over the forearm flexor mass;
• prevents full muscular contraction, and therefore, reduces stress at the insertion of the tendon to the lateral epicondyle;

Steroid Injection

• steroid injection is also an option;
  • steroid is injected adjacent to ECRB tendon (not in the tendon);
• references:
  • Cortisone injection with anesthetic additives for radial epicondylalgia (tennis elbow).
  • Local injection treatment of tennis elbow - hydrocortisone, triamcinolone and lidocaine compared.
  • A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis
  • Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis

Surgical Treatment

• approach involves elevation of the ECRB at the midportion of lateral epicondyle;
• additional pathology:
  • anterior portion of the EDC may be involved;
  • exostosis of the lateral epicondyle may be present;
• incision: 3-4 cm longitudinal incision is made just anterior to lateral epicondyle;
• fascia overlying the posterior edge of the ECRL is incised and elevated to expose the ECRB which lies underneath the ECRL;
  • just posterior the the ECRL lies the extensor aponeurosis, the anterior edge of which may be abnormal;
  • ECRL is then sharply dissected off the anterior ridge and displaced anteromedially to expose the ECRB;
• ECRB is inferior to the origin of the ECRL and deep to the EDC (border between the ECRB and EDC is often poorly defined);
• degenerated tissue is excised;
  • if possible attempt to limit the debridement to the disease tissue anterior to the EDC tendon at the mid-axis of the epicondyle;
  • Organ et al (1997) that in order to avoid recurrent symptoms, resect the pathologic tissue present in  ECRB;
  • in about 1/3 cases, the anterior aspect of the EDC tendon origin is involved as well;
    • Salvage Surgery for Lateral Tennis Elbow.
• care is taken not to release normal appearing tendon;
• release operations, which weaken the extensor aponeurosis should be avoided;
• defect between the ECRL and the extensor aponeurosis is firmly repaired;
• PIN compression: if there is PIN entrapment, the two can be treated through one incision that is slightly more anterior and distal;

surgical complications:

• debridement of lateral epicondylitis may result in posterolateral instability, if there is excessive debridement of collateral ligament origins as well as the origins of the extensor muslces from the lateral epicondyle;

controversies:

• lateral epicondyle drilling
  •  Khashaba et al (2001), the authors questioned whether drilling was advantageous in ECRB;
  • in prospective trial, authors shows that drilling confered no benefit and actually caused more pain, stiffness, and wound bleeding than not drilling;
  • ref: Nirschl tennis elbow release with or without drilling.
• PIN decompression should it be included in this procedure?
  • Leppilahti J, et al compared decompression of  PIN and lengthening of distal tendon of ECRB in a randomised trial of 28 patients;
  • 14 underwent decompression of PIN and 14, lengthening of ERCB;
  • average duration of preoperative symptoms was 23 months;
  • PIN is exposed in groove between BR and brachialis muscles and decompressed at arcade of Frohse by means of a 1-2 cm incision through supinator;
  • ECRB tendon was lengthened by Z-plasty at the dorsilateral aspect of the forearm;
  • outcome after the primary operation was successful in 50% of the PIN group and in 43% of the ECRB group;
  • 4 of the 5 patients with a poor outcome were reoperated in the former group and 3 in the latter;
  • overall outcome after a mean follow-up of 31 months after the primary operation was successful in 60% of the cases;
  • Surgical treatment of resistant tennis elbow. A PRS comparing decompression of PIN and lengthening of the tendon of ECRB muscle.
• joint exploration:
  • Radiocapitellar Cartilage Injuries Associated With Tennis Elbow Syndrome
  • Is Posterior Synovial Plica Excision Necessary for Refractory Lateral Epicondylitis of the Elbow?
• references:
  • The surgical treatment of chronic lateral humeral epicondylitis by common extensor release.
  • Surgical treatment of persistent elbow epicondylitis.
  • Tennis elbow. The surgical treatment of lateral epicondylitis.
  • Lateral extensor release for tennis elbow. A prospective long-term follow-up study.
  • The results of operative treatment of medial epicondylitis.

References

• Lack of scientific evidence for treatment of lateral epicondylitis of the elbow.  An attempted meta analysis.
• The role of supinator in the pathogenesis of chronic lateral elbow pain: a biomechanical study.
• Randomized Prospective Evaluation of Injection Techniques for the Treatment of Lateral Epicondylitis