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Tennis Elbow – Lateral Epicondylitis

from An Atlas of Human Anatomy by Carl Toldt, M.D., 1919.

Discussion

Microscopic Findings

Diff dx

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

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

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;
  • 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:

References