Lateral Epicondylitis (Epicondylalgia) of the Elbow
Richard T. Herrick, M.D., F.A.C.S., F.I.C.S.
Stella Herrick, A.T., A.C.S.M.
I. Background
Lateral epicondylitis (tennis elbow) is an acquired condition affecting the elbow area. It is presumably caused by inflammation or degenerative changes which occur after either microscopic or macroscopic tears of the origin of the forearm common extensor aponeurosis at the lateral epicondyle. It can occur with any prolonged repetitive forearm activity, such as racquet sports, bowling, carpentry, assembly line work, or lifting. Although seen in adolescents, young adults and the older population, it most commonly occurs in patients between the ages of 30 and 50 years and may be bilateral. Although 95% of reported cases occur in patients other than tennis players, it is estimated that from 10% to 50% of people who play tennis on a regular basis will experience symptoms of this disorder at some time. Pain in the lateral elbow area associated with forearm use during either sports or occupational activities is the most frequent presenting complaint. Onset of the discomfort may be sudden or gradual. Pain frequently radiates proximally into the arm or distally into the dorsal aspect of the forearm.
Lateral epicondylitis should be differentiated from the much less common radial tunnel syndrome which is due to an entrapment of the radial nerve under the arcade of Frohse.
II. Diagnostic Criteria
A. Pertinent historical and physical findings
Patients complain of tenderness over the lateral epicondyle area or of pain radiating distally and proximally from the lateral epicondyle with any forceful use of the forearm muscles, such as shaking hands, pouring coffee, using a tennis backhand stroke or lifting a chair. An aching sensation may persist after the activity ceases. Almost all patients exhibit some decreased wrist and/or elbow motion in the affected arm.
B. Appropriate diagnostic tests and examinations
1. AP, lateral and oblique x-rays of elbow
2. EMG and nerve conduction studies if radial nerve entrapment is suspected.
C. Inappropriate diagnostic tests and examinations
1. Elbow arthroscopy, unless loose bodies are also suspected.
2. Routine bone scan, unless a chronic case has developed.
3. Thermography, unless nerve injury is suspected, or objective response to treatment is required.
4. Arthrogram of elbow joint, unless intraarticular derangement is suspected.
5. Cervical spine x-rays, unless cervical radiculopathy is suspected.
D. Evolving diagnostic tests and examinations
1. MRI
2. Ultrasound
E. Supporting evidence
This condition appears to be associated with more than one pathologic cause at the lateral epicondylar region. Some studies have demonstrated the presence of acute tears in the common extensor aponeurosis while others have demonstrated degenerative tissue in the same area.
III. Treatment
A. Outpatient treatment
1. Nonoperative treatment
a. Indications: Lateral elbow pain associated with forearm use sufficient to cause disability
b. Treatment options
1) Eliminate pain-causing activities by making adaptations in work activity and sport technique
2) "Counter force"(tennis elbow) strap
3) Splint and/or require upper extremity rest for six weeks or longer.
4) Physical modalities such a ice, heat, massage, interferential, and/or galvanic stimulation, ultrasound, phonophoresis(periodic physician monitoring required)
5) Forearm muscle stretching and/or strengthening exercises emphasizing extensors
6) Non-steroidal anti-inflammatory drugs
7) Corticosteroid injections of trigger point (usually origin of extensor carpi radialis brevis)
c. Home health care: None
d. Rehabilitation
1) Use range of motion, strength, and flexibility exercises
2) Gradually increase a slow return to the causative occupational or sports activity
2. Ambulatory surgery
a. Indications
1) Failure to respond to nonoperative treatment program after 6 to 12 months
b. Treatment options
1) Excision of torn or inflamed portion of common extensor aponeurosis with or without partial excision of lateral epicondyle
2) Repair or reattachment of extensor origin to lateral epicondyle with or without partial excision of lateral epicondyle
3) Open or percutaneous extensor tenotomy
c. Home health care: none
d. Rehabilitation
1) Mobilization exercises for fingers and shoulder during postoperative healing, increasing to resistive exercises when appropriate
2) Wrist flexion and extension exercises after postoperative healing, increasing to resistive exercises when appropriate
3) No provocative activity for operated arm for an appropriate period of time
B. Inpatient treatment
1. Nonoperative inpatient treatment is not indicated.
2. Operative treatment
a. Indications for admission
1) Concurrent disease or unstable medical condition requiring hospital monitor-ing
2) Significant postoperative pain
b. Procedure options
1) Excision of torn or inflamed portion of common extensor aponeurosis with or without partial excision of lateral epicondyle
2) Repair or reattachment of extensor origin to lateral epicondyle with or without partial excision of lateral epicondyle
3) Open or percutaneous extensor tenotomy
c. Indications for discharge
1) Uncomplicated: One to two days if patient is comfortable
2) Complicated: Extra days needed if associated medical condition is not stabilized
d. Home health care: None
e. Rehabilitation
1) Mobilization exercises for fingers and shoulder during postoperative period
2) Wrist flexion and extension exercise after postoperative healing, increasing to resistive exercises when appropriate
3) No provocative activity for operated arm for an appropriate period of time
f. Supporting evidence
The vast majority of patient with lateral epicondylitis who ultimately require surgical treatment can be adequately treated on an ambulatory basis. Hospitalization is required only in those patients with a significant associated medical condition which increases the risk of ambulatory treatment or significant postoperative pain.
C. Inappropriate treatment
1. More than three steroid injections over a three-month period
2. Distal extensor tendon lengthening (in athletes, may produce weakness)
3. Annular ligament resection
4. Selective radial nerve release at radial tunnel (unless there is concomitant entrapment)
D. Exceptions to above criteria
1. Entrapment of radial nerve in association with lateral epicondylitis may require radial tunnel
release; however, this requires an additional diagnosis.
2. Painful annular ligament in association with lateral epicondylitis may require partial excision.
E. Estimated duration of care
1. Nonoperative treatment for 6 to 12 months should be undertaken before surgery is considered.
2. Postoperative follow-up should continue for four to six months or more before the patient
returns to full activities.
F. Anticipated outcomes
1. Pain in the lateral epicondyle area is diminished or minimal.
2. Pain is diminished and the patient returns to full activity involving the wrist, forearm, and elbow.
3. A job change may be necessary.
G. Evolving therapeutic procedures
1. Lighter sports rackets with improved designs
2. Identification of susceptible persons by muscle strength and biomechanical evaluation
3. Improved and lighter bracing
H. Modifiers (age, sex, and co-morbidity): None, except that patients with collagen diseases (e.g.
rheumatoid arthritis) may have longer rehabilitation.
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