Lateral Epicondylitis (Tennis Elbow)

Topic updated on 07/13/16 4:08pm
  • Overuse injury involving eccentric overload at origin of common extensor tendon  
    • leads to tendinosis and inflammation at origin of ECRB   
  • Epidemiology
    • incidence
      • most common cause for elbow symptoms in patients with elbow pain
    • demographics
      • up to 50% of all tennis players develop 
  • Pathophysiology
    • mechanism
      • occurs in activities with repetitive pronation and supination with elbow in extension
      • common in tennis players (backhand implicated)
    • pathoanatomy
      • usually begins as a microtear of the origin of ECRB 
      • may also involve microtears of ECRL and ECU
    • pathohistology
      • microscopic evaluation of the tissue reveals
        • angiofibroblastic hyperplasia 
        • disorganized collagen 
  • Associated conditions
    • radial tunnel syndrome 
      • is present in 5%
  • Prognosis
    • non-operative treatment effective in up to 95% of cases
  • Common extensor origin
    • muscles that originate from lateral supracondylar ridge
      • extensor carpi radialis longus 
    • muscles that originate on lateral epicondyle
      • extensor carpi radialis brevis  
      • extensor carpi ulnaris 
      • extensor digitorum 
      • extensor digiti minimi 
      • anconeus 
        • shares same attachment site as ECRB 
  • Ligaments
    • lateral ulnar collateral ligament 
  • Symptoms
    • pain with resisted wrist extension
    • pain with gripping activities
    • decreased grip strength
  • Physical exam
    • palpation & inspection
      • point tenderness at ECRB insertion into lateral epicondyle
        • few mm distal to tip of lateral epicondyle
    • neuromuscular
      • may have decreased grip strength
      • neurological exam helps to differentiate from entrapment syndromes
    • provocative tests 
      • the following maneuvers exacerbate pain at lateral epicondyle
        • resisted wrist extension with elbow fully extended
        • resisted extension of the long fingers
        • maximal flexion of the wrist
  • Diagnosis
    • diagnosis is primarily based on symptoms and physical exam
  • Radiographs 
    • recommended views
      • AP/Lateral of elbow
    • findings
      • usually normal
  • MRI 
    • increased signal intensity at ECRB tendon may be seen 
    • not necessary for diagnosis

  • Histology
    • histopathological studies of the ECRB tendon tissue shows
      • fibroblast hypertrophy
      • disorganized collagen
      • vascular hyperplasia
  • Diagnosis
    • diagnosis is primarily based on symptoms and physical exam
  • Nonoperative
    • activity modification, ice, NSAIDS, physical therapy, ultrasound
      • indications
        • first line of treatment
      • techniques
        • tennis modifications (slower playing surface, more flexible racquet, lower string tension, larger grip)
        • counter-force brace (strap)
        • steroid injections (up to three) 
        • stretching of extensors
      • outcomes
        • up to 95% success rate with nonoperative treatment, but patience is required
  • Operative
    • release and debridement of ECRB origin
      • indications
        • if prolonged nonoperative (9-12 months) fails
  • Release and debridement of ECRB origin 
    • can be done open or arthroscopic
    • radial tunnel release if coexistent radial tunnel syndrome
  • Iatrogenic LUCL injury 
    • excessive resection of the LUCL
    • should not extend beyond equator of radial head
    • may lead to posterolateral instability 
  • Missed radial nerve entrapment syndrome
    • common in up to 5% of patients with lateral epicondylitis  
  • Iatrogenic neurovascular injury
    • radial nerve injury


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Qbank (6 Questions)

(OBQ09.107) Figure A shows the characteristic microscopic findings of lateral epicondylitis. Which of the following is the most appropriate term to describe the abnormal finding in the region marked with the two asterisks?
Topic Review Topic
FIGURES: A          

1. Osteoblastic rimming
2. Reactive hyperemia
3. Localized hemorrhage with neutrophils proliferation
4. Angiofibroblastic dysplasia
5. Cystic degeneration with fatty infiltration

(OBQ09.119) Which of the following structures shares the same origin site as the tendon that undergoes angiofibroplastic hyperplasia during the pathogenesis of tennis elbow? Topic Review Topic

1. Brachioradialis
2. Anconeus
3. Annular ligament
4. Flexor carpi ulnaris
5. Palmaris longus

(OBQ08.194) A 50-year-old carpenter has chronic pain over the lateral aspect of the elbow. He notes pain when using a hammer. On exam, he has pain with resisted wrist extension while the elbow is fully extended. Which muscle attachment is likely to be involved? Topic Review Topic

1. Distal biceps brachii
2. Brachioradialis
3. Extensor carpi radialis brevis
4. Extensor carpi radialis longus
5. Supinator

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