The Problem
Lateral epicondylitis – better known as “tennis elbow” – is a tendinosis of common attachment of the forearm extensor tendons (extensor carpi radialis brevis (ECRB), extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris). It is a commonly seen source of lateral elbow pain in adult patients in their 5th and 6th decades of life. The pathologic process is believed to be initiated by a microtear within the origin of the ECRB. On histologic evaluation, lateral epicondylitis has been shown to resemble angiofibroblastic hyperplasia. There is a paucity of inflammatory cells present, indicating that it is a chronic, degenerative process that likely results from repetitive microtrauma. While the condition is generally self-limiting within 10 – 18 months, a variety of treatment options exist to reduce symptoms and improve function in this typically active patient population.
Clinical Presentation
The prevalence of lateral epicondylitis has been reported to range from 1 – 3% of the general population. Lateral epicondylitis is most commonly seen in patients aged 45-55 years who present with a complaint of lateral elbow pain with activity. While commonly associated with tennis players, lateral epicondylitis more commonly occurs in nonathletes, with those employed in manual labor that requires repetitive forearm and wrist extension and those who use vibratory tools at increased risk.
Patients typically present with a chief complaint of activity related lateral elbow pain. The pain is typically insidious in onset but its development is often associated with recent changes in their occupational or athletic activities. Lateral epicondylitis patients commonly describe significant pain with activities that involve active wrist and elbow extension in addition to discomfort when shaking hands. The pain may radiate down the lateral aspect of the forearm.
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Diagnostic Workup
Physical examination
Inspection of the affected elbow may reveal soft tissue swelling about the lateral aspect of the elbow. Tenderness to palpation is often present over the common extensor origin, just anterior and distal to the lateral epicondyle. Typically, patients have full elbow and wrist range of motion. The patient’s pain can usually be reproduced with resisted wrist extension with the elbow extended and forearm pronated in addition to a positive Maudsley’s Test which is production of pain with resisted middle finger extension. The chair test is another provocative test that can be performed in the office. Patients will have reproduction of their pain while attempting to lift a chair with forearm in pronation. Diminished grip strength may be present with dynamometer testing due to pain.
Imaging
While lateral epicondylitis is a clinical diagnosis, plain radiographs can exclude the presence of bony pathology. While AP and lateral views of the elbow are usually normal, patchy calcification in the soft tissue overlying the common extensor tendon origin may be seen. MRI usually demonstrates increased signal in the region of the common extensor origin and may show thickening of affected tendons, ECRB tendon tears and soft tissue calcification.
Non-Operative Management
Non-operative management is the mainstay of treatment for cases of lateral epicondylitis and is reported to be successful in up to 95% of patients. Non-operative management includes activity modification and rest, often coupled with physical therapy with goals of maintaining range of motion, eccentric muscle strengthening and modalities to reduce soft tissue swelling and inflammation.
Some authors recommend using bracing in the form of a counterforce brace to reduce the tension in forearm extensors by preventing full contraction. The brace is applied over the flexor mass and provides a new fulcrum during muscle contraction, limiting the stress applied to the common extensor origin. Wrist extension splints may also be used.
Additional components of non-operative management include oral nonsteroidal anti-inflammatory medication and corticosteroid injections. Corticosteroid +/- a local anesthetic is injected at the site of maximal tenderness with the needle advanced to the periosteum and redirected to facilitate spreading the solution around the common extensor origin. There is evidence showing superior symptom relief compared to NSAIDs at 4 weeks but no difference in the long-term outcome. Potential downsides of corticosteroid injections include skin depigmentation, fat atrophy and a possible increase in blood glucose levels in diabetic patients. Platelet-rich plasma (PRP) injections have gained recent attention in the management of lateral epicondylitis, with a level 1 study showing superior outcomes compared to corticosteroid injections. The PRP is injected into and around the ECRB tendon using a peppering technique as described above for corticosteroid injections.
For our lateral epicondylitis patients initiating treatment we typically use a multimodal approach including a corticosteroid injection (1cc of dexamethasone and 3cc of lidocaine) coupled with a 6 week course of an oral anti-inflammatory medication, counterforce bracing and 6 weeks of physical therapy. For patients who respond to this treatment but have recurrence of their symptoms, we will recommend a second corticosteroid injection and discuss the potential use of PRP as an alternative.
Indications for Surgery
Surgical intervention is indicated for patients whose symptoms and functional limitations persist despite 6-12 months of non-operative management. Prior to surgery, all other causes of lateral elbow pain should be ruled out, with an MRI often obtained to exclude alternative etiologies.
Surgical Technique
Many methods have been described for the operative management of recalcitrant lateral epicondylitis. The three most commonly used approaches are the open technique, the arthroscopic technique and the percutaneous technique. To date no approach has been shown to be superior with most reports of surgical management describing success rates in the 95 – 97% range.
Open Technique
A 3 cm curvilinear or longitudinal incision is made centered over the lateral epicondyle with soft tissue dissection performed to identify the interval between the ECRL and common extensor origin.
Elevate the normal-appearing tendon of the extensor digitorum communis exposing the deeper abnormal-appearing, grey, edematous and friable tendinotic ECRB tissue. This abnormal tissue is excised exposing the underlying bone of the lateral epicondyle.
The lateral epicondyle is decorticated to expose a bleeding surface and stimulate healing with care taken to avoid entering the elbow joint. We also use a 0.45 K-wire to drill 3-4 holes in the lateral epicondyle to facilitate bleeding at the ECRB origin.
Repair of ECRL and EDC is then performed with absorbable sutures.
Skin is closed and patient is placed into a posterior splint until the first post-operative office visit.
Arthroscopic Technique
Useful approach for patients with concomitant intra-articular pathology.
The patient is positioned prone with two chest rolls with care taken to pad all bony prominences. Apply a tourniquet to the proximal arm. Using an arm board, position patient with ipsilateral shoulder in 90 degrees of abduction and neutral rotation. The operative elbow should be in 90 degrees of flexion with their hand pointing toward the floor.
Typically the site is visualized with the arthroscope in the medial portal. The lateral capsule and ECRB origin are approached from their undersurface through the superior-lateral portal site. The ECRB is debrided with a mechanical shaver and the lateral epicondyle can be decorticated with a burr. Care must be taken to avoid injuring the lateral collateral ligament.
Percutaneous Technique
Can be performed in the office setting or the operating room.
After local anesthetic administered throughout the area a 1 cm incision is made directly over the lateral epicondyle.
The common extensor origin is split and the ECRB origin is released by a stab incision.
Downsides to this approach include the fact that the pathologic tissue is not removed and the lateral epicondyle is not decorticated.
Pearls and Pitfalls of Technique
Pearls
Maximize non-operative management as 95% of patients improve without surgery.
After removal of the pathologic tissue during surgical management consider decorticating or drilling the lateral epicondyle to promote bleeding
Pitfalls
Ensure that no other diagnosis is present in patients with persistent symptoms.
Avoid excessive debridement of collateral ligament origins, which may result in iatrogenic instability.
Potential Complications
Infection
Hematoma
Radial nerve injury
Lateral ulnar collateral ligament (LUCL) injury
Recurrence of symptoms
Post-operative Rehabilitation
Patients are placed into a posterior, long arm splint with elbow in 70-80 degrees of flexion until their first post-operative visit. At that visit the splint is removed and unrestricted use of the elbow is permitted. We recommend avoiding heavy lifting for 3-4 weeks post-operatively. Post-op PT is directed to restore ROM and work on eccentric strengthening of the extensor musculature.
Outcomes/Evidence in the Literature
Mishra, AK, Skrepnik, NV, Edwards, SG, Jones, GL, Sampson, S, Vermillion, DA, Ramsey, ML, Karli, DC, Rettig, AC. “Efficacy of Platelet-Rich Plasma for Chronic Tennis Elbow: A Double-Blind, Prospective, Multicenter, Controlled Trial of 230 Patients”. Am J Sports Med. 2013. (Clinically significant success rates, as measured by a >25% reduction in pain score versus baseline, were found in platelet-rich plasma-treated patients at 24 weeks after treatment (p=0.012).)
Gosens, T, Peerbooms, JC, van Laar, W, den Oudsten, BL. “Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up”. Am J Sports Med. vol. 39. 2011. pp. 1200-8. (Reduction in Disabilities of the Arm, Shoulder, and Hand (DASH) score sustained over 2 years in the group treated with platelet-rich plasma over the group treated with corticosteroids.)
Ahmad, Z, Brooks, R, Kang, SN, Weaver, H, Nunney, I, Tytherleigh-Strong, G, Rushton, N. “The Effect of Platelet-Rich Plasma on Clinical Outcomes in Lateral Epicondylitis”. Arthroscopy. vol. 29. 2013. pp. 1851-62. (A systematic review of the current evidence on the clinical outcomes of PRP injections for lateral epicondylitis. PRP improved clinical satisfaction scores, as demonstrated by two different cohort studies. There is evidence for symptom improvement over treatment with bupivacaine. The evidence for symptom improvement over corticosteroids is equivocal.)
Söderberg, J, Grooten, WJ, Ang, BO. “Effects of eccentric training on hand strength in subjects with lateral epicondylalgia: a randomized-controlled trial”. Scand J Med Sci Sports. vol. 22. 2012. pp. 797-803. (Pain-free grip strength as measured with vigorimeter (kPa) at baseline, mid-intervention follow-up at week 3 and at end-intervention follow-up at week 6. Exercise group (N=18), control group (n=19). Error bars show mean and 95% con?dence intervals.)
Cullinane, FL, Boocock, MG, Trevelyan, FC. “Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review”. Clin Rehabil. 2013. (A systematic review of randomized and controlled clinical trials incorporating eccentric exercise as a treatment for patients diagnosed with lateral epicondylitis. Conclusion: The majority of consistent findings support the inclusion of eccentric exercise as part of a multimodal therapy programme for improved outcomes in patients with lateral epicondylitis.)
Khashaba, A. “Nirschl tennis elbow release with or without drilling”. Br J Sports Med. vol. 35. 2001. pp. 200-1. (Decortication of the lateral epicondyle during tendon release surgery was evaluated in this randomized double blind comparative prospective trial of 23 elbows (18 patients). The authors conclude that drilling confers no benefit and actually causes more pain, stiffness, and wound bleeding than not drilling.)
Summary
Lateral epicondylitis is a relatively common cause of lateral elbow pain with activity in adults in their 40s and 50s. While commonly referred to as tennis elbow, lateral epicondylitis more typically occurs in non-athletes and laborers involved in repetitive activities. Conservative management is successful in 95% of patients, and for most patients, symptoms abate within 1 year. In rare instances, when non-operative approaches fail and patients remain symptomatic and functionally limited, surgical treatment is considered with open and arthroscopic approaches described.
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