Lateral and medial epicondylitis are common elbow tendinopathies involving tendon origins that most commonly present in middle age. These entities are typically self-limited, with a multitude of conservative and operative options described that attempt to facilitate an earlier resolution of symptoms. In contrast, biceps and triceps tendinitis are insertional tendinopathies. Olecranon bursitis is an inflammation of the dorsal bursa at the elbow. This chapter evaluates the literature and evidence regarding diagnostic maneuvers and treatment options to facilitate effective treatment of patients with these problems.
Lateral and Medial Epicondylitis
History
Initially described as a result of playing lawn tennis, lateral epicondylitis affects approximately 3% of the population at some point in their lives ; it is far more common than medial epicondylitis, with a 3-6 : 1 ratio. Patients with lateral and medial epicondylitis present with pain on the respective side of the elbow that is typically insidious in onset, although some patients experience the onset of tendinopathy after a traumatic incident. Also known as “tennis elbow” (lateral) or “golfer’s elbow” (medial), these entities present most commonly in persons between 30 and 50 years of age. Men and women are equally affected, with a higher rate of occurrence in nonathletes.
The pathobiology of lateral epicondylitis has been shown to involve the tendon origin of the extensor carpi radialis brevis (ECRB), with infiltration of vascular buds and fibroblast proliferation termed angiofibroblastic hyperplasia. The most common presenting complaint is pain with lifting. Because many activities of daily lifting are performed with the forearm in neutral rotation, lifting in this position requires slight wrist extension, which may cause overuse or microtears of the ECRB tendon origin, thus causing pain. Nirschl and Ashman classified lateral epicondylitis by pathologic and pain phases as a guide to the severity of the problem ( Table 65-1 ).
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Medial epicondylitis is less common than lateral epicondylitis and is not well understood. At surgery, Gabel and Morrey observed a nidus of granulation tissue at the flexor-pronator origin overlying the pronator teres and flexor carpi radialis origin. They noted that this entity often overlaps with symptomatic ulnar nerve compression.
Physical Examination
Upon examination of the patient with tennis elbow, tenderness typically is appreciated at or just distal to the lateral epicondyle with palpation. The most characteristic examination maneuver is the Thomson test, which produces pain at the lateral elbow with resisted wrist extension of the patient’s fist ; the pain often is exacerbated when the patient is asked to make a fist, and his or her attempt to actively extend the wrist is then resisted ( Fig. 65-1 ). The Cozen test entails use of a similar maneuver, except that the examiner grasps the elbow to stabilize it as the patient is asked to extend the fist while facing resistance.
At the medial aspect of the elbow, tenderness is noted at the flexor-pronator origin at the medial epicondyle. Pain with resisted forearm pronation is believed to be the most sensitive test for medial epicondylitis, whereas pain with resisted wrist flexion may also be indicative of this condition. Because of the overlap of medial epicondylitis and ulnar nerve compression, the Tinel test should be performed over the ulnar nerve posterior to the medial epicondyle.
Alternative diagnoses to the epicondylitides include radial tunnel syndrome, which is characterized by aching pain in the proximal forearm distal to the lateral epicondyle, with many similar positive provocative tests ; medial triceps tendinitis or snapping ; and injury or sprain to the lateral and medial collateral ligaments.
Imaging
Tennis and golfer’s elbow are primarily clinical diagnoses; the role of imaging is to rule out other issues involving the elbow. Plain radiographs are typically normal, with faint calcifications occasionally seen at the tendon origin. Pomerance evaluated 294 radiographs in patients diagnosed with lateral epicondylitis and noted that 7% had this finding—however, radiographic findings resulted in a change in management practices only twice in this series of patients.
Ultrasound has been used to evaluate the tendon origin, with findings of decreased echogenicity and peritendinous soft tissue thickening. Abnormalities of the deep fibers of the ECRB also may be visualized. Magnetic resonance imaging (MRI) has also been used in the workup of epicondylitis, with typical findings of a signal change at the ECRB origin on T1-weighted images and fluid or thinning seen at the tendon origin on T2-weighted images; these findings are interpreted as enthesopathy or a partial tear. van Kollenburg et al. noted that patients with lateral epicondylitis were significantly more likely to have signal changes interpreted as ECRB tendinosis on MRI than were control subjects ( P < .001) but that both groups had similar proportions of signal changes in the lateral collateral ligament and readings of a partial ECRB defect. A recent study suggests that the role of MRI is not to provide diagnostic or prognostic information but rather to rule out pathology in equivocal or recalcitrant cases of epicondylitis.
Decision-Making Principles
Because the treatment of epicondylitis is primarily nonsurgical, decision making is based on a discussion with the patient about the evidence regarding various treatment options. It is important for the patient to understand that no matter what treatment is chosen, epicondylitides often take a long time to resolve. Because no one treatment method or algorithm has universal acceptance or has been deemed superior to any other in these conditions, patients are often managed with a “trial and error” approach, with special consideration given to the individual’s vocational and avocational activities. Avoidance of a known aggravating activity is likely where treatment should begin. The remaining methods of treatment are designed to alleviate or reduce symptoms, although their effect may not be immediate or curative. Surgery for epicondylitis is considered as a last resort after other treatments have failed, and the patient must be warned of often uncertain outcomes. Although many retrospective studies have reported good outcomes for surgery, more recent metaanalyses have not been able to support a definitive role for surgery in persons with epicondylitis.
Treatment Options
An increasing amount of evidence indicates that lateral and medial epicondylitis are self-limited entities that resolve on their own over time. Smidt et al. performed a randomized controlled trial comparing corticosteroid injection, physiotherapy, or a wait-and-see approach in 185 patients in the Netherlands. At 1 year, success rates were 69% for injections, 91% for therapy, and 83% for the wait-and-see approach, with no significant differences between therapy and observation ( Fig. 65-2 ). Szabo has recommended reassurance that continued use of the arm will not damage or worsen the tendinosis and emphasis of the self-limited nature of lateral or medial epicondylitis.
Splinting
Use of a forearm support band or tennis elbow strap has been proposed to reduce stress at the ECRB tendon origin. In a cadaver study Meyer et al. noted that increased band compression caused concomitant force reduction at the ECRB origin. Other investigators noted that wearing a support band increased the rate of fatigue of the wrist extensors and advised against use of support bands. A recent randomized trial comparing use of a forearm band and extensor-strengthening exercises showed that both groups improved with time, with no differences noted between these approaches.
The use of wrist splinting has also been described, based on the hypothesis that wrist splinting will decrease the stretch and use of the ECRB. Van De Streek et al. compared use of a forearm splint with elbow band treatment in 43 patients in a randomized trial and noted no differences in grip or pain after 6 weeks, concluding that both approaches showed some effect.
Therapy
The use of deep massage, eccentric exercises, strengthening exercises, ultrasound, and iontophoresis have all been proposed as therapeutic interventions for epicondylitis; however, evidence to support the superiority of any one of these techniques is limited. In the aforementioned study comparing therapy, injection, and observation, physiotherapy had the highest success rate at 1 year. The modality of friction massage to relieve pain and increase blood flow was described by Cyriax. A recent randomized trial showed that a supervised exercise program had superior results compared with Cyriax physiotherapy for tennis elbow, although both groups improved with respect to pain and function. A metaanalysis evaluating exercise in the treatment of epicondylitis showed that resistance exercises resulted in improvement in tennis elbow symptoms; eccentric stretching was the type of exercise most frequently studied.
Ultrasound is thought to provide benefit through deep heating of tissues. Binder et al. noted a significant difference in patients with lateral epicondylitis who were treated with ultrasound compared with placebo treatment; however, later randomized trials have shown no differences between groups treated with ultrasound and sham ultrasound. van der Windt et al. concluded that the evidence that ultrasound may be of benefit in persons with tennis elbow is weak.
Iontophoresis delivers water-soluble medications such as dexamethasone or saline solution through the skin with the use of electrical current. Stefanou et al. noted a short-term benefit of dexamethasone iontophoresis in a randomized study in which this modality was compared with injection of dexamethasone. However, in a rigorous double-blind comparison, Runeson and Haker noted no significant differences in 64 patients who were randomly assigned to iontophoresis or placebo.
Injections
Several types of injections have been used for the treatment of epicondylitis. The most common is a corticosteroid injection, which has been shown in systematic reviews to provide short-term pain relief for up to 6 weeks ( Fig. 65-3 ). Because it has been shown that epicondylitides are not inflammatory, the mechanism of action of a steroid injection is uncertain. A randomized trial of corticosteroid versus placebo injection for tennis elbow showed no differences in outcomes as measured by either Disabilities of the Arm, Shoulder, and Hand scores or pain scores.
Investigators have recently become interested in injections of whole blood and platelet-rich plasma (PRP). The purported mechanism of these injections is stimulation of the reversal of the angiofibroblastic tendinosis via the delivery of humoral mediators and growth factors. Whole or autologous blood contains these factors, and PRP is produced by centrifugation of whole blood to isolate the plasma component to concentrate platelets. In a retrospective study, Edwards and Calandruccio initially described pain relief and functional improvement in two thirds of patients with chronic lateral epicondylitis who were treated with one or two autologous blood injections. Studies of PRP in persons with lateral epicondylitis have shown promising results, with significantly better results compared with corticosteroid injections in both cohort-control studies and randomized trials. A recent study comparing autologous blood with PRP showed better short-term results with PRP but no other significant differences in pain or function at 6-month follow-up.
Less commonly used injections include botulinum toxin and prolotherapy. Botulinum works by inducing temporary paralysis of the extensor origin, and limited studies have shown effective results in decreasing pain. A randomized multicenter trial in Germany showed significantly better results with botulinum injection compared with placebo at 18 weeks, although middle finger extension was temporarily weakened by the botulinum. A different formulation, prolotherapy, consists of injection of either hypertonic glucose or saline solution into the ECRB origin in an effort to sclerose pathologic neovascularization and provide a toxic effect on granulation tissue. Evidence is limited, although a recent randomized trial comparing prolotherapy with corticosteroid therapy showed improvement in both groups without significant differences between the groups.
Surgical Treatment
Several surgery options are available for persons with epicondylitis, including open or arthroscopic debridement, extensor release or repair, extensor repair, and denervation. Surgery typically is reserved for patients for whom extensive nonoperative treatment has failed. The classic surgical approach to lateral epicondylitis is the Nirschl procedure, which and involves open debridement of all identifiable granulation and/or fibrous tissue at the ECRB origin ( Fig. 65-4 ) followed by decortication or drilling of the lateral epicondyle prominence to improve blood supply. The overlying fascial edges of the extensor carpi radialis longus and extensor digitorum communis are closed.
Other authors have described percutaneous or open release of the extensor origin down to the capsule of the elbow, after which the extensors are allowed to retract distally. The extensor muscular origin is attached at multiple points to the surrounding fascial bands and to underlying joint capsule, and thus extensor weakness is not observed after this procedure. An alternate procedure involves debridement of devitalized tissue and repair of the ECRB to the lateral epicondyle using suture anchors or bone tunnels. Finally, denervation of the lateral elbow has been described by Kaplan and Wilhelm, with careful dissection and division of multiple cutaneous radial nerve branches while preserving the posterior interosseous nerve.
Arthroscopic management of lateral epicondylitis has been demonstrated, with debridement and release of the underside origin of the ECRB. The proposed advantages of arthroscopy are minimal incisions and the ability to manage concomitant intraarticular pathology, which has been seen in up to one third of patients. It is only necessary to access the anterior compartment of the elbow with use of a modified anterolateral portal that is established using an inside-out technique, starting 2 to 3 cm proximal and anterior to the lateral epicondyle. Any synovitis is debrided with use of a shaver, and then the ECRB is released using monopolar thermal dissection or a shaver, taking care to limit the release to the area anterior to the midline of the radiocapitellar joint in order to preserve the lateral collateral ligament origin.
My management of lateral or medial epicondylitis begins with a discussion of the evidence for and against the multiple treatment options. I emphasize the typically self-limited course of epicondylitis but note that this tendinosis may remain symptomatic up to 1 to 2 years before resolving, except in a small number of people. I also reassure patients that they are not causing themselves harm or damage by using the arm and that they are not causing joint instability or tissue damage that will lead to disability. For each patient, I demonstrate eccentric stretching exercises for tendinosis and inform the patient that this expectant treatment alone can be sufficient to treat epicondylitis.
I offer referral for therapy, focusing on eccentric stretching, ultrasound, massage, and balanced use of the upper extremity, and also discuss injection types. I always emphasize the limited course of pain relief from steroid injections (approximately 6 weeks) but will provide a steroid injection at a patient’s request. For patients who present with symptoms that have lasted longer than 6 months and especially for patients with chronic epicondylitis, I will offer an autologous blood injection, because my anecdotal experience has shown that these injections work best in that patient group.
For surgical management of lateral epicondylitis, I perform the Nirschl procedure with open debridement of the ECRB origin. I typically perform this procedure after anesthesia is induced with the Bier block technique and make a longitudinal incision over the lateral epicondyle and ECRB origin. The fascia is incised with retraction of the extensor carpi radialis longus and extensor digitorum communis, exposing the deep ECRB. The origin is debrided of any gray, shiny tissue so that healthy tendon remains. I typically do not open the elbow joint. I use a rongeur or osteotome to decorticate the prominence of the lateral epicondyle, taking care not to go too far inferiorly to protect the origin of the lateral collateral ligament. After providing irrigation, I close the fascia of the extensor carpi radialis longus and extensor digitorum communis using 2-0 resorbable sutures and then close the skin using a resorbable Monocryl subcuticular suture.
For medial epicondylitis, I perform an open debridement of the flexor-pronator origin, focusing on the interval between the pronator teres and the flexor carpi radialis at their attachment to the medial epicondyle. Although typically I am not able to visualize a nidus of abnormal tissue as reported by Gabel and Morrey, I remove any devitalized tissue at the origin and decorticate the medial epicondyle with a rongeur. Closure and other management techniques are similar to the ones I use to treat lateral epicondylitis.
Postoperative Management
The patient wears a splint postoperatively for 2 weeks and then begins therapy for 4 to 6 weeks with a 5-lb lifting limit. Strengthening exercises are begun at 6 weeks, and return to heavy lifting and strenuous sports is not permitted until 3 months after surgery.
Return to Play
Resumption of athletic activities after surgery for lateral or medial epicondylitis depends on the sport. Strenuous or contact sport activity is permitted 3 months after surgery if the patient has tolerated the strengthening phase of rehabilitation. Earlier return, typically at 6 weeks, is allowed for individual sports such as golf, skiing, and swimming, with the elbow taped or supported as necessary.
For patients who are not treated with surgery, return to sport is allowed according to their tolerance level, with the understanding that the elbow may be painful when certain motions are performed or after heavy use.
Results
Open Surgical Management: Lateral Epicondylitis
Dunn et al. reported a 10- to 14-year follow-up of the Nirschl open debridement technique in 139 patients in a retrospective review. The authors noted decreased pain scores and improved American Shoulder and Elbow Surgeons scores, with good to excellent results of 84% when combining two other functional scales; in addition, 93% of patients were able to return to their sport. A prospective randomized comparative study between percutaneous and open ECRB release showed improvements in both groups, but the percutaneous-release group had significantly better Disabilities of the Arm, Shoulder, and Hand scores and improvement in sports performance, along with earlier return to work. A recent Cochrane review of the available evidence for surgical treatment concluded that evidence is insufficient to support the use of surgical treatment for lateral epicondylitis or the application of one surgical technique as superior.
Arthroscopic Release: Lateral Epicondylitis
Lattermann et al. noted improvement of pain and function scores in a retrospective review of 36 patients with lateral epicondylitis who were treated arthroscopically, although 31% noted mild pain with strenuous activities. Other authors have noted similar positive findings, although persons performing heavy labor and worker’s compensation claimants had overall worse outcomes. Szabo et al. compared open, arthroscopic, and percutaneous release of the ECRB in a group of 109 patients with 47.8-month mean follow-up. A comparison of Andrews-Carson scores before and after surgery showed significant improvement with no differences between groups, and these investigators concluded that all three procedures were highly effective in treating lateral epicondylitis.
Surgical Treatment of Medial Epicondylitis
Most reports of treatment for medial epicondylitis involve open debridement of the flexor-pronator origin in patients for whom lengthy conservative management has failed. Vangsness and Jobe reported that 34 of 35 patients treated operatively had good or excellent results rated subjectively, with strength and motion equal to the unaffected contralateral arm at 85-month follow-up. Gabel and Morrey noted excellent outcomes in a retrospective review of 26 elbows treated for medial epicondylitis and reported significantly better results in patients without concomitant ulnar nerve compression neuropathy. Zonno et al. performed a cadaveric study to evaluate the safety of arthroscopic debridement of medial epicondylitis, but this technique has not been reported in clinical studies to date.
Complications
A notable complication of nonoperative treatment is soft tissue atrophy and thinning of skin after corticosteroid injections, which is a risk that should be addressed when treating patients with this modality. Subcutaneous injection should be avoided to minimize this complication. Repeated injections increase the risk of atrophy.
Surgical complications include posterolateral rotatory instability if the lateral collateral ligament is damaged in the approach to the common extensors. Kalainov and Cohen noted this complication after a corticosteroid injection in three elbows. The risk of this complication is minimized by taking care not to dissect too far posteriorly on the lateral epicondyle during the surgical approach. Other reported complications are rare, including development of synovial fistulae and transient paresthesias.
Future Considerations
Short-term evidence supports expectant treatment of epicondylitis, with the patient being assured that this self-limited entity tends to resolve over time. However, symptoms do not resolve in a subset of patients, for whom surgical treatment eventually is required. Identification of this group is a focus of continued study. The current evidence for conservative treatment of epicondylitides is strong, with surgery reserved for persons for whom multiple modalities have failed. Potential future considerations include refinement of biologic treatments such as autologous blood and PRP, as well as exploration of the neurologic contributions in patients with chronic epicondylitis.
Distal Biceps and Triceps Tendinitis
History
Biceps and triceps tendinitis are more properly termed insertional tendinopathies. Similar to epicondylitis and Achilles tendinopathy, they tend to present in middle age with an insidious onset, indicating chronic degenerative changes in aging tendons that do not respond well to overuse. Although patients may recall a traumatic event, a careful history will often elicit prodromal aching or pain.
Patients with biceps tendinitis present with anterior elbow pain, which worsens with activities requiring forceful supination (such as application of torque) or elbow flexion. Differential diagnosis includes pronator syndrome, posterior interosseous nerve compression, or phlebitis of the brachial vein. Triceps tendinitis is more rarely seen; patients with this condition report posterior elbow soreness and pain when pushing open doors or performing other activities that require triceps activation without the benefit of gravity.
Physical Examination
In patients with biceps tendinitis, the most important determination is to rule out a complete biceps rupture. The most effective way to rule out a complete rupture is to perform the biceps hook test. In this test the examiner places the patient’s forearm in supination with the elbow flexed at 90 degrees and then hooks his or her finger around the intact biceps tendon from lateral, lifting it slightly anteriorly ( Fig. 65-5 ). O’Driscoll et al. noted that the hook test was more sensitive and specific for biceps ruptures than magnetic resonance imaging (MRI) in a series of patients treated with surgery.
