Pathophysiology

Several hypotheses for the pathophysiology are discussed in Chapter 82 along with a detailed description of the histopathology. Although the terms tendinitis and epicondylitis imply an inflammatory process, histologic studies have confirmed that lateral epicondylitis may not be an inflammatory condition. Tissue studies of damaged tendons from overuse injuries have not contained large numbers of inflammatory cells at the time of study. Instead, damaged tendons demonstrated an increased number of fibroblasts, vascular hyperplasia, and disorganized collagen, which is consistent with tendinosis. This constellation of findings led Nirschl to coin the phrase angiofibroblastic hyperplasia . The term refers to the degenerative changes that occur when a tendon has failed to heal properly after an injury or after repetitive microtrauma resulting from overuse.

Symptoms/Clinical Presentation

Patients will present with lateral elbow and forearm pain experienced during activities such as lifting, grasping, gripping, or hitting a backhand in tennis. The pain associated with lateral epicondylitis is generally localized to the common extensor origin, but patients may report pain radiating proximally and distally. Pain is usually worse with resisted wrist extension, especially with the elbow extended, but can be elicited with radial deviation, finger extension, or forearm supination. In the mild stages, the symptoms will develop after completion of an activity. As the severity progresses, the symptoms are noted soon after starting an activity. In severe cases, the symptoms will occur with minimal activity such as brushing teeth and shaking hands, and rest pain may be noted.

Diagnosis

The diagnosis of lateral epicondylitis is mainly clinical. It is critical to determine the location of the symptoms. The most consistent finding in lateral epicondylitis is pain localized 1 to 3 cm distal to the lateral epicondyle. ^, Symptoms just 4 to 5 cm distal to the lateral epicondyle are often related to radial tunnel syndrome. Compression of the radial nerve should be considered in the differential diagnosis, particularly for lateral elbow pain resistant to conservative therapies. Other conditions with similar symptoms include radiohumeral arthritis, posterolateral rotatory instability, fracture, triceps tendinitis, cervical radiculopathy, and referred pain from shoulder or wrist disorders. Please refer to Chapter 82 for a comprehensive review of the differential diagnosis and examination.

Although the ECRB tendon is often the source of pain, other muscles can contribute to the condition including the extensor carpi radialis longus (ECRL), and the extensor digitorum communis (EDC). Swelling is not often present. Limitations of active wrist extension may be present secondary to pain. The most diagnostic maneuver is the resisted wrist extension test, which produces pain over the lateral epicondyle ( Fig. 83-4 ). Several other provocative tests are described in Chapter 82 . The findings of these maneuvers should be closely correlated with the history and examination.

Resisted wrist extension.

Radiographs may be obtained to exclude other conditions that cause lateral elbow pain including occult fractures, arthritis, and osteochondral loose bodies. ^, However, the radiographic findings rarely have an impact on treatment. Pomerance determined that less than 1% (2/294) of patients had their management course altered by radiographs.

MRI is not routinely performed to make the diagnosis of lateral epicondylitis. The study is helpful to rule out other factors including lateral ulnar collateral ligament tears or intra-articular disorders. The study is not helpful in following response to treatment because the changes on MRI are often not noted for weeks after resolution of symptoms. MRI, however, may also be valuable in preoperative planning and in appreciating the full extent of the disease.

Medical Management

Central to conservative nonoperative management of lateral epicondylitis are patient education, protection of the elbow, and avoidance of activities that aggravate pain. Patients should be taught proper techniques for lifting and other sporting activities. ^, In general, lifting should be performed with the arms close to the body and supinated. A “wait-and-see” strategy may be a viable treatment strategy for lateral epicondylitis. Smidt and colleagues randomized 185 patients into either a physiotherapy, corticosteroid injection, or observation group. At 52 weeks, success rates for the observation group were comparable to those of the other study groups.

Referral to physical or occupational therapy may be helpful in the prevention and treatment of lateral epicondylitis. (See Chapter 82 for a detailed discussion of conservative management.) In general, therapy consists of three phases. The first phase emphasizes rest to control pain and decrease disability. In addition to limiting activities, modalities including heat, ice massage, and ultrasound can be helpful. The second phase, rehabilitation, involves stretching or flexibility exercises for the extensor wad muscle tendon units, which are started when the pain has subsided with rest. Stretching exercises of the extensors are initially performed with the elbow in flexion and progressed to performing the exercises with the elbow in extension. In the third phase, a gradual strengthening program is instituted with isometric followed by isotonic exercises. If pain develops during the program, the exercises are not progressed; the patient returns to the previous phase until the symptoms resolve. If lateral epicondylitis has developed from a sporting activity, proper sport-specific counseling should be a part of the rehabilitation process. In particular, tennis players should consider playing on a soft surface, using new tennis balls frequently, and selecting the appropriate racket with proper grip size and string tension. Hitting a backhand while leading with the elbow often is a factor in lateral epicondylitis; therefore, professional stroke instruction is beneficial. ^,

Elbow bands can be used to reduce pain from lateral epicondylitis. A counterforce brace applies a compressive force over the extensor mechanism of the forearm. ^, This band essentially prevents full muscular expansion by creating a new functional origin of the extensor musculature of the forearm. The efficacy of the device has been disputed. Studies have shown that elbow bands may decrease pain and increase grip strength, whereas other studies show no difference when compared with sham bracing.

Corticosteroid injections have been effective in treating lateral epicondylitis. The injection consists of a combination of local anesthetics and corticosteroid ( Fig. 83-5 ). The most common combination is 0.5 mL methylprednisolone and 0.5 mL lidocaine. In a randomized study of 164 patients being treated with corticosteroid injections, naproxen, or placebo, 92% of patients in the injection group had complete resolution or improvement compared with 57% in the naproxen group and 50% in the placebo group. Risks associated with steroid injections include elevation of glucose in patients with diabetes, steroid flare, and skin changes with subcutaneous fat necrosis, discoloration, and atrophy. ^, Multiple injections are discouraged because of the risk of collagen degeneration. Although commonly used, benefits seen from corticosteroid use are short term and their long-term effects are uncertain. ^,

Steroid and local anesthetic injection into the proximal tendon of the extensor carpi radialis brevis for lateral epicondylitis.

Surgical Management

Conservative treatment is generally effective for the vast majority (>90%) of patients with lateral epicondylitis. Surgical treatment is recommended when the patient experiences persistent debilitating pain despite 6 to 12 months of nonsurgical management, and other causes for the pain have been excluded. Three main categories of operative treatments have been described and studied in the literature: open, percutaneous, and arthroscopic. Each has advantages and disadvantages, but studies comparing the different techniques are limited.

The current standard for most open procedures reported in the literature is the Nirschl procedure and its modifications. The common thread among these procedures is identification of abnormal diseased tissue, most commonly at the origin of the ECRB, followed by excision of the lesion, and repair.

The technique, as originally described by Nirschl and Pettrone and subsequently modified by numerous authors, is as follows. A 5-cm gently curved incision is made centered just distal to the lateral epicondyle. The deep fascia is incised in line with the incision, and the common extensor origin is then identified. An interval between ECRL and EDC is created to visualize the underlying ECRB. Once the ECRB is exposed, the degenerative tissue, which often appears gray and friable, is sharply excised. Sometimes a portion of the EDC is involved as well and is removed concurrently. Nirschl and colleagues described a scratch maneuver using the edge of the scalpel to scrape away abnormal tendinosis tissue while leaving normal tissue intact. The remaining normal tendon is sutured back to surrounding fascia or periosteum. The lateral epicondyle is drilled or decorticated with a rongeur, purportedly to stimulate bleeding and a healing response. However, one level 1 study compared the Nirschl procedure with and without drilling and found that drilling had no benefit in their series and caused more pain and stiffness postoperatively. Some authors have advocated repair of the origin of the ECRB back to the epicondyle using sutures through bone tunnels or suture anchors, although this is not universally practiced. The interval between the ECRL and the EDC is then repaired, and the skin is then closed. Postoperatively, the elbow is immobilized for a short period to allow for soft tissue healing after which range-of-motion exercises are started. Complications include iatrogenic posterolateral rotatory instability secondary to excessive debridement and neuroma of the posterior cutaneous nerve of the forearm.

Other open release techniques include simple release of the common extensor origin without repair, division of the deep fascia overlying the common extensors, and Z -lengthening of the ECRB origin. These tension-relieving procedures have had generally good results, although there are concerns about strength deficits postoperatively. Some authors have proposed a percutaneous technique in which the common extensor origin is released through a less invasive incision. ^,

More recently, there has been interest in using arthroscopic techniques for treatment of lateral epicondylitis. In addition to the ability to evaluate the joint for intra-articular pathology, the technique allows for debridement of the undersurface of the ECRB tendon without division of the common extensor aponeurosis as well as a possibly shorter recovery time.

For the arthroscopic technique, two portals are used: a proximal medial portal for viewing and a lateral working portal. Before establishment of the portals, the joint is injected with 30 mL of saline solution to displace the neurovascular structures anteriorly. The medial portal is established, taking care to maintain contact of the trocar with the anterior surface of the humerus. The arthroscope is inserted and the initial joint inspection is then performed. The superior lateral portal is then established under direct visualization, and a motorized shaver or radiofrequency ablation device is placed in the joint. The lateral capsule is then resected, allowing visualization of the undersurface of the ECRB. The brevis is then released off of the lateral epicondyle, removing pathologic tissue in the process. Care must be taken to limit the distal extent of debridement to the superior half of the radial head. More aggressive resection risks injuring the origin of the lateral collateral complex and producing iatrogenic instability. The lateral epicondyle is then decorticated with a burr. Postoperatively, the patients are placed in soft dressings, and early active range of motion is begun with return to full activity as tolerated. Complications include nerve injury from portal placement, the development of heterotopic ossification, and posterolateral rotatory instability.

Results of Surgical Management

Several series in the literature have reported the results of the various surgical techniques for lateral epicondylitis, all with generally good results. In 1979, Nirschl and Pettrone reported their series of patients treated with an open approach. They reported an overall improvement rate of 97%, with 85% returning to full activity. In a recent long-term study assessing the mini-open Nirschl technique, Jobe and Ciccotti found that at a mean follow-up of 12.6 years, 84% of patients were found to have good to excellent results by various lateral epicondylitis outcome scores.

Simple release of the common extensor origin has also had favorable results, with one prospective long-term follow-up study finding that after 5 years, approximately 90% of patients treated with this technique reported good to excellent results and had no to slight pain. For percutaneous release techniques, several studies had success rates of approximately 90%. ^,

Various short-term studies demonstrated the efficacy of the arthroscopic approach. Baker and colleagues reported on a series of patients treated arthroscopically and demonstrated short-term success with a 95% improvement rate. A recent article evaluated the long-term follow-up (mean, 130 months) of the same cohort of patients treated in this manner and confirmed that the early high rate of success of this procedure can be maintained.

Unfortunately, there are very few comparative studies evaluating two or three techniques. There is only one prospective, randomized, controlled trial comparing two different procedures: the open Nirschl procedure and percutaneous release. The authors found that both treatment groups demonstrated significant improvement in Disabilities of the Arm, Shoulder, and Hand scores, although no comparison between the two groups was made regarding which treatment resulted in a greater amount of improvement. The subjective outcome measure determined by the patients’ assessment was significantly better for the percutaneous group. Furthermore, the patients treated percutaneously returned to work approximately 3 weeks faster than those in the open group (median, 2 weeks vs. 5 weeks).

Recently, a study was published comparing the results of all three techniques. Although nonrandomized and retrospective, it is the largest comparative series to date. When evaluating groups of patients treated with the open technique, percutaneous technique, and arthroscopic technique, all three groups improved in clinical outcomes measures, with no statistical difference between them. In another retrospective, nonrandomized study comparing the results of open versus arthroscopic treatment, both groups were similar in both outcome measures and postoperative function, with no statistical difference. The arthroscopic group did, however, return to work sooner, at 1.7 months, compared with 2.5 months for the open group.

There is still no consensus on which operative procedure offers the best results. Therefore, the choice of procedure often will be surgeon dependent.