Abstract
The term lateral epicondylitis describes inflammation, pain, or tenderness in the region of the lateral epicondyle of the humerus. Although epicondylitis implies an inflammatory process, inflammatory cells are not identified histologically. The syndrome is also known as tennis elbow, as it is commonly seen in overuse from a tennis backhand (especially with poor technique). Symptoms may include pain in the area just distal to the lateral epicondyle, with radiation proximally or distally. On physical examination, there is usually pain over the extensor muscle origin. Pain is increased with resisted wrist extension. The diagnosis is usually made clinically. Treatment is usually conservative, although surgery may be required in recalcitrant cases. The anatomy, symptoms, physical examination, functional limitations, diagnostic studies, and treatments (including potential disease and treatment complications) for lateral epicondylitis are discussed.
Keywords
epicondylitis, extensor carpi radialis brevis, lateral epicondylitis, repetitive stress, tennis elbow tendinosis
| Synonyms | |
| |
| ICD-10 Codes | |
| M77.10 | Lateral epicondylitis, unspecified elbow |
| M77.11 | Lateral epicondylitis, right elbow |
| M77.12 | Lateral epicondylitis, left elbow |
Definition
Epicondylitis is a general term used to describe inflammation, pain, or tenderness in the region of the medial or lateral epicondyle of the humerus. The actual nidus of pain and pathologic change has been debated. Lateral epicondylitis implies an inflammatory lesion with degeneration at the tendinous origin of the extensor muscles (the lateral epicondyle of the humerus). The tendon of the extensor carpi radialis brevis muscle is primarily affected. Other muscles that can contribute to the condition are the extensor carpi radialis longus and the extensor digitorum communis.
Although the term epicondylitis implies an inflammatory process, inflammatory cells are not identified histologically. Instead, the condition may be secondary to failure of the musculotendinous attachment with resultant fibroplasia, termed tendinosis . Other postulated primary lesions include angiofibroblastic tendinosis, periostitis, and enthesitis. Overall the focus of injury appears to be the common extensor tendon origin. Symptoms may be related to failure of the repair process.
Repetitive stress has been implicated as a factor in this condition. Overuse from a tennis backhand (especially a one-handed backhand with poor technique) can frequently lead to lateral epicondylitis (hence the term tennis elbow is frequently used synonymously with lateral epicondylitis, regardless of its etiology). Repetitive computer use (especially with a mouse) as well as golf, swimming, and baseball can cause or exacerbate epicondylitis.
Symptoms
Patients usually report pain in the area just distal to the lateral epicondyle. They may complain of pain radiating proximally or distally. Patients may also complain of pain with wrist or hand movement, such as gripping a doorknob, carrying a briefcase, or shaking hands. Patients occasionally report swelling as well.
Physical Examination
On examination, the hallmark of epicondylitis is tenderness over the extensor muscle origin. The common origin of the extensor muscles can be located one fingerbreadth below the lateral epicondyle. With lateral epicondylitis, pain is increased with resisted wrist extension, especially with the elbow extended, the forearm pronated, the wrist radially deviated, and the hand in a fist. The middle finger test can also be used to assess for lateral epicondylitis. Here, the proximal interphalangeal joint of the long finger is resisted in extension and pain is elicited over the lateral epicondyle. Swelling is occasionally present. In cases of recalcitrant lateral epicondylitis, the diagnosis of radial nerve entrapment should be considered. The radial nerve can become entrapped just distal to the lateral epicondyle where the nerve pierces the intermuscular septum (between the brachialis and brachioradialis muscles). There may be localized tenderness along the course of the radial nerve around the radial head. Motor and sensory findings are usually absent.
Functional Limitations
The patient may complain of an inability to lift or carry objects on the affected side secondary to increased pain. Typing, using a computer mouse, or working on a keyboard may recreate the pain. Even handshaking or squeezing may be painful in lateral epicondylitis. Athletic activities may cause pain, especially with an acute increase in repetition, poor technique, and equipment changes (frequently with a new racket or restringing).
Diagnostic Studies
The diagnosis is usually made on clinical grounds. Magnetic resonance imaging (MRI), which is particularly useful for soft tissue definition, can be used to assess for tendinitis, tendinosis, degeneration, partial or complete tears, and detachment of the common extensor tendons at the lateral epicondyle. MRI is rarely needed, however, except in recalcitrant epicondylitis, and it will not alter the treatment significantly in the early stages. The lateral collateral ligament complexes can be evaluated for tears as well as for chronic degeneration and scarring. Ultrasonography has been used to diagnose lateral epicondylitis. The common extensor tendon and the radial nerve may appear swollen on the affected side. Findings of radial nerve involvement may indicate that the pain was secondary to radial nerve entrapment. Arthrography may be beneficial if capsular defects and associated ligament injuries are suspected. Barring evidence of trauma, early radiographs are of little help in this condition but may be useful in cases of resistant tendinitis and to rule out occult fractures, arthritis, and an osteochondral loose body.
Posterior interosseous nerve syndrome
Bone infection or tumors
Ulnar or median neuropathy around the elbow
Osteoarthritis
Acute calcification around the lateral epicondyle
Osteochondral loose body
Anconeus compartment syndrome
Triceps tendinitis
Degenerative arthrosis
Elbow synovitis
Lateral ligament instability
Radial head fracture
Bursitis
Collateral ligament tears
Hypertrophic synovial plica
Treatment
Initial
Initial treatment consists of relative rest, avoidance of repetitive motions involving the wrist, activity modification to avoid stress on the epicondyle, anti-inflammatory medications, and thermal modalities such as heat and ice for acute pain. Patients who develop lateral epicondylitis from tennis should modify their stroke (especially improving the backhand stroke to ensure that the forearm is in midpronation and the trunk is leaning forward) and their equipment, usually by reducing string tension and enlarging the grip size. Frequently a two-handed backhand will relieve the stress sufficiently.
In addition, a forearm band (counterforce brace) worn distal to the extensor muscle group origin can be beneficial ( Fig. 22.1 ). The theory behind this device is that it will dissipate forces over a larger area of tissue than the lateral attachment site. Alternatively, the use of wrist immobilization splints may be helpful. A splint set in neutral can be helpful for lateral epicondylitis by relieving the tension on the flexors and extensors of the wrist and fingers. A splint set in 30 to 40 degrees of wrist extension will relieve the tension on the extensor tendons, including the extensor carpi radialis brevis muscle as well as other wrist and finger extensors. Dynamic extension bracing has also been proposed.
