Lateral Epicondylitis of the Elbow

, Dario Pitino¹ and Giacomo Delle Rose¹

(1)

Shoulder and Elbow Surgery, Humanitas Research Hospital, Via Manzoni 56, Rozzano (MI), 20089, Italy

Keywords

ElbowEpicondylitisTennis elbowShock wavePRP

Lateral epicondylitis is commonly defined “tennis elbow.”

The abuse from physicians and patients of the term of epicondylitis is very frequent in the clinical practice.

The term of epicondylitis defines a frequent myotendinosis occurring more specifically at the common extensor tendon that originates from the lateral epicondyle.

The tendon damage is related to repetitive strain injury caused by repetitive overuse of the extensor muscles of the wrist.

28.1 Etiology

The typical age at onset of epicondylitis is between 35 and 50 years, with a median of 41 years [1]. The disease is most common in not professional athletes in the third, fourth, and fifth decade, but this tendinopathy also occurs in patients such as teenagers and in the elderly amateur athletes over seventy.

No gender predominance was found in the reports.

The dominant arm is affected more frequently in athletes.

In the tennis epicondylitis is very common, but also in other athletic activities is quite frequent, as baseball, fencing, and swimming.

28.2 Injury Mechanism

The primary cause of tendinosis is overuse: excessive intensity and duration of arm use.

Inadequate or wrong training compromises the integrity of the tendon structure.

In some cases the tendon degeneration occurs after a direct trauma.

Lateral epicondylitis is directly related to activities that increase tension loads of the wrist and finger extensors and the supinator muscles. The extensor carpi radialis brevis is active in the elbow flexion and extension, but also in the varus and valgus stress.

The primary overload abuse in tendinosis is caused by intrinsic eccentric and concentric muscular contraction. The overload causes micro tears within the tendon starting the tendon degeneration.

28.3 Pathology

The primary anatomical structure involved is the extensor carpi radialis brevis tendon origin. In many cases also the anterior portion of the extensor digitorum communis tendon is involved.

Epicondylitis was historically believed to be an inflammatory disease at the insertion of the tendon, but in 1979, it was described as an “angiofibroblastic hyperplasia.” The tendon lesion is characterized by the alteration of normal collagen structure with fibroblast proliferation in association with an immature vascular reparative cellular response.

The degree of angiofibroblastic infiltration appears to correlate generally with the duration of symptoms.

On gross examination, the tendon with tendinosis reveals gray, dull, sometimes edematous and friable, tissue very similar to mature granulation tissue [2].

28.4 Clinical and Diagnostic Examination

Epicondylitis typically causes lateral elbow pain and functional impairment in the use of the arm in daily activities, nocturnal pain, and limitation or impossibility to perform the athletic activity. The pain increases with wrist extension, and grip strength is diminished.

The palpation of the lateral epicondyle and, overall, of the extensor aponeurosis is painful.

The area of maximal tenderness typically lies 5 mm distal and anterior to the tip of the lateral epicondyle.

Provocative stress testing consists of resisted wrist and finger extension with the elbow in flexion. Increased pain is common when the elbow is brought into extension.

The elbow has commonly a full range of motion

Radiographic examination is necessary to exclude bony epiphyseal disease. In a small percentage of patients plain X-rays reveal an irregular profile of the tip of the lateral epicondyle. Small calcific deposits in the substance of the tendon can rarely occur. Magnetic resonance imaging (MRI) in T2 and fat sat scans clearly confirm the pathology in the tendons with proximal insertion at the lateral epicondyle.

The patients with epicondylitis can be divided in three different categories:

Category I

Acute pathology with reversible inflammation without angiofibroblastic invasion.

Minor pain is reported, usually after heavy or specific activities.

Anti-inflammatory drugs and physiotherapy, followed by rehabilitative exercise and specific limitation to avoid overuse of the arm, achieve a quick response to the treatment of this pathology.
Category II

Partial angiofibroblastic invasion of the tendon characterizes the pathology.

The tissue modification is permanent, but some healing response may occur.

Patients have intense pain with activity and moderate pain at rest. After periods of rest, however, most daily activities can be accomplished without significant discomfort.

Magnetic resonance imaging in coronal view usually shows a pathologic signal in the ERB tendon.

If less than half of the tendon diameter is involved, treatment concepts that promote healing gradually bring about resolution, and this process can be managed nonoperatively. Occasionally, however, these patients require surgery for a more complete resolution of symptoms.
Category III

Extensive angiofibroblastic degeneration, frequently associated at partial or complete tear of the tendon, is found in these patients.

The patients are exacerbated for significant functional impairment in daily activities and pain. Pain at rest in the night and during the day.

T2 and FS coronal sections of MRI reveal major signal changes.

The patients in this condition often require surgery for pain relief, considering the frequent failure of the nonoperative measures.

28.5 Differential Diagnosis

Differential diagnosis has to consider:

Carpal tunnel syndrome, more frequent in women; Tinel test and Phalen test are positive; to confirm the suspect, EMG is necessary.
Entrapment of the motor branch of the radial nerve (posterior interosseus nerve) at the Frohse arcade, with more anterior pain and EMG positive.
Distal biceps brachii tendinitis: pain in the flexion and supination of the elbow against resistance and pain localized in the anterior cubital fossa.
Cervicobrachial pain related to nerve root compression, with pain evocated by neck mobilization.
Osteoid osteoma of the proximal radius: the pain increases with alcohol assumption and is controlled by acetylsalicylic acid; TC scan, MRI, and bone scan are necessary for the diagnosis.
Necrosis of the humeral lateral condyle (capitulum humeri), osteochondritis dissecans of the capitulum humeri and Panner’s disease are evident with the elbow MRI.
Focal synovitis: suspected in the MRI, but confirmed with the elbow arthroscopy.
Synovial plica of the humeral-radial joint: tenderness at the palpation of the posterolateral soft spot.

The diagnosis is commonly made through clinical history and physical examination; however, in the athletes it is imperative to perform plain x-rays and MRI of the elbow, to confirm the diagnosis of epicondylitis, but overall to prevent mistakes in the so wide spectrum of the differential diagnosis, as above reported.

28.6 Treatment

Most patients improve with nonoperative measures, such as activity modification, physical therapy and injections. A small percentage of patients will require surgical release of the extensor carpi radialis brevis tendon, performed via percutaneous, arthroscopic, or open approaches.

28.6.1 Nonsurgical Treatment

The main problem of the patient with elbow tendinosis is pain, but the pain control does not necessarily imply enhancement of healing. Relative rest (not absence of activity but abstinence from abuse) and application of cold are appropriate. Activity that aggravates the condition should be eliminated. The use of nonsteroidal anti-inflammatory medications seems to be helpful in some patients. The physical therapy has been helpful in relieving pain at the beginning of the disease.

If the patient does not respond to an appropriate pain control program, a cortisone local injection may be indicated [3]. The author uses 1.5 mL of 0.2 % lidocaine (Xylocaine) mixed with 40 mg of 40 mg methylprednisolone hemisuccinate, instilled with a 25 or 27 G needle under the tendon of the extensor brevis just anterior and slightly distal to the lateral epicondyle. After the injection, the local anesthesia permits to perform scarifications by the needle of the area of tendinosis. If the injection is too superficial or is done on a repetitive basis, subdermal atrophy may occur.

The repeated use of cortisone injections is related to tenocyte cellular death and weakening of the surrounding normal tissues.

28.6.2 Promotion of Healing

A biologic healing response includes infiltration of healthy neovascular and fibroblastic elements, collagen production, and collagen maturation at the cellular level in addition to the restoration of strength and endurance.

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