Key points

Pain over the lateral aspect of the elbow, without nerve injury or elbow instability, often is diagnosed as lateral epicondylitis or, colloquially, tennis elbow. It is a common complaint, seen most frequently in women between ages 40 years and 60 years, although it is common in men too. Typical presenting symptoms include pain with prolonged wrist extension activities, pain with resisted wrist or elbow extension, and pain at rest radiating from the elbow along the dorsum of the forearm.

The proposed etiology of lateral epicondylitis is repetitive microtrauma to the origin of the long wrist extensors, in particular, the extensor carpi radialis brevis (ECRB) and the extensor digitorum communis (EDC). Nirschl proposed histologic findings of angiofibroblastic tendinosis. There may be an early inflammatory stage; however, after the presentation of symptoms, there is degeneration and ultimately fibrosis.

Diagnosis

The typical patient presents with a complaint of pain over the lateral aspect of the elbow, particularly with resisted wrist extension activities or activities with the forearm in pronation. Symptoms may present acutely or may have a lingering progression. Using a keyboard, gardening, sports activities, and writing often are presenting complaints. Exacerbating factors should be discussed, along with sports and recreational activities. Care should be taken to determine whether there is a history of elbow injury or instability.

Physical examination

Physical examination findings are related to determining the area of discomfort and eliminating confounding findings. Palpation over the lateral condylar ridge, just proximal to the lateral epicondyle, often elicits pain, particularly when combined with resisted wrist extension. Active range of motion often is limited by pain, but passive motion usually is normal. The path of the radial nerve should be palpated, particularly along the span of the supinator muscle to differentiate from radial tunnel syndrome or a palsy of the posterior interosseous nerve. Nerve symptoms, in particular, loss of active digital or thumb extension, are not part of the diagnosis of lateral epicondylitis.

Imaging

Radiographs do not prove lateral epicondylitis; however, they may help determine or eliminate other causes of lateral elbow pain.

Magnetic resonance imaging often is ordered by referring primary care physicians. Frequently there are findings of signal change over the lateral elbow; however, the true importance of this is not known. Cadaver studies have shown degenerative changes with age. Recent ultrasound studies also have shown an incidence of damage to the extensor origin in 21% of scanned patients. ^,

Treatment

Treatment of lateral epicondylitis has been controversial for a long time. As far back as 1936, Cyriax proposed simply avoiding provocative movements and that it could take as long as 12 months to resolve. Nirschl on the other hand proposed excision of the degenerative portion and repair of the extensor origin.

In the author’s practice, patients with signs consistent with lateral epicondylitis are treated with forearm stretches and eccentric ECRB strengthening. The author has found this to be a physical therapy modality that has been effective as part of a treatment program when occupational therapy is required. Counterforce bracing can be helpful but the author typically uses wrist extension splinting to offload the extensors. Patients are counseled that symptoms may be present for approximately 9 months to 12 months. Proximal strengthening and core activation also can help decrease symptoms.

Injections and other interventions also are controversial. Steroid injections can provide early improvement in symptoms, although they may not prove more durable than any other treatment. Injection at the site of pain (epicondyle) or within muscle both have appeared effective. Normal saline injections have an approximately 30% efficacy by themselves, which implies there are multiple confounding factors associated with symptoms. Prolotherapy and platelet-rich plasma have had some anecdotal success, but there is no large-scale benefit to either modality and the expense makes their value dubious. A comparison of corticosteroid, autologous blood, and normal saline showed no difference in outcome between any of the modalities at 2 months and at 6 months. There are multiple studies in the literature regarding multiple treatment interventions. The overwhelming majority do not have a comparison to physical therapy, which makes assessment of true efficacy difficult. A meta-analysis of the literature found 22 studies comparing nonsurgical intervention with either a nonintervention or observation arm and found no discernible difference in outcome between any of the treatment modalities.

Surgery

Surgical treatment has been proposed as a successful treatment of lateral epicondylitis. The reported outcomes are in line with nonsurgical interventions as well as with nontreatment. As described by Nirschl, the incision is made laterally directly over the common extensor origin. The ECRB and EDC are effectively confluent at the origin from the lateral column, and a longitudinal incision is made in the extensor tendon. The muscle is split rather than being elevated from the lateral column and the degenerative tissue, if identified, is excised. The lateral epicondyle then is débrided of fibrinous tissue and the extensor tendon then is repaired. Arthroscopic débridement is reported as a possible treatment, with débridement of the capsule and undersurface of the ECRB. Buchbinder and colleagues in a Cochran review determined that there is insufficient evidence that any specific surgical intervention, or even surgery in general, is supported compared with any other treatment or even with simple observation.

If surgery is pursued, the operative surgeon should be careful with release and cognizant of the location of the lateral collateral complex of the elbow. There are reports of exuberant débridement resulting in disruption of the lateral collateral complex and creating an iatrogenic posterolateral rotatory instability of the elbow. Multiple corticosteroid injections can lead to thinning or depigmenting of the skin as well as to failure of the lateral collateral complex and posterolateral rotatory instability.

Return to activity

As Drake and Ring ^, have discussed, the most important factor in treating lateral epicondylitis is communicating that this is a self-limited process. Once the acute pain has been stabilized, either with counterforce bracing or wrist extension splinting, patients may be counseled to return to activities as symptoms allow. Patients should be counseled that pain is likely to be present, particularly after a period activity, but, provided it is within acceptable limits and there are no symptoms of instability, they may return to sports activities.

Summary

Lateral epicondylitis is a common complaint in patients between 40 years and 60 years of age. It is frustrating and may have a prolonged course. Multiple treatment options have been proposed. Many can be effective in the short term but none has demonstrated a clear long-term benefit over simple activity modification and forearm rehabilitation or even simple observation. Irrespective of intervention, nearly all report durable relief at approximately 12 months. Surgical treatment has been proposed, but, again, scant evidence exists for any superiority in outcome. The most effective aspect of surgical intervention may be a period of enforced immobility and rehabilitation after the chosen treatment.