My Elbow Hurts
Charles M. Jobin, MD, FAAOS
Charles Cassidy, MD, FAAOS
Dr. Jobin or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Acumed, LLC, Biomet, and Zimmer; serves as a paid consultant to or is an employee of Acumed, LLC, Biomet, DePuy, a Johnson & Johnson Company, Integra Lifesciences, Smith & Nephew, and Zimmer; has received research or institutional support from Acumed, LLC; and serves as a board member, owner, officer, or committee member of the American Board of Orthopaedic Surgery, Inc. and the American Shoulder and Elbow Surgeons. Dr. Cassidy or an immediate family member serves as a paid consultant to or is an employee of AM Surgical and serves as an unpaid consultant to Synthes.
Introduction
Elbow pain is a common musculoskeletal complaint of adults. Elbow tendinitis is the most common cause for why people complain, “my elbow hurts.” Elbow tendinitis affects both the lateral and medial elbow but other disorders such as compressive neuropathy of the ulnar nerve at the cubital tunnel and distal biceps tendon injuries are also common disorders of the elbow.
LATERAL EPICONDYLITIS
Lateral epicondylitis is an overuse injury involving repetitive overloading at the origin of common extensor tendons at the lateral epicondyle. This leads to tendinosis and a dysplasia of tissue at the tendinous origin of extensor carpi radialis brevis (ECRB).
Epidemiology
Most common cause of elbow pain in patients who present with elbow symptoms
Affects 1% to 3% of adults annually
More common in the dominant arm
Most common in patients between ages 35 and 50 years1
Men and women equally affected, and condition is independent of ethnicity 2
Although lateral epicondylitis is commonly referred to as tennis elbow, only 10% of affected patients actually play tennis.3
In racket sports, risk factors for lateral epicondylitis include poor swing mechanics, a heavy racket, incorrect racket grip size, and high string tension.
Lateral epicondylitis develops in approximately 50% of recreational tennis players at some point.
Certain occupations may also predispose to the development of lateral epicondylitis.
In one study, 50% to 70% of patients reported that work was associated with the onset of symptoms.2
Industries with the highest incidence include construction, manufacturing, and wholesale/retail, likely because of their manual nature, involving repetitive activities of the wrist and elbow.2
Vibratory tools, in particular, have been implicated.
10.5% of manual workers may experience elbow pain and 2.5% have a confirmed diagnosis of lateral epicondylitis.3
Consequently, lateral epicondylitis is a public health issue, causing significant economic impact because of absenteeism from work and associated health care costs.
Pertinent Anatomy/Pathoanatomy
The common extensor origin on the lateral epicondyle of the distal humerus is the anatomic area that is affected in lateral epicondylitis.
The extensor carpi radialis longus (ECRL) originates from the lateral supracondylar ridge, whereas the remaining muscles originate from the lateral epicondyle, including the ECRB, extensor
digitorum communis, extensor digiti minimi, extensor carpi ulnaris, and anconeus (Figure 1).
Figure 1 Cadaver photo of the location of the posterior interosseous nerve (arrowhead) crossing deep to the extensor communis radialis longus (ECRL) and extensor communis radialis brevis (ECRB), entering the supinator at the level of the radial head. The lateral epicondyle is marked with a star. The ECRB and extensor digitorum communis (EDC) have been separated to aid in visualization. (Reprinted from Calfee RP, Patel A, DaSilva MF, et al: Management of lateral epicondylitis: Current concepts. J Am Acad Orthop Surg 2008;16[1]:19-29.)
The lateral ulnar collateral ligament (LUCL) also originates from the lateral epicondyle and traverses posterolaterally and around the radial head to the ulnar supinator crest.
The nerves that are in this area include the posterior interosseous nerve (PIN), which enters a split in the supinator muscle (arcade of Frohse) just distal to the radial head.
Compression of the PIN can lead to radial tunnel syndrome, which is a diagnosis of exclusion and may coexist with lateral epicondylitis.
The pathophysiology of lateral epicondylitis includes overuse of the ECRB.
With grip, the ECRB is instrumental in stabilizing the wrist to allow the digits to function effectively.
Overuse is precipitated by repetitive wrist extension and forearm pronation.
The pathoanatomy of lateral epicondylitis may begin as a microtear of the origin of ECRB.
In a small number of cases (10%), the condition can involve microtears of ECRL and/or extensor carpi ulnaris.
The classic histologic finding of the affected tissue is angiofibroblastic hyperplasia, which includes fibroblast hypertrophy, disorganized collagen, vascular hyperplasia,4 and a tendinosis-like microstructure.
Pertinent History/Physical Examination Findings
The pertinent history of lateral epicondylitis includes lateral elbow pain worse with activity that does not resolve over a few weeks and started with a minor injury or seemingly benign activity such as yard work, sport activity, or manual labor.
Commonly there is associated loss of grip strength.
Pain may occasionally radiate down the dorsal forearm.
The physical examination findings include point tenderness at or near the ECRB origin, typically no more than 0 to 2 cm distal to the bony lateral epicondyle.
Provocative tests include pain on resisted wrist extension exacerbated by elbow extension, and pain with full passive stretch of the ECRB by extending and pronating the elbow with the wrist maximally flexed.
Grip strength may be diminished, and the finding is accentuated by having the patient grip the dynamometer while the elbow is extended.
A careful nerve examination should also be performed to exclude concomitant entrapment neuropathy of the radial, ulnar, and median nerves at the elbow.
The classic findings of radial tunnel syndrome include tenderness over the PIN 3 to 5 cm distal to the lateral epicondyle, pain on resisted supination, and pain on resisted long finger extension.
Differential diagnosis includes elbow plica syndrome, posterolateral rotatory instability and radial tunnel syndrome, occult fracture of the radial head/neck, radiocapitellar arthritis, capitellar osteochondritis dissecans, biceps or triceps tendinitis, and cervical radiculopathy.
Relevant Imaging
Radiography
Approximately 47% of patients with lateral epicondylitis have calcifications adjacent to the lateral epicondyle on radiographs,5 although presence of calcifications does not appear to be related to the timing of clinical presentation.2
Radiographs also should be used to exclude other common causes of elbow symptoms such as early arthritis with osteophytes, loose bodies, joint space narrowing, fracture, or other bony lesions.
Magnetic resonance imaging
Noncontrast MRI is not necessary for diagnosis of lateral epicondylitis but helps rule out concomitant intra-articular pathology or other diagnosis.
MRI often shows increased signal at the ECRB tendon origin, thickening and edema of the ECRB tendon, or a partial articular surface tear of the ECRB origin; bony edema at the lateral epicondyle is rare.
Interestingly, one study demonstrated that there is an inverse relationship between the degree of tendinopathy and reported pain. In other words, the pain is often worse with partial ECRB tears than with complete tears.
Ultrasonography
Less expensive but requires an experienced operator and evaluator.
Ultrasonography findings of lateral epicondylitis include structural changes affecting the extensor tendons, such as thickening, thinning, hypoechoic areas, and tendon tears, bone irregularity, and calcific deposits.
Neovascularization can also be assessed by color Doppler.
Nonsurgical Measures
Mainstay of treatment for lateral epicondylitis; almost 95% of patients fully recover without surgery by 6 months
Currently no accepted standardized treatment regimen
Very few studies have compared outcomes with and without treatment, so remains unclear whether favorable outcomes should be attributed to the nonsurgical treatment used or to the natural history of the disorder3
Reasonable to initially try rest and avoidance of provocative activities
For tennis players, trials of a larger racket grip size, use of a slower playing surface, more flexible racket, lower string tension, and evaluation of technique may be important components of nonsurgical treatment
Physical therapy: stretching, eccentric muscle strengthening, and joint mobilization
Deep friction massage is often used in physical therapy programs but has not been found to be helpful.3
Other modalities with limited evidence include low-frequency transcutaneous electrical nerve stimulation, ultrasonography, and pulsed magnetic wave therapies.3
Physical therapy regimens may include strengthening exercises of the scapular stabilizers and shoulder muscles, which are necessary for correct elbow function.
Physical therapy may be beneficial in the short term, but most studies show no advantage in the long term.6
NSAIDs are often used for short-term symptomatic relief, but data are limited regarding the efficacy of NSAIDs in the treatment of lateral epicondylitis,6 and there have been no differences found between oral and topical NSAIDs.7
Injections: second-line treatment option
Corticosteroid injections
One of the most widely used treatments for lateral epicondylitis; provide substantial symptomatic relief for several weeks.
At 4 weeks, 92% of patients experience improved or complete pain relief.6
Can be especially useful when short-term improvements are needed—for example, in a professional tennis player in midseason.
Other evidence suggests that corticosteroids should be avoided, as most patients improve without corticosteroids and better long-term results are achieved without them.7
Adverse effects have been reported with long-term use of corticosteroids—patients who receive corticosteroids are better at 6 weeks, but are substantially worse at 1 year.3
Other evidence indicates short-term benefits of corticosteroids are paradoxically reversed after 6 weeks, with
high recurrence of pain at 1 year (72%) compared with only 8% recurrence in those who receive physical therapy alone.6
Having more than three corticosteroid injections is the strongest predictor of surgical treatment failure in the future.3
The worse long-term outcomes with corticosteroid injections have been thought to be related to weakening of the tendon or inducing iatrogenic posterolateral rotatory instability.
Biologic injectables, including autologous blood injections (ABIs) and platelet-rich plasma (PRP) injections, are becoming more commonly used.
ABIs stimulate an inflammatory response, which is thought to bring in nutrients to promote healing.
There have been good short-term results with this modality; however, no benefit has been shown with long-term follow-up.7
Currently, ABI is recommended only for cases in which other nonsurgical modalities have failed.
PRP injections introduce platelets and high concentrations of growth factors that may induce a local healing response in the tendon.
Data are conflicting, but some reliable evidence shows that when compared with dry needling, patients treated with PRP had improved pain scores.6
PRP injections have limited adverse effects, and in both short-term and long-term follow-up they show decreased pain scores.6
May even reduce the need for surgical intervention6
Major concerns with PRP include the significant differences that exist between the available PRP systems, formulations, and techniques, and the expense that is not currently covered by most insurance.
When comparing injectable treatments, studies show a short-term advantage of corticosteroid injections compared with PRP injections, but PRP injections appear to be superior in the long term, with benefits lasting up to 2 years or longer.6
PRP injections have a lower risk of complications compared with corticosteroid injections.
Simply inserting a needle may have therapeutic benefit, and dry needling of the epicondylar area has been shown to have better results than NSAIDs and forearm bracing.
Overall, biologic therapies, including PRP and ABI, have been shown to be more efficacious than steroids in the long-term management of lateral epicondylitis and have minimal side effects.6
Less commonly used nonsurgical treatments
Percutaneous radiofrequency treatments are performed by introducing a radiofrequency electrode percutaneously under ultrasound guidance, which ablates the pathologic tissue.
Good outcomes have been reported with this treatment modality.7
Extracorporeal shock wave therapy (ESWT) is performed by applying a generator of specific frequency sound waves directly onto the skin overlying the ECRB tendon, which is proposed to promote tissue healing, as well as have an analgesic effect.
ESWT has not been shown to be beneficial over other treatments and placebo.6
Low-level laser therapy has shown some short-term benefits when using an adequate dose and wavelength.3,7
Acupuncture has shown good outcomes on short-term follow-up, but long-term results are unclear.7
Botulinum A injections into the extensor muscles have been used as a method to reduce tension on the ECRB origin, which may be beneficial for pain relief.7
The temporary paralysis of the extensors may prevent further microtrauma to the ECRB origin, allowing the pathologic tissue to heal.
Effects seem to be short-lived and may cause incapacitating extensor muscle weakness.
Bracing
Commonly used braces include counterforce braces with a proximal forearm strap and wrist extension splints.
Thought to work by reducing tension in the wrist extensor tendons and the compressive force of the forearm strap limits expansion and force generated by the extensor muscles
There is conflicting evidence on the efficacy of bracing for lateral epicondylitis—although some studies have shown improvements in pain and grip strength.3,6,7
Prolonged use can lead to development of nerve dysfunction.
Risk factors for failure of nonsurgical treatment include older age, obesity, smoking, manual labor, dominant arm involvement, workers’ compensation, concurrent radial tunnel syndrome, multiple prior corticosteroid injection, splinting or orthopaedic surgery, use of psychoactive medications, and poor coping mechanisms.
Surgical Intervention
Not considered before 6 to 12 months of nonsurgical treatment
Should be reserved for a clear diagnosis of isolated lateral epicondylitis.
Often MRI is obtained to ensure no other significant intra-articular pathology.
The three most commonly performed surgical procedures for lateral epicondylitis all involve the release of the ECRB origin, which can be accomplished via open, percutaneous, or arthroscopic methods.
Choice of procedure depends mainly on the comfort level of the surgeon, as there remains controversy regarding the best surgical approach.
No consensus regarding the best surgical technique.
Among newly trained orthopaedic surgeons, 85.8% of procedures for lateral epicondylitis were done with an open technique, 6.4% with a percutaneous approach, and 7.8% arthroscopically.6
Arthroscopic treatment may be preferable when other intra-articular pathologies need to be addressed at the same time, such as plica, synovitis, loose bodies, or evaluation and treatment of cartilage lesions.
Risk factors associated with surgical failure: older age, obesity, smoking, and prior corticosteroid injection.3
Open release and débridement
Performed with an incision over the common extensor origin.
Dissection is carried down to the level of the fascia, which is then incised longitudinally between the lower border of the ECRL and common extensor tendon.
The lower border of the ECRL is elevated superiorly, revealing the deeper ECRB. Typically, the diseased ECRB tendon is grayish and does not have the glistening appearance of the normal white tendon.
The abnormal tendon is excised until more normal tendon boundaries are encountered, typically about 8 × 16 mm in area.
The epicondyle is decorticated and roughened to expose some marrow elements of the bone and stimulate a healing response if a repair is performed.
If the deep capsule is breached, it can be repaired with a simple absorbable stitch.
The ECRB-extensor digitorum communis interval is then repaired side to side and, if a repair to the epicondyle is performed, then an anchor may be used to secure the tendon to bone.
Percutaneous procedure
Performed using topographic landmarks.
A stab incision is made anterior to the lateral epicondyle, at the level of the tendinous origin of the common extensors.
Through this incision, the scalpel is rotated superiorly, releasing the ECRB origin.
Care must be taken to protect the lateral ligament complex.
Arthroscopic release and débridement
Advantages: excellent joint visualization and ability to address any intra-articular pathology (Figure 2).
Through a proximal medial portal, the anterior radiocapitellar joint is visualized and a lateral portal is used to resect the lateral capsule anterior to the epicondyle, with care to protect the anterior capsule where the radial nerve passes.
Through the capsular window, the ECRB tendon is identified and is resected form the epicondylar origin.
Figure 2 Arthroscopic view of a capsular tear via a medial portal in a right elbow. A, Initial view of the lateral capsule with a linear tear. B, Normal extensor carpi radialis brevis (ECRB) tendon following débridement of degenerative deep tissue. C, Final view of the ECRB and extensor carpi radialis longus (ECRL), with a clear distinction marking the proximal extent of débridement. (Reprinted from Calfee RP, Patel A, DaSilva MF, et al: Management of lateral epicondylitis: Current concepts. J Am Acad Orthop Surg 2008;16[1]:19-29.)
Importantly, the resection of the ECRB tendon should not pass posterior to the mid-radial head to protect the LUCL from iatrogenic transection.
The epicondyle may be decorticated with a burr or drilled with a Kirschner wire to help stimulate a healing response at the lateral epicondyle as well.
Postoperative care
The elbow can be wrapped with a soft dressing or a long arm splint for comfort for 7 to 10 days and then elbow range of motion is allowed. Some surgeons also apply a wrist splint to prevent excessive activation of extensor muscles.
Patients are instructed not to lift more than 5 lb or engage in repetitive activities until 6 weeks postoperatively and then they are allowed to begin strengthening and full weight bearing.
Prophylactic preoperative antibiotics are standard if implants such as a suture anchor is placed, and some institutions will not give antibiotics for soft-tissue release surgeries without hardware.
No venous thromboembolism prophylaxis is required unless there is a clotting disorder.
Pain medications include standard multimodal analgesia such as acetaminophen, NSAIDs, gabapentin, and a light-strength narcotic.
Pearls and pitfalls
Iatrogenic injury to the LUCL from ECRB débridement posterior to the mid-radial head and through the LUCL fibers
If the LUCL is débrided, this may lead to posterolateral rotatory instability of the elbow with posterior subluxation of the radial head on the capitellum in supination and valgus stress.8
Radial nerve injury is a rare but serious complication of arthroscopic débridement and is often related to the use of suction during motorized shaver débridement.
Only gravity suction should be used when the shaver blades are turned off.
With arthroscopic treatment, all major nerves are at risk with portal creation and débridement.
Understanding the basics of safe elbow arthroscopy is a must during any elbow arthroscopic procedure.
Missed diagnosis, possibly missed radial nerve entrapment syndrome, which can be seen in up to 5% of patients with lateral epicondylitis
Heterotopic ossification related to excessive tissue injury around the elbow, head trauma in the postoperative period, prolonged elbow immobilization, or remaining bony debris at the surgical field.
Heterotopic bone risk may be reduced with thorough irrigation following bone decortication.
Oral indomethacin for 2 to 3 weeks postoperatively may have some protective effects against development of heterotopic ossification.
The overall complication rate for surgical interventions for lateral epicondylitis is low—with a complication rate of 4.3% for open procedures, 1.9% for percutaneous procedures, and 1.1% for arthroscopic procedures.2
Outcomes of surgical treatment of lateral epicondylitis are positive but not perfect.
Excellent outcomes in 75% were found by Nirschl and Pettrone4 from open débridement. They also found 97% of patients were improved from surgery, and 85% were able to fully resume their preinjury activity.
Although these outcomes are encouraging, a significant proportion of patients report persistent mild intermittent lateral epicondylar symptoms.10
In a long-term prospective study, 24% had persistent pain at 1 year postoperatively, decreasing to 9% at 5 years postoperatively.11
Arthroscopic débridement outcomes are almost equally encouraging but not perfect, with only 62% to 80% of patients experiencing complete elimination of lateral elbow pain.12,13 However, arthroscopic surgery allowed patients a faster return to work at an average of 11 days.Related posts:
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