Open and Arthroscopic Treatment of Lateral Epicondylitis

Abhishek Julka

Peter J. Evans

ANATOMY

The common extensor origin is located on the lateral epicondyle.
The common extensor origin includes the extensor carpi radialis brevis (ECRB), extensor digitorum communis (EDC), extensor digiti minimi, and extensor carpi ulnaris.
The ECRB is the primary muscle-tendon unit affected, followed by the EDC with the tendons becoming confluent at their origin.¹³

PATHOGENESIS

Epicondylitis results from repetitive microtrauma, followed by an incomplete reparative response, resulting in chronic tendinosis.¹³
Functionally, this condition can more correctly be described as “gripper’s elbow,” as synergistic wrist extension increases finger flexion strength. Patients afflicted with lateral epicondylar tendinopathy commonly engage in repetitive forceful gripping activities as they lift, pull, twist, and push objects.
Recently, concurrent radiocapitellar cartilage lesions have been noted in a high prevalence on arthroscopic examination.¹⁴

NATURAL HISTORY

Lateral epicondylitis is a self-limiting condition that resolves in over 80% of patients over the course of 1 year.⁴
Most patients receiving active treatment (ie, anti-inflammatory medication, orthotics, ultrasound, physical or occupational therapy, injections) improve with nonoperative treatment.
Typically, fewer than 10% of patients require surgical intervention.

PATIENT HISTORY AND PHYSICAL FINDINGS

Acute phase: Lateral elbow pain or ache occurs with activities that typically resolves with rest, ice, or anti-inflammatory medication.
Intermediate phase: Lateral elbow pain or ache occurs with activity and at rest and may not resolve without prolonged activity restriction.
Chronic phase: Pain or ache occurs with sleep and is unresponsive to rest, medication, and injections.¹³
Examination methods include the following:
- Palpation of the lateral epicondyle for tenderness, a universal finding in lateral epicondylitis
- Pain either at the epicondyle or radiating distally along the ECRB is a positive finding in any of these circumstances:
  - Passive stretch test: With the elbow in full extension, the wrist is flexed, and the forearm is pronated.
  - Mill test: With the elbow flexed, the forearm slightly pronated, and the wrist slightly dorsiflexed, the patient actively supinates against the examiner, who resists this rotation.
  - Thompson test: With the elbow extended, the wrist in slight dorsiflexion, and making a fist, the patient dorsiflexes against the examiner, who resists this motion.

IMAGING AND OTHER DIAGNOSTIC STUDIES

DIFFERENTIAL DIAGNOSIS

NONOPERATIVE MANAGEMENT

Appropriate initial treatment includes avoidance of painful activities and symptomatic relief with ice and nonsteroidal anti-inflammatory drugs (NSAIDs).
Daytime strapping is biomechanically and clinically effective.
Nighttime wrist bracing to prevent palmar wrist flexion and prolonged tension on the extensor tendons
Physical or occupational therapy to supervise and instruct on stretching and strengthening protocol for patients not otherwise inclined to perform these exercises
Corticosteroid injection have repeatedly not outperformed placebo injections in the literature and have even shown inferior results. They may be used sparingly once other nonoperative measures are exhausted.²,³,⁵
Platelet-rich plasma injections showed some promising early results¹,¹¹ but have not held up to more critical scrutiny.⁸

SURGICAL MANAGEMENT

A minority of patients fail nonoperative management.
Careful patient selection is critical to ensure an excellent outcome following surgical management.
No prospective randomized studies have yet been done to examine the advantages of open versus arthroscopic techniques for the treatment of lateral epicondylitis. However, the authors choose arthroscopic treatment if there are any signs of a plica or synovial irritation (end point pain) as it allows for direct examination and treatment of these additional pathologies.
Two relatively new methods of percutaneous tenotomy are available and undergoing evaluation: Tenex Microtenotomy (Tenex Health Inc., Lake Forest, CA) and Topaz MicroDebrider (ArthroCare, Austin, TX). Both are percutaneous methods that allow for a minimally invasive approach to replicate outcomes of open and arthroscopic methods.
The Topaz MicroDebrider provides a preset amount of energy to débride and stimulate neovascularization as its mechanism of action, whereas the Tenex Microtenotomy has a proposed advantage of removal of pathologic tissue as well via a phacoemulsification mechanism of action.
Studies examining results from percutaneous tenotomy have been optimistic in the short term,⁷,¹⁰ but comparative studies of percutaneous methods have yet to be published.