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lateral epicondylitis; lateral elbow tendinopathy (tennis elbow)

Pain at the lateral epicondyle of the elbow due to tendonitis/tendinosis of the extensor carpi radialis brevis, extensor digitorum communis &/or the extensor carpi radialis longus. Etiology: 1) repetitive eccentric extensor muscle overload a) lifting objects with wrists in extension b) hitting an object as in tennis placing strain on extensors at wrist 2) in tennis a) improper grip size b) strings too tight c) metal racquet d) practice > 2 hours/day e) improper backhand technique Epidemiology: - beauticians, painters, golfers, tennis players, weight lifters Pathology: 1) tendonitis of the extensor muscles at the lateral humeral epicondyle 2) does not affect elbow joint Clinical manifestations: 1) pain & tenderness over lateral elbow worsened by activities that cause resisted extension of the wrist 2) increased pain with resisted extension at wrist with elbow fully extended 3) diminished grip strength may be present 4) motion loss of 10 degrees compared with unaffected side with chronic cases Laboratory: generally of no value Radiology: indicated in cases of trauma Differential diagnosis: (also see epicondylitis) 1) radial tunnel syndrome a) paresthesia b) positive Tinnel's sign over nerve c) tenderness to palpation 4 cm distal to the lateral epicondyle d) pain with resisted supination with elbow extended e) weakness of full finger extension 2) interosseous nerve entrapment (within supinator muscle) a) tenderness posterior to the lateral epicondyle b) small finger extensor weakness 3) lack of tenderness with paresthesia suggests cervical radiculopathy 4) radial head fracture 5) lateral epicondyle evulsion fracture 6) radiculopathy of C6 nerve root 7) olecranon bursitis Management: (see epicondylitis) 1) NSAIDs (oral & topical) 2) counter force (tennis elbow) brace 3) wrist splint in 20 degree flexion relieves tension on the extensor mass 4) physical therapy provides early benefit that disappears by 1 year [9] 5) stretching & strengthening exercise of the extensor muscles 6) glucocorticoid injection at point of maximum tenderness over the radial epicondyle of the humerus a) provides prompt relief of symptoms [2] b) short-term benefit, but worse-off at 1 year [3,8,9] c) avoid glucocorticoid injection [11] 7) surgical release of extensor tendon is rarely needed 8) extracorporeal shock wave therapy [4,5,6] 9) use of botulinum toxin suggested [7] 10) transcutaneous electrical nerve stimulation (TENS) not useful [10]

Related

epicondylus lateralis humeri (lateral epicondyle of humerus or elbow)

General

epicondylitis repetitive strain disorder; repetitive motion disorder; cumulative trauma disorder; overuse syndrome

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 769-71
  2. Clyman B, in: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 200
  3. Journal Watch 22(8):65, 2002 Smidt et al, Lancet 359:657, 2002
  4. Journal Watch 24(2):16-17, 2004 Gerdesmeyer L, JAMA 290:2573, 2003 PMID: 14625334
  5. Boddeker HM et al, Arch Orthop Trauma Surg, 122:222, 2003 PMID: 12029512
  6. Journal Watch 25(14):115, 2005 Pettrone FA, McCall BR. Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg Am. 2005 Jun;87(6):1297-304. PMID: 15930540
  7. Wong SM et al, Treatment of lateral epicondylitis with botulinum toxin: A randomized, double-bind, placebo-controlled trial. Ann Intern Med 2005; 143:793 PMID: 16330790
  8. Bisset L et al, Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: Randomized trial. BMJ 2006, 333:939 PMID: 17012266 - Smidt N, van der Windt DAVVM Tennis elbow in primary care. BMJ 333:927 PMID: 17082522
  9. Coombes BK et al Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients With Unilateral Lateral Epicondylalgia. A Randomized Controlled Trial. JAMA. 2013;309(5):461-469. PMID: 23385272 http://jama.jamanetwork.com/article.aspx?articleid=1568252
  10. Chesterton LS et al Transcutaneous electrical nerve stimulation as adjunct to primary care management for tennis elbow: pragmatic randomised controlled trial (TATE trial). BMJ 2013;347:f5160 PMID: 23999980 http://www.bmj.com/content/347/bmj.f5160
  11. Medical Knowledge Self Assessment Program (MKSAP) 16, 17. American College of Physicians, Philadelphia 2012, 2015. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  12. Van Hofwegen C, Baker CL 3rd, Baker CL Jr. Epicondylitis in the athlete's elbow. Clin Sports Med. 2010 Oct;29(4):577-97 PMID: 20883898
  13. Ahmad Z, Siddiqui N, Malik SS et al Lateral epicondylitis: a review of pathology and management. Bone Joint J. 2013 Sep;95-B(9):1158-64. Review. PMID: 23997125
  14. NEJM Knowledge+ Question of the Week. Oct 23, 2018 https://knowledgeplus.nejm.org/question-of-week/679/
  15. Smidt N, Lewis M, VAN DER Windt DA, Hay EM, Bouter LM, Croft P. Lateral epicondylitis in general practice: course and prognostic indicators of outcome. J Rheumatol. 2006 Oct;33(10):2053-59. Epub 2006 Aug 1. PMID: 16881095
  16. Garg R, Adamson GJ, Dawson PA, Shankwiler JA, Pink MM. A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis. J Shoulder Elbow Surg. 2010 Jun;19(4):508-12. Epub 2010 Apr 2. PMID: 20363158
  17. Urits I, Markel M, Choi P, et al. Minimally invasive treatment of lateral epicondylitis. Best Pract Res Clin Anaesthesiol. 2020;34:583-602. PMID: 33004169