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Lateral Epicondylitis Surgery

  • Author: Brett D Owens, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Mar 04, 2015
 

Background

Lateral epicondylitis, or tennis elbow, is a commonly encountered problem in orthopedic practice.

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History of the Procedure

The first description of lateral epicondylitis (tennis elbow) generally is attributed to Runge in 1873. Since this initial report, much controversy over the pathophysiology and treatment of this disorder has existed.

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Problem

Lateral epicondylitis (tennis elbow) is an overuse injury involving the extensor muscles that originate on the lateral epicondylar region of the distal humerus. It is more properly termed a tendinosis that specifically involves the origin of the extensor carpi radialis brevis (ECRB).[1, 2, 3, 4] (See the images below.)

Type I lateral epicondylitis seen through the 30° Type I lateral epicondylitis seen through the 30° arthroscope.
Type 2 lateral epicondylitis showing a linear tearType 2 lateral epicondylitis showing a linear tear in the origin of the extensor carpi radialis brevis muscle.
Type 3 lateral epicondylitis showing a large tear Type 3 lateral epicondylitis showing a large tear in the origin of the extensor carpi radialis brevis muscle.
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Epidemiology

Frequency

Lateral epicondylitis (tennis elbow) has been demonstrated to occur in up to 50% of tennis players. However, this condition is not limited to tennis players and has been reported to be the result of overuse from many activities. Lateral epicondylitis is extremely common in today's active society.

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Etiology

Any activity involving wrist extension or supination can be associated with overuse of the muscles originating at the lateral epicondyle. Tennis has been the activity most commonly associated with the disorder. The risk of overuse injury is increased two- to threefold in those who play more than 2 hours weekly and two- to fourfold in players older than 40 years.

Several risk factors have been identified, including improper technique, size of racquet handle, and racquet weight. For work-related lateral epicondylitis, a systematic review identified the following three risk factors((Ref5}:

  • Handling tools heavier than 1 kg
  • Handling loads heavier than 20 kg at least 10 times per day
  • Repetitive movements for more than 2 hours per day

The review also found that low job control and low social support were psychosocial factors associated with lateral epicondylitis.[5]

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Pathophysiology

Many proposed explanations for lateral epicondylitis (tennis elbow) have involved inflammatory processes of the radial humeral bursa, synovium, periosteum, and annular ligament. However, Nirschl and Pettrone defined the basic process as microscopic tearing with formation of reparative tissue (ie, angiofibroblastic hyperplasia) in the origin of the ECRB.[6] This microtearing and repair response can lead to macroscopic tearing and structural failure of the origin of this muscle.

Concomitant intra-articular lesions (eg, loose bodies, synovitis, ulnohumeral osteophytes, chondral lesions) have been visualized during elbow arthroscopy in patients with lateral epicondylitis. However, whereas concomitant intra-articular pathology has been noted, this process is currently considered an extra-articular one.

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Presentation

Patients present complaining of lateral elbow and forearm pain exacerbated by use. The typical patient is a man or woman aged 35-55 years who is either a recreational athlete or one who engages in rigorous daily activities.

Upon examination, the patient has a point of maximal tenderness just distal (5-10 mm) to the lateral epicondyle in the area of the ECRB. Wrist extension or supination (but not flexion or pronation) against resistance with the elbow extended should provoke the patient's symptoms. Another helpful test is the chair raise test, in which the patient stands behind the chair and attempts to raise it by placing the hands on the top of the chair back and lifting. In patients with lateral epicondylitis, this test elicits pain over the lateral elbow.

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Indications

Approximately 90-95% of patients with lateral epicondylitis (tennis elbow) respond to conservative measures and do not require surgical intervention. Patients whose condition is unresponsive to 6 months of conservative therapy (including corticosteroid injections) are candidates for surgical treatment.

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Relevant Anatomy

The ECRB arises from the lateral epicondyle. It lies deep to the extensor carpi radialis longus (ECRL) and superficial to the joint capsule. The annular and collateral ligaments are located beneath and just distal to the origin of the ECRB.[7]

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Contraindications

No absolute contraindications to lateral epicondylitis (tennis elbow) surgery exist. It is advisable to offer surgery only after patients have failed 3-6 months of nonoperative modalities, such as steroid injections, splinting, and occupational therapy. Relative contraindications include any comorbidities that would place the patient at a more serious level of surgical risk.

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Contributor Information and Disclosures
Author

Brett D Owens, MD Professor of Surgery, F Edward Hebert School of Medicine, Uniformed Services University of Health Sciences; Assistant Professor of Orthopedic Surgery, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Chief of Orthopedic Surgery, Keller Army Hospital

Brett D Owens, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Orthopaedic Trauma Association, Society of Military Orthopaedic Surgeons

Disclosure: Received consulting fee from Musculoskeletal Transplant Foundation for consulting; Received consulting fee from Johnson & Johnson (MITEK) for consulting; Received royalty from SLACK Publishing for other; Received salary from American Journal of Sports Medicine for employment.

Coauthor(s)

Jennifer Moriatis Wolf, MD Associate Professor, Department of Orthopedic Surgery, University of Connecticut Health Center

Jennifer Moriatis Wolf, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Thomas R Hunt III, MD Professor and Chairman, Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine

Thomas R Hunt III, MD is a member of the following medical societies: American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Southern Orthopaedic Association, AO Foundation, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Mid-America Orthopaedic Association

Disclosure: Received royalty from Tornier for independent contractor; Received ownership interest from Tornier for none; Received royalty from Lippincott for independent contractor.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Mark D Lazarus, MD Associate Professor of Orthopedic Surgery, Medical College of Pennsylvania-Hahnemann University, Chief of Shoulder and Elbow Service, Department of Orthopedic Surgery, Hahnemann University Hospital

Disclosure: Nothing to disclose.

Acknowledgements

Timothy R Kuklo, MD, JD Associate Professor, Department of Surgery, Uniformed Services University of the Health Sciences

Disclosure: Nothing to disclose.

Kevin P Murphy, MD Assistant Professor of Surgery, Uniformed Services University of the Health Sciences; Director, Sports Medicine, Department of Orthopedic Surgery and Rehabilitation, Walter Reed Army Medical Center

Kevin P Murphy, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

References
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Type I lateral epicondylitis seen through the 30° arthroscope.
Type 2 lateral epicondylitis showing a linear tear in the origin of the extensor carpi radialis brevis muscle.
Type 3 lateral epicondylitis showing a large tear in the origin of the extensor carpi radialis brevis muscle.
Representation of the relationships in arthroscopic release for lateral epicondylitis
Lateral epicondylitis. Incision for open debridement of lateral epicondyle. Lateral epicondyle is circled.
Revision debridement for lateral epicondylitis. The fascia covering the origin of the extensor carpi radialis brevis muscle and the extensor carpi radialis longus muscle is fibrotic.
Origin of extensor carpi radialis brevis exposed.
Lateral epicondylitis. Osteotome positioned over lateral epicondyle.
 
 
 
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