eMedicine Specialties > Orthopedic Surgery > Elbow

Lateral Epicondylitis

Author: Brett D Owens, MD, Chief, Sports Medicine and Shoulder Service, William Beaumont Army Medical Center
Coauthor(s): Jennifer Moriatis Wolf, MD, Assistant Professor, Department of Orthopedics, University of Colorado Health Sciences Center; Director, Musculoskeletal Block, Director, Orthopedic Medical Student Courses/Sub-Internships, University of Colorado School of Medicine; 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
Contributor Information and Disclosures

Updated: Nov 3, 2009

Introduction

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

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.

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 muscle.1,2,3,4

Type I lateral epicondylitis seen through the 30&...

Type I lateral epicondylitis seen through the 30° arthroscope.

[ CLOSE WINDOW ]
Type I lateral epicondylitis seen through the 30&...

Type I lateral epicondylitis seen through the 30° arthroscope.



Type 2 lateral epicondylitis showing a linear tea...

Type 2 lateral epicondylitis showing a linear tear in the origin of the extensor carpi radialis brevis muscle.

[ CLOSE WINDOW ]
Type 2 lateral epicondylitis showing a linear tea...

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...

Type 3 lateral epicondylitis showing a large tear in the origin of the extensor carpi radialis brevis muscle.

[ CLOSE WINDOW ]
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.



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.

Etiology

Any activity involving wrist extension and/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 2-3 times in players with more than 2 hours of play per week and 2-4 times 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 3 risk factors: handling tools heavier than 1 kg, handling loads heavier than 20 kg at least 10 times per day, and repetitive movements  for more than 2 hours per day.5 The review also found that low job control and low social support were psychosocial factors associated with lateral epicondylitis.

Pathophysiology

Many proposed etiologies for lateral epicondylitis (tennis elbow) have involved inflammatory processes of the radial humeral bursa, synovium, periosteum, and the annular ligament. However, Nirschl and Pettrone attributed the cause to microscopic tearing with formation of reparative tissue (ie, angiofibroblastic hyperplasia) in the origin of the extensor carpi radialis brevis (ECRB) muscle.6 This microtearing and repair response can lead to macroscopic tearing and structural failure of the origin of the ECRB 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, while concomitant intra-articular pathology has been noted, this process is currently considered an extra-articular process.

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 either is 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 extensor carpi radialis brevis (ECRB) muscle. 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. The patient stands behind their chair and attempts to raise it by putting their hands on the top of the chair back and lifting. In patients with lateral epicondylitis, pain results over the lateral elbow.

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 surgery.

Relevant Anatomy

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

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.

More on Lateral Epicondylitis

Overview: Lateral Epicondylitis
Workup: Lateral Epicondylitis
Treatment: Lateral Epicondylitis
Follow-up: Lateral Epicondylitis
Multimedia: Lateral Epicondylitis
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Cyriax JH. The pathology and treatment of tennis elbow. J Bone Joint Surg. 1936;18:921-40.

  2. Nirschl RP. Tennis injuries. In: The Upper Extremity in Sports Medicine. 1995:789-803.

  3. Faro F, Wolf JM. Lateral epicondylitis: review and current concepts. J Hand Surg [Am]. Oct 2007;32(8):1271-9. [Medline].

  4. De Smedt T, de Jong A, Van Leemput W, Lieven D, Van Glabbeek F. Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment. Br J Sports Med. Nov 2007;41(11):816-9. [Medline].

  5. van Rijn RM, Huisstede BM, Koes BW, Burdorf A. Associations between work-related factors and specific disorders at the elbow: a systematic literature review. Rheumatology (Oxford). May 2009;48(5):528-36. [Medline].

  6. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. Sep 1979;61(6A):832-9. [Medline].

  7. Bunata RE, Brown DS, Capelo R. Anatomic factors related to the cause of tennis elbow. J Bone Joint Surg Am. Sep 2007;89(9):1955-63. [Medline].

  8. Levin D, Nazarian LN, Miller TT, O'Kane PL, Feld RI, Parker L, et al. Lateral epicondylitis of the elbow: US findings. Radiology. Oct 2005;237(1):230-4. [Medline].

  9. American College of Radiology. ACR Appropriateness Criteria® chronic elbow pain. National Guideline Clearinghouse. Available at http://www.guideline.gov/summary/summary.aspx?doc_id=8273&nbr=004605. Accessed May 15, 2009.

  10. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. Feb 1999;81(2):259-78. [Medline].

  11. Bowen RE, Dorey FJ, Shapiro MS. Efficacy of nonoperative treatment for lateral epicondylitis. Am J Orthop. Aug 2001;30(8):642-6. [Medline].

  12. Ciccotti MG, Charlton WP. Epicondylitis in the athlete. Clin Sports Med. Jan 2001;20(1):77-93. [Medline].

  13. Borkholder CD, Hill VA, Fess EE. The efficacy of splinting for lateral epicondylitis: a systematic review. J Hand Ther. Apr-Jun 2004;17(2):181-99. [Medline].

  14. Trudel D, Duley J, Zastrow I. Rehabilitation for patients with lateral epicondylitis: a systematic review. J Hand Ther. Apr-Jun 2004;17(2):243-66. [Medline].

  15. Jafarian FS, Demneh ES, Tyson SF. The immediate effect of orthotic management on grip strength of patients with lateral epicondylosis. J Orthop Sports Phys Ther. Jun 2009;39(6):484-9. [Medline].

  16. Edwards SG, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg [Am]. Mar 2003;28(2):272-8. [Medline].

  17. Bjordal JM, Lopes-Martins RA, Joensen J, Couppe C, Ljunggren AE, Stergioulas A, et al. A systematic review with procedural assessments and meta-analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskelet Disord. May 29 2008;9:75. [Medline]. [Full Text].

  18. Haake M, König IR, Decker T, Riedel C, Buch M, Müller HH. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis: a randomized multicenter trial. J Bone Joint Surg Am. Nov 2002;84-A(11):1982-91. [Medline].

  19. [Best Evidence] Staples MP, Forbes A, Ptasznik R, Gordon J, Buchbinder R. A randomized controlled trial of extracorporeal shock wave therapy for lateral epicondylitis (tennis elbow). J Rheumatol. Oct 2008;35(10):2038-46. [Medline].

  20. [Best Evidence] Placzek R, Drescher W, Deuretzbacher G, Hempfing A, Meiss AL. Treatment of chronic radial epicondylitis with botulinum toxin A. A double-blind, placebo-controlled, randomized multicenter study. J Bone Joint Surg Am. Feb 2007;89(2):255-60. [Medline].

  21. Baker CL Jr, Murphy KP, Gottlob CA. Arthroscopic classification and treatment of lateral epicondylitis: two- year clinical results. J Shoulder Elbow Surg. Nov-Dec 2000;9(6):475-82. [Medline].

  22. Owens BD, Murphy KP, Kuklo TR. Arthroscopic release for lateral epicondylitis. Arthroscopy. Jul 2001;17(6):582-7. [Medline].

  23. Grewal R, MacDermid JC, Shah P, King GJ. Functional outcome of arthroscopic extensor carpi radialis brevis tendon release in chronic lateral epicondylitis. J Hand Surg [Am]. May-Jun 2009;34(5):849-57. [Medline].

  24. Rajeev A, Pooley J. Lateral compartment cartilage changes and lateral elbow pain. Acta Orthop Belg. Feb 2009;75(1):37-40. [Medline].

  25. Kuklo TR, Taylor KF, Murphy KP. Arthroscopic release for lateral epicondylitis: a cadaveric model. Arthroscopy. Apr 1999;15(3):259-64. [Medline].

  26. Baker CL Jr, Baker CL 3rd. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med. Feb 2008;36(2):254-60. [Medline].

  27. Dunn JH, Kim JJ, Davis L, Nirschl RP. Ten- to 14-year follow-up of the Nirschl surgical technique for lateral epicondylitis. Am J Sports Med. Feb 2008;36(2):261-6. [Medline].

  28. Zeisig EC, Fahlström M, Ohberg L, Alfredson H. A 2-year sonographic follow-up after intratendinous injection therapy in patients with tennis elbow. Br J Sports Med. Jul 29 2008;[Medline].

  29. Meknas K, Odden-Miland A, Mercer JB, Castillejo M, Johansen O. Radiofrequency microtenotomy: a promising method for treatment of recalcitrant lateral epicondylitis. Am J Sports Med. Jun 16 2008;[Medline].

[ CLOSE WINDOW ]

Further Reading

Related eMedicine topics

 Elbow and Forearm Overuse Injuries

Medial Epicondylitis

Tendonitis

Clinical guidelines

Chronic elbow pain .
American College of Radiology.  1998 (revised 2005).  5 pages.  NGC:004605
 
Elbow (acute & chronic).
Work Loss Data Institute.  2003 (revised 2007 Jun 11).  158 pages. [NGC Update Pending] NGC:005797
 
Elbow disorders.
American College of Occupational and Environmental Medicine.  1997 (revised 2007).  67 pages.  NGC:005681

Clinical studies

Prolotherapy for the Treatment of Chronic Lateral Epicondylitis

Botulinum Toxin Versus Active Strength Training in the Treatment of Lateral Epicondylitis

[ CLOSE WINDOW ]

Keywords

lateral epicondylitis, tennis elbow, lateral epicondylosis, lateral epicondyle injury, epicondyle injury, elbow pain, elbow trauma, chronic elbow pain, forearm pain, elbow injury, forearm injury

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Brett D Owens, MD, Chief, Sports Medicine and Shoulder Service, William Beaumont Army Medical Center
Brett D Owens, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Society of Military Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Jennifer Moriatis Wolf, MD, Assistant Professor, Department of Orthopedics, University of Colorado Health Sciences Center; Director, Musculoskeletal Block, Director, Orthopedic Medical Student Courses/Sub-Internships, University of Colorado School of Medicine
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, and Phi Beta Kappa
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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Thomas R Hunt III, MD, John D Sherrill Professor and Director of Orthopaedic Surgery, Surgeon in Chief of UAB Highlands Hospital, Director of Hand and Upper Extremity Fellowship, University of Alabama at Birmingham
Thomas R Hunt III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, American Society for Surgery of the Hand, AO Foundation, Mid-America Orthopaedic Association, and Southern Orthopaedic Association
Disclosure: Tornier Consulting fee Review panel membership; Tornier Royalty None; Tornier Ownership interest None

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

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 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, and Arkansas Medical Society
Disclosure: Nothing to disclose.

RELATED MEDSCAPE ARTICLES
Articles
 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.