eMedicine Specialties > Orthopedic Surgery > Elbow

Lateral Epicondylitis

Brett D Owens, MD, Chief, Sports Medicine and Shoulder Service, William Beaumont Army Medical Center
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

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° 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.

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.

Workup

Imaging Studies

Radiographs can be helpful in ruling out other disorders or concomitant intra-articular pathology (eg, osteochondral loose body, posterior osteophytes). Calcification in the degenerative tissue of the extensor carpi radialis brevis (ECRB) muscle origin can be seen in chronic cases.⁸
Magnetic resonance imaging can help confirm the presence of degenerative tissue in the ECRB muscle origin and can help diagnose concomitant pathology. A guideline from the American College of Radiology (ACR) recommends MRI as the most appropriate imaging study for patients with suspected chronic epicondylitis when radiographs are nondiagnostic.⁹ The ACR considers ultrasonography of the elbow a reasonable alternative to MRI if expertise is available. However, these imaging studies are very rarely needed.,

Other Tests

If the clinical examination indicates a possible neural etiology for the patient's symptoms, electromyography can be helpful in excluding posterior interosseous nerve compression syndrome as the diagnosis.

Diagnostic Procedures

Anesthetic injections into the origin of the extensor carpi radialis brevis (ECRB) muscle can help confirm the diagnosis, as the patient should experience relief from symptoms.

Histologic Findings

Despite the misnomer of lateral epicondylitis (tennis elbow), the histology of lesions shows neither acute nor chronic inflammatory cell infiltrate. Lesions are characterized by fibroblastic invasion with neovascularization. One study noted mesenchymal cell proliferation indicative of a healing process. However, most other studies indicate degenerative changes.¹⁰

Staging

Nirschl defined the following progressive stages:

Stage 1 - Inflammatory changes that are reversible
Stage 2 - Nonreversible pathologic changes to origin of the extensor carpi radialis brevis (ECRB) muscle
Stage 3 - Rupture of ECRB muscle origin
Stage 4 - Secondary changes such as fibrosis or calcification

Treatment

Medical Therapy

Nonsurgical treatment is the mainstay of care for patients with lateral epicondylitis (tennis elbow). The goal of initial treatment is cessation of the offending activity. Rest, use of a counterforce brace, and nonsteroidal anti-inflammatory drugs (NSAIDs) often provide relief of symptoms. Often, wrist splinting is necessary.^11,12,13,14

Jafarian et al compared 3 common types of orthoses for their effect on grip strength in patients with lateral epicondylosis. In a randomized, controlled study of 52 patients, maximum and pain-free grip strength were assessed with the patient wearing an elbow strap orthosis, an elbow sleeve orthosis, a wrist splint, or a placebo orthosis. Use of the elbow strap and sleeve orthoses resulted in an immediate and equivalent increase in pain-free grip strength; consequently, the researchers suggest that either of these types of orthosis may be used. The wrist splint provided no immediate improvement in either pain-free or maximum grip strength.¹⁵

Both corticosteroid and autologous blood injections have been shown to be effective. Corticosteroid injections at the lateral epicondyle have been shown to significantly decrease pain scores in the early post-injection period. Autologous blood injections for lateral epicondylitis were described in 2003 and showed encouraging pain relief in two thirds of patients treated.¹⁶

Low-level laser therapy appears to provide short-term pain relief and improvement in disability, even in cases resistant to other nonsurgical therapy. A systematic review noted, however, that success with laser therapy has been limited to studies that used direct irradiation of the tendon insertion and wavelengths of 904 nm (and possibly 632 nm), for a total dose of 0.5 to 7.2 joules.¹⁷

When the patient is free of pain through a full range of motion, begin strengthening therapy in a very slow and progressive way. When the patient regains strength and nears resumption of activity, place the emphasis on preventing future irritation (eg, correct technique or address equipment concerns in athletes who participate in racquet sports, modify jobs or activities in patients who are not athletes).

The use of extracorporeal shockwave therapy raised initial excitement. However, 2 prospective, randomized, blinded trials showed no benefit of this intervention over placebo.^18,19

Another proposed modality is injection of botulinum toxin at the extensor origin. A large multicenter, randomized, controlled trial in Germany showed a significant decrease in pain scores in patients with lateral epicondylitis treated with botulinum toxin when compared to control patients treated with saline.²⁰ Most patients experienced finger extension weakness, which resolved within 4 months.

Surgical Therapy

A myriad of surgical procedures has been described for the treatment of lateral epicondylitis (tennis elbow). However, most surgical procedures involve debridement of the diseased tissue of the extensor carpi radialis brevis (ECRB) muscle with decortication of the lateral epicondyle. This procedure has been performed through open, percutaneous, and arthroscopic approaches. While the classic open approach provides excellent reproducible results, the mentioned minimally invasive approaches are reported to allow earlier rehabilitation and resumption of activities.^21,22

Preoperative Details

Note the length of time of the patient's symptoms. Also note the conservative therapeutic course that has been implemented, including any corticosteroid injections. Consider the patient's workers' compensation status, as patients with workers' compensation claims may not respond as well to intervention.²³

A full evaluation should be performed on patients with lateral epicondylitis (tennis elbow) so that any other associated conditions can be detected. Some authors have noted a relatively high incidence of concomitant intra-articular pathology. For example, one study of 117 consecutive elbow arthroscopies in patients with lateral elbow pain resistant to conservative treatment found established degenerative changes involving articular cartilage, principally of the lateral compartment, in a substantial percentage of these patients.²⁴

Intraoperative Details

In the classic open-release procedure for lateral epicondylitis (tennis elbow) as described by Nirschl, the patient is positioned supine.⁶ A 3-cm longitudinal incision is made over the lateral epicondyle. An incision is made through the extensor aponeurosis. The extensor carpi radialis brevis (ECRL) muscle is retracted medially, revealing the degenerative origin of the ECRB. All pathologic tissue is excised. The lateral epicondyle is decorticated with an osteotome or by drill holes. The ECRL is sewn to the extensor aponeurosis in an attempt to repair the defect. (See Images 5-8.)

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.

The extensor origin exposed

Lateral epicondylitis. Osteotome positioned over lateral epicondyle.

With elbow arthroscopy, the lateral capsule and undersurface of the ECRB tendon are easily visualized and evaluated through the proximal medial portal. Advancing the 30° arthroscope past the radial head brings the camera directly in front of the ECRB tendon, which can then be followed to its origin on the lateral epicondyle. Associated synovitis may be noted at this location. The capsule is adherent to the undersurface of the ECRB tendon. Often, the capsule is torn with the ECRB tendon or is thin and translucent. A 4.5-mm synovial resector then is introduced through the proximal lateral portal. If the capsule is present, it is debrided to reveal the undersurface of the ECRB muscle.

The release of the ECRB tendon is begun at the site of pathology and is continued back to its origin on the lateral epicondyle. After release of the visible ECRB origin, a 4.5-mm round burr is used to decorticate the lateral epicondyle and distal portion of the lateral condylar ridge in the area of the ECRB muscle origin. A cadaveric study showed that this release removed an average of 23 mm of ECRB tendon and 22 mm of lateral epicondyle.²⁵ While more aggressive resection may be possible with the 70° arthroscope, this potentially can injure the lateral collateral ligament complex. Resection to the limit of the visualization provided by the 30° arthroscope produces adequate release while protecting the lateral collateral ligaments. (See Images 1-4.)

Postoperative Details

Surgical treatment of lateral epicondylitis (tennis elbow) is an outpatient surgical procedure. If the open approach is used, the elbow is usually protected initially with a splint or brace at 90°.

Follow-up

Early motion in a brace may be initiated at 3-5 days after surgical treatment of lateral epicondylitis (tennis elbow), with strengthening exercises usually started by 3 weeks, depending on the patient's symptoms. Return to racquet sports can be expected by 4-6 months. Depending on the specific job requirements, patients can return to work in 6-12 weeks, although job modification or persistent use of a counterforce brace during work activities may be necessary.^26,27,28

Patient Education: For excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center. Also, see eMedicine's patient education article Tennis Elbow.

Complications

One of the most concerning complications of aggressive surgical debridement for lateral epicondylitis (tennis elbow) is lateral elbow instability. The proximity of the lateral collateral ligaments and the annular ligament makes them susceptible to injury. In addition, when the arthroscopic technique is used, the radial nerve is at risk.

Other complications include recurrence or incomplete relief of pain.

Outcome and Prognosis

Surgical treatment of lateral epicondylitis (tennis elbow) has yielded predictably favorable results, with approximately 85% of patients reporting complete pain relief. Some patients may have persistent symptoms despite surgical treatment, and these patients may benefit from a more aggressive debridement.

Future and Controversies

While much of the controversy regarding the pathology of lateral epicondylitis (tennis elbow) has been discussed, the surgical treatment options described have all yielded excellent results. While some less invasive approaches have been proposed and have shown excellent results,²⁹ large prospective studies have not been performed to provide conclusive evidence of significant benefit of a particular procedure over another.

Multimedia

Media file 1: Type I lateral epicondylitis seen through the 30° arthroscope.

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

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

Media file 4: Representation of the relationships in arthroscopic release for lateral epicondylitis

Media file 5: Lateral epicondylitis. Incision for open debridement of lateral epicondyle. Lateral epicondyle is circled.

Media file 6: 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.

Media file 7: The extensor origin exposed

Media file 8: Lateral epicondylitis. Osteotome positioned over lateral epicondyle.

References

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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

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.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of Dr. Timothy Kuklo to the development and writing of this article.

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