Lateral Epicondylitis 

  • Author: Bryant James Walrod, MD; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Oct 25, 2011
 

Background

The most common overuse syndrome is related to excessive wrist extension and commonly referred to as “tennis elbow,” but it is actually more common in non-tennis players. It is also commonly referred to as lateral epicondylitis, but this is usually a misnomer because, in general, microscopic evaluation of the tendons does not show signs of inflammation, but rather angiofibroblastic degeneration and collagen disarray. Light microscopy reveals both an excess of fibroblasts and blood vessels that are consistent with neovessels or angiogenesis.[1]

The tendons are relatively hypovascular proximal to the tendon insertion. This hypovascularity may predispose the tendon to hypoxic tendon degeneration and has been implicated in the etiology of tendinopathies.[2] Most typically, the primary pathology is tendinosis of the extensor carpi radialis brevis (ECRB) tendon 1-2 cm distal to its attachment on the lateral epicondyle.[2, 3]

For patient education resources, see the Hand, Wrist, Elbow, and Shoulder Center, as well as Tennis Elbow.

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Epidemiology

Frequency

United States

The annual incidence is 1-3% of the U.S. population. Men and women are equally affected. Typically, lateral epicondylitis affects individuals greater than age 40 years. There is usually a history of repetitive activity aggravating the extensor tendons of the forearm.

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Functional Anatomy

The area of maximal tenderness is usually an area just distal to the origin of the extensor muscles of the forearm at the lateral epicondyle. Most typically the ECRB is involved, but others may include the extensor carpi radialis longus (ECRL), extensor digitorum, and extensor carpi ulnaris.

The radial nerve splits into the superficial radial and posterior interosseus nerve (PIN) at the radiocapitellar joint. The PIN may become entrapped by pericapsular structures, causing radial tunnel syndrome.

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Sport-Specific Biomechanics

Tennis is the most common sport to cause lateral epicondylitis, but the condition can also be seen in those who play squash and badminton. Symptoms can occur after an improper backhand hitting technique, which can occur when the athlete attempts to increase power by increasing forearm force rather than relying on core, rotator cuff, and scapular power. This results in snapping the wrist with supination and irritation of the extensor tendons. Symptoms can also occur when an athlete does not get his or her feet into position and hits the ball late or with a bent elbow. The power of the hit is again generated from the forearm instead of the core.

Other causes of extensor tendinopathy in tennis are using new racquet, using a racquet that is strung too tightly, or using a racquet that is too heavy, as well as hitting wet or heavy balls or hitting into the wind. Another common racquet abnormality that causes lateral elbow extensor tendinosis is having a grip that is too large. Lateral epicondylitis is also seen more commonly in athletes who hit with a 1-handed backhand versus a 2-handed backhand.

Industrial athletes have certain occupational and leisure activities that lead to overuse injuries of the forearm wrist extensors, causing pain at the lateral epicondyle. These include carpenters, bricklayers, seamstresses and tailors, politicians (excessive handshaking), and musicians (eg, pianists, drummers). Such injuries can also be seen in individuals who perform a lot of computer work, a lot of typing, and a lot of mouse work for their occupations.

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Contributor Information and Disclosures
Author

Bryant James Walrod, MD  Clinical Assistant Professor, Department of Family and Preventive Medicine, Medical College of Wisconsin

Disclosure: Nothing to disclose.

Coauthor(s)

Craig C Young, MD  Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Director of Primary Care Sports Medicine Fellowship, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Andrew D Perron, MD  Residency Director, Department of Emergency Medicine, Maine Medical Center

Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD  Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

References

  1. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. Nov 4 2006;333(7575):939. [Medline]. [Full Text].

  2. Altan L, Kanat E. Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices. Clin Rheumatol. Aug 2008;27(8):1015-9. [Medline].

  3. 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].

  4. Lin CL, Lee JS, Su WR, Kuo LC, Tai TW, Jou IM. Clinical and Ultrasonographic Results of Ultrasonographically Guided Percutaneous Radiofrequency Lesioning in the Treatment of Recalcitrant Lateral Epicondylitis. Am J Sports Med. Aug 11 2011;[Medline].

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

  6. Connell DA, Ali KE, Ahmad M, Lambert S, Corbett S, Curtis M. Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiol. Jun 2006;35(6):371-7. [Medline].

  7. Wolf JM, Ozer K, Scott F, Gordon MJ, Williams AE. Comparison of autologous blood, corticosteroid, and saline injection in the treatment of lateral epicondylitis: a prospective, randomized, controlled multicenter study. J Hand Surg Am. Aug 2011;36(8):1269-72. [Medline].

  8. Kazemi M, Azma K, Tavana B, Rezaiee Moghaddam F, Panahi A. Autologous blood versus corticosteroid local injection in the short-term treatment of lateral elbow tendinopathy: a randomized clinical trial of efficacy. Am J Phys Med Rehabil. Aug 2010;89(8):660-7. [Medline].

  9. Thanasas C, Papadimitriou G, Charalambidis C, Paraskevopoulos I, Papanikolaou A. Platelet-Rich Plasma Versus Autologous Whole Blood for the Treatment of Chronic Lateral Elbow Epicondylitis. Am J Sports Med. Aug 2 2011;[Medline].

  10. Altan L, Kanat E. Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices. Clin Rheumatol. Mar 26 2008;epub ahead of print. [Medline].

  11. 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].

  12. Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. Jul 2005;39(7):411-22; discussion 411-22. [Medline].

  13. [Best Evidence] 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].

  14. [Best Evidence] Buchbinder R, Green SE, Youd JM, et al. Shock wave therapy for lateral elbow pain. Cochrane Database Syst Rev. Oct 19 2005;CD003524. [Medline].

  15. Smidt N, Assendelft WJ, Arola H, et al. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Ann Med. 2003;35(1):51-62. [Medline].

  16. Ramsay DJ, Bowman MA, Greenman, PE, et al, for the NIH Consensus Panel. NIH Consensus Conference. Acupuncture. JAMA. Nov 4 1998;280(17):1518-24. [Medline].

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

  18. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. Nov 2006;34(11):1774-8. [Medline].

  19. [Best Evidence] Wong SM, Hui AC, Tong PY, et al. Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. Dec 6 2005;143(11):793-7. [Medline]. [Full Text].

  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. [Best Evidence] Hayton MJ, Santini AJ, Hughes PJ, et al. Botulinum toxin injection in the treatment of tennis elbow. A double-blind, randomized, controlled, pilot study. J Bone Joint Surg Am. Mar 2005;87(3):503-7. [Medline].

  22. Paoloni JA, Appleyard RC, Nelson J, Murrell GA. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med. Nov-Dec 2003;31(6):915-20. [Medline].

  23. Zeisig E, Fahlström M, Ohberg L, Alfredson H. Pain relief after intratendinous injections in patients with tennis elbow: results of a randomised study. Br J Sports Med. Apr 2008;42(4):267-71. [Medline].

  24. Brosseau L, Casimiro L, Milne S, et al. Deep transverse friction massage for treating tendinitis. Cochrane Database Syst Rev. 2002;CD003528. [Medline].

  25. 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].

 
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