Introduction
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 excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center. Also, see eMedicine's patient education article Tennis Elbow.
Related eMedicine topics:
Elbow and Forearm Overuse Injuries
Overuse Injury
Tendonitis
Related Medscape topics:
Resource Center Exercise and Sports Medicine
CME/CE Physical Therapy Modalities Helpful for the Family Clinician to Know
CME Tendinopathy -- From Basic Science to Treatment
CME Tendon Problems a Possible Adverse Effect of Statin Therapy
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.
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.
Related eMedicine topics:
Hand, Nerve Compression Syndromes: Upper Extremity
Nerve Entrapment Syndromes
Radial Nerve Entrapment
Related Medscape topics:
Specialty Site Neurology & Neurosurgery
Specialty Site Orthopaedics
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 a 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.
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.
Clinical
History
- The typical age of those affected is 40 to 50 years.
- Patients most typically report an insidious onset, but they will often relate a history of overuse without specific trauma.
- Symptom onset generally occurs 24-72 hours after repeated wrist extension activity.
- Delayed symptoms are probably due to microscopic tears in the tendon.
- The patient complains of pain over the lateral elbow that worsens with activity and improves with rest. The patient will also often describe aggravating conditions such as a backhand stroke in tennis or the overuse of a screwdriver.
- Pain may radiate down the posterior aspect of the forearm.
- The patient can often pinpoint pain 1.5 cm distal to the origin of the ECRB.
- Pain can vary from being mild (eg, with aggravating activities like tennis or the repeated use of a hand tool), or it can be such severe pain that simple activities like picking up and holding a coffee cup (ie, "coffee cup sign") will act as a trigger for the pain.
Physical
- Inspection: Very rarely does one notice swelling or ecchymosis.
- Palpation: Maximal tenderness is elicited 1-2 cm distal to the origin of the ECRB at the lateral epicondyle.
- Pain is increased with resisted wrist extension, with the wrist radially deviated and pronated.
- Resisted extension of the middle finger is also painful secondary to stress placed on the ECRB tendon, as it is preferentially stressed in this position when it must contract synergistically to anchor the third metacarpal, such that extension can take place at the digits.4
- Increased pain is noted with resisted supination and hand shaking.
- Always examine ROM of the shoulder, elbow, and wrist on the affected side.
- Examine ROM and test for crepitus at the radiohumeral joint of the affected limb to evaluate for radiohumeral bursitis, osteochondritis of the capitellum, or PIN entrapment.
- If decreased ROM if noted on physical examination, consider obtaining an x-ray to further evaluate the joint.
Related eMedicine topics:
Bursitis
Humeral Capitellum Osteochondritis Dissecans
Related Medscape topics:
Resource Center Joint Disorders
Resource Center Pain Management: Pharmacologic Approaches
Causes
- Poor general conditioning leads to fatigue of the core and shoulder muscles, which puts an overemphasis on the extensor muscles of the forearm.
- Improper training (eg, poor positioning when striking a tennis ball)
- Improper technique (eg, hitting a tennis ball late on the backhand)
- Poor or improper equipment (eg, a grip that is too big or a racquet that is strung too tightly)
More on Lateral Epicondylitis |
 Overview: Lateral Epicondylitis |
| Differential Diagnoses & Workup: Lateral Epicondylitis |
| Treatment & Medication: Lateral Epicondylitis |
| Follow-up: Lateral Epicondylitis |
| References |
| Next Page » |
References
Alfredson H, Ohberg L, Forsgren S. Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections. Knee Surg Sports Traumatol Arthrosc. Sep 2003;11(5):334-8. [Medline].
Wilson JJ, Best TM. Common overuse tendon problems: a review and recommendations for treatment. Am Fam Physician. Sep 1 2005;72(5):811-8. [Medline]. [Full Text].
Calfee RP, Patel A, DaSilva MF, Akelman E. Management of lateral epicondylitis: current concepts. J Am Acad Orthop Surg. Jan 2008;16(1):19-29. [Medline].
Bell S. Elbow and arm pain. In: Brukner P, Kahn K, eds. Clinical Sports Medicine. 3rd ed. New South Wales, Australia: McGraw-Hill; 2006:293.
Smidt N, van der Windt DA, Assendelft WJ, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. Feb 23 2002;359(9307):657-62. [Medline].
Green S, Buchbinder R, Barnsley L, et al. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Cochrane Database Syst Rev. 2002;CD003686. [Medline].
Assendelft W, Green S, Buchbinder R, Struijs P, Smidt N. Tennis elbow. Clin Evid. Jun 2004;1633-44. [Medline].
Struijs PA, Smidt N, Arola H, et al. Orthotic devices for the treatment of tennis elbow. Cochrane Database Syst Rev. 2002;CD001821. [Medline].
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].
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].
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].
Buchbinder R, Green SE, Youd JM, et al. Shock wave therapy for lateral elbow pain. Cochrane Database Syst Rev. Oct 19 2005;CD003524. [Medline].
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].
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].
Edwards SG, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg [Am]. Mar 2003;28(2):272-8. [Medline].
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].
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].
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].
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].
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].
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].
Brosseau L, Casimiro L, Milne S, et al. Deep transverse friction massage for treating tendinitis. Cochrane Database Syst Rev. 2002;CD003528. [Medline].
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].
Further Reading
Keywords
tennis elbow, lateral elbow stress syndrome, wrist extensor tendonitis, lateral elbow overuse syndrome, elbow and forearm overuse injuries, coffee cup sign, coffee-cup sign
