History

Patients with lateral epicondylitis present with complaints of lateral elbow and forearm pain exacerbated by use. The typical patient is a man or woman in the age range of 35-55 years who either is a recreational athlete or engages in rigorous daily activities.

Physical Examination

Upon examination, the patient has a point of maximal tenderness just (5-10 mm) distal 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.

Differential Diagnoses

Riolo T, Levchenko A. Lateral epicondylitis. Kahn SB, Xu RY, eds. Musculoskeletal Sports and Spine Disorders: A Comprehensive Guide. Cham, Switzerland: Springer; 2017. Chap 18.
Faro F, Wolf JM. Lateral epicondylitis: review and current concepts. J Hand Surg Am. 2007 Oct. 32 (8):1271-9. [QxMD MEDLINE Link].
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. 2007 Nov. 41 (11):816-9. [QxMD MEDLINE Link]. [Full Text].
Bunata RE, Brown DS, Capelo R. Anatomic factors related to the cause of tennis elbow. J Bone Joint Surg Am. 2007 Sep. 89 (9):1955-63. [QxMD MEDLINE Link].
Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979 Sep. 61 (6A):832-9. [QxMD MEDLINE Link].
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). 2009 May. 48 (5):528-36. [QxMD MEDLINE Link].
Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002 Feb 23. 359 (9307):657-62. [QxMD MEDLINE Link]. [Full Text].
Degen RM, Cancienne JM, Camp CL, Altchek DW, Dines JS, Werner BC. Three or more preoperative injections is the most significant risk factor for revision surgery after operative treatment of lateral epicondylitis: an analysis of 3863 patients. J Shoulder Elbow Surg. 2017 Apr. 26 (4):704-709. [QxMD MEDLINE Link].
Levin D, Nazarian LN, Miller TT, O'Kane PL, Feld RI, Parker L, et al. Lateral epicondylitis of the elbow: US findings. Radiology. 2005 Oct. 237 (1):230-4. [QxMD MEDLINE Link].
[Guideline] ACR Appropriateness Criteria® chronic elbow pain. American College of Radiology. Available at https://acsearch.acr.org/docs/69423/Narrative. 2022; Accessed: April 10, 2023.
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. 1999 Feb. 81 (2):259-78. [QxMD MEDLINE Link].
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. 2008 Oct. 36 (10):1960-5. [QxMD MEDLINE Link].
Bowen RE, Dorey FJ, Shapiro MS. Efficacy of nonoperative treatment for lateral epicondylitis. Am J Orthop (Belle Mead NJ). 2001 Aug. 30 (8):642-6. [QxMD MEDLINE Link].
Ciccotti MG, Charlton WP. Epicondylitis in the athlete. Clin Sports Med. 2001 Jan. 20 (1):77-93. [QxMD MEDLINE Link].
Borkholder CD, Hill VA, Fess EE. The efficacy of splinting for lateral epicondylitis: a systematic review. J Hand Ther. 2004 Apr-Jun. 17 (2):181-99. [QxMD MEDLINE Link].
Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC. Rehabilitation for patients with lateral epicondylitis: a systematic review. J Hand Ther. 2004 Apr-Jun. 17 (2):243-66. [QxMD MEDLINE Link].
Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002 Feb 23. 359 (9307):657-62. [QxMD MEDLINE Link].
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. 2009 Jun. 39 (6):484-9. [QxMD MEDLINE Link].
Edwards SG, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg Am. 2003 Mar. 28 (2):272-8. [QxMD MEDLINE Link].
Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2011 Jun. 39 (6):1200-8. [QxMD MEDLINE Link].
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: a randomized controlled clinical trial. Am J Sports Med. 2011 Oct. 39 (10):2130-4. [QxMD MEDLINE Link].
Arirachakaran A, Sukthuayat A, Sisayanarane T, Laoratanavoraphong S, Kanchanatawan W, Kongtharvonskul J. Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis. J Orthop Traumatol. 2016 Jun. 17 (2):101-12. [QxMD MEDLINE Link].
Chen X, Jones IA, Park C, Vangsness CT Jr. The Efficacy of Platelet-Rich Plasma on Tendon and Ligament Healing: A Systematic Review and Meta-analysis With Bias Assessment. Am J Sports Med. 2018 Jul. 46 (8):2020-2032. [QxMD MEDLINE Link].
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. 2008 May 29. 9:75. [QxMD MEDLINE Link]. [Full Text].
Haake M, König IR, Decker T, Riedel C, Buch M, Müller HH, et al. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis : a randomized multicenter trial. J Bone Joint Surg Am. 2002 Nov. 84 (11):1982-91. [QxMD MEDLINE Link].
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. 2008 Oct. 35 (10):2038-46. [QxMD MEDLINE Link].
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. 2007 Feb. 89 (2):255-60. [QxMD MEDLINE Link].
Guo YH, Kuan TS, Chen KL, Lien WC, Hsieh PC, Hsieh IC, et al. Comparison Between Steroid and 2 Different Sites of Botulinum Toxin Injection in the Treatment of Lateral Epicondylalgia: A Randomized, Double-Blind, Active Drug-Controlled Pilot Study. Arch Phys Med Rehabil. 2017 Jan. 98 (1):36-42. [QxMD MEDLINE Link].
Ruch DS, Orr SB, Richard MJ, Leversedge FJ, Mithani SK, Laino DK. A comparison of débridement with and without anconeus muscle flap for treatment of refractory lateral epicondylitis. J Shoulder Elbow Surg. 2015 Feb. 24 (2):236-41. [QxMD MEDLINE Link].
Baker CL Jr, Murphy KP, Gottlob CA, Curd DT. Arthroscopic classification and treatment of lateral epicondylitis: two-year clinical results. J Shoulder Elbow Surg. 2000 Nov-Dec. 9 (6):475-82. [QxMD MEDLINE Link].
Owens BD, Murphy KP, Kuklo TR. Arthroscopic release for lateral epicondylitis. Arthroscopy. 2001 Jul. 17 (6):582-7. [QxMD MEDLINE Link].
Solheim E, Hegna J, Øyen J. Arthroscopic versus open tennis elbow release: 3- to 6-year results of a case-control series of 305 elbows. Arthroscopy. 2013 May. 29 (5):854-9. [QxMD MEDLINE Link].
Kwon BC, Kim JY, Park KT. The Nirschl procedure versus arthroscopic extensor carpi radialis brevis débridement for lateral epicondylitis. J Shoulder Elbow Surg. 2017 Jan. 26 (1):118-124. [QxMD MEDLINE Link].
Seng C, Mohan PC, Koh SB, Howe TS, Lim YG, Lee BP, et al. Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Sustainability and Sonographic Progression at 3 Years. Am J Sports Med. 2016 Feb. 44 (2):504-10. [QxMD MEDLINE Link].
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. 2009 May-Jun. 34 (5):849-57. [QxMD MEDLINE Link].
Rajeev A, Pooley J. Lateral compartment cartilage changes and lateral elbow pain. Acta Orthop Belg. 2009 Feb. 75 (1):37-40. [QxMD MEDLINE Link].
Kuklo TR, Taylor KF, Murphy KP, Islinger RB, Heekin RD, Baker CL Jr. Arthroscopic release for lateral epicondylitis: a cadaveric model. Arthroscopy. 1999 Apr. 15 (3):259-64. [QxMD MEDLINE Link].
Baker CL Jr, Baker CL 3rd. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med. 2008 Feb. 36 (2):254-60. [QxMD MEDLINE Link].
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. 2008 Feb. 36 (2):261-6. [QxMD MEDLINE Link].
Zeisig E, Fahlström M, Ohberg L, Alfredson H. A two-year sonographic follow-up after intratendinous injection therapy in patients with tennis elbow. Br J Sports Med. 2010 Jun. 44 (8):584-7. [QxMD MEDLINE Link].

Media Gallery

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.

of 8

Author

Brett D Owens, MD Director, Sports Medicine Research Lab, Director, Sports Medicine, Department of Orthopedics, The Miriam Hospital, The Warren Alpert Medical School of Brown University; Partner, Director, Cartilage Research Lab, University Orthopedics, Inc; Professor, Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University; Professor, Department of Epidemiology, Brown University School of Public Health; Professor, Department of Surgery, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

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, American Shoulder and Elbow Surgeons, Arthroscopy Association of North America, Herodicus Society, Magellan Society - Orthopaedic Research and Education Foundation, Orthopaedic Trauma Association, Society of Military Orthopaedic Surgeons

Disclosure: Received consulting fee from Musculoskeletal Transplant Foundation/CONMED for consulting; Received consulting fee from Johnson & Johnson (MITEK) for consulting; Received royalty from Elsevier, SLACK Publishing, and Springer 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: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: The Journal of Hand Surgery; American Society for Surgery of the Hand<br/>Received research grant from: Dept of Defense.

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

Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India

Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee Surgeons

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.

Sections Lateral Epicondylitis (Tennis Elbow) Surgery
Overview
Presentation
DDx
Workup
Treatment
Media Gallery
References

Lateral Epicondylitis (Tennis Elbow) Surgery Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

What would you like to print?