Practice Essentials
Lateral epicondylitis (tennis elbow), first described by Runge in 1873, is a commonly encountered problem in orthopedic practice. It is an overuse injury involving the extensor muscles that originate on the lateral epicondylar region of the distal humerus. Lateral epicondylitis is not an inflammatory disease; it is more properly termed a tendinosis that specifically involves the origin of the extensor carpi radialis brevis (ECRB) et the lateral condyle. [1, 2, 3]
The goals of any treatment for lateral epicondylitis are to decrease pain and to increase function while awaiting resolution of the tendinopathy. Initial first-line treatment for this self-limited condition consists of nonsurgical therapy and activity modification, as well as time. Corticosteroid injections have been shown to have only a short-term effect (average, 6 weeks). Surgical treatment, typically open or arthroscopic debridement of the tendon origin, should be reserved for patients in whom extensive conservative therapy has failed.
For patient education resources, see Tennis Elbow.
Anatomy
The ECRB arises from the lateral epicondyle. It lies deep to the extensor carpi radialis longus (ECRL) and superficial to the joint capsule. The annular and collateral ligaments are located beneath and just distal to the origin of the ECRB. [4]
Pathophysiology
Many proposed explanations for lateral epicondylitis have involved inflammatory processes of the radial humeral bursa, synovium, periosteum, and annular ligament. However, Nirschl and Pettrone defined the basic process as microscopic tearing with formation of reparative tissue (ie, angiofibroblastic hyperplasia) in the origin of the ECRB. [5] This microtearing and repair response can lead to macroscopic tearing and structural failure of the origin of this 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, whereas concomitant intra-articular pathology has been noted, this process is currently considered an extra-articular one.
Etiology
Any activity involving wrist extension 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 two- to threefold in those who play more than 2 hours weekly and two- to fourfold 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 the following three risk factors [6] :
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Handling tools heavier than 1 kg
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Handling loads heavier than 20 kg at least 10 times per day
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Repetitive movements for more than 2 hours per day
The review also found that low job control and low social support were psychosocial factors associated with lateral epicondylitis. [6]
Epidemiology
Lateral epicondylitis has been demonstrated to occur in as many as 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.
Prognosis
Nonoperative management has been the mainstay of treatment. A study by Smidt et al, which compared observation ("wait-and-see") with physical therapy and corticosteroid injection in a randomized trial, found that at 1 year, there were no significant differences among groups with regard to resolution of symptoms. [7] The majority of patients in each cohort (69-91%) had resolution of lateral epicondylitis.
Surgical treatment of lateral epicondylitis 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. A study by Degen et al found that the most important predictor of whether ipsilateral revision surgery after failed operative treatment of lateral epicondylitis would be necessary was having three or more preoperative ipsilateral injections. [8]
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Type I lateral epicondylitis seen through the 30° arthroscope.
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Type 2 lateral epicondylitis showing a linear tear in the origin of the extensor carpi radialis brevis muscle.
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Type 3 lateral epicondylitis showing a large tear in the origin of the extensor carpi radialis brevis muscle.
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Representation of the relationships in arthroscopic release for lateral epicondylitis
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Lateral epicondylitis. Incision for open debridement of lateral epicondyle. Lateral epicondyle is circled.
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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.
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Origin of extensor carpi radialis brevis exposed.
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Lateral epicondylitis. Osteotome positioned over lateral epicondyle.
