II. Epidemiology

  1. Incidence: 1-3% of U.S. adults per year
  2. Ages: 30-40 years old

III. Pathophysiology

  1. Tendinopathy (not a Tendonitis)
    1. The term Tendonitis is a misnomer, as this is a degenerative tendon change, not an inflammatory change
  2. Much more common compared with Medial Epicondylitis (by factor of 4-10 fold)
  3. Affects the supinator Muscle tendons (and the extensor Forearm tendon) at their medial epicondyle origins
    1. Extensor carpi radialis brevis
  4. Occupational repetitive use injury is most common cause
    1. Named for the one-handed backhand swing related injury in tennis (but only affects 5-10% of tennis players)

IV. Causes

  1. Repeated overuse of Forearm flexors or extensors
  2. Minor tears of tendinous attachments at epicondyles
  3. Causative activities (Occupational Injury is more common than Athletic Injury)
    1. Golf or racquet sports
    2. Throwing sports
    3. Hammering
    4. Hand sanding
    5. Computer mouse use

V. Symptoms

  1. Dull ache at lateral epicondyle
  2. Gradual onset of pain
  3. Worsened with affected Muscle use
    1. Forearm Rotation or grasping
    2. Opening a jar
  4. Pain radiates into Forearm

VI. Signs

  1. Maximum tenderness localized to region 1 cm distal to the lateral epicondyle
  2. Provocative maneuvers eliciting pain
    1. Wrist extension against resistance
    2. Supination against resistance
    3. Pain on resisted wrist extension
    4. Pain on isolated resisted long finger (middle finger) extension
    5. Pain with resisted gripping

VII. Differential Diagnosis

VIII. Imaging: Elbow XRay

  1. Usually negative (evaluates more for differential diagnosis)
  2. Occasional traction spur may be seen

IX. Management: Initial pain management

  1. Rest
  2. Ice Therapy (Cryotherapy) for 20 minutes four times daily and after Exercise
  3. Moist heat or Ultrasound
  4. NSAIDs
  5. Tennis Elbow counterforce strap
    1. Dampens force transmitted to elbow from wrist, hand
      1. Struijis (2004) Am J Sports Med 32:462-9 [PubMed]
    2. May offer initial benefit for comfort but Stretching and strengthening are preferred modalities given their much better efficacy
      1. Wrist brace may be preferred
  6. Activity restriction
    1. Avoid grasping in pronation
    2. Lift only with wrist in supination
  7. Ergonomic workplace and sports modifications

X. Management: Rehabilitation Exercises

  1. Physical therapy with Eccentric Exercises
  2. Painless passive wrist flexion
  3. Progressive resisted wrist extension
    1. Use elastic band tied between foot and hand

XI. Management: Refractory Cases

  1. Deep friction massage
  2. Dry Needling
  3. Blood and Platelet rich plasma injections
    1. Creaney (2011) Br J Sports Med 45(12): 966-71 [PubMed]
  4. Nitroglycerin patch (one quarter of a 5 mg Nitroglycerin patch)
    1. Paoloni (2009) Br J Sports Med 43(4): 299-302 [PubMed]
  5. Epicondyle Injection (Corticosteroid local injection)
    1. May be associated with worse longterm outcomes
    2. Coombes (2013) JAMA 309(5): 461-9 [PubMed]
  6. Long Arm Cast of elbow and wrist
    1. Avoid immobilization if possible
    2. Indicated for failed conservative therapy above
    3. Wrist immobilized so affected Muscles relaxed
    4. Lateral Epicondylitis cast
      1. Elbow flexed at 90 degrees
      2. Forearm supinated
      3. Slight wrist dorsiflexion into 10-20 degrees

XII. Management: Ineffective measures

XIII. Prognosis

  1. Self limited, expect full recovery
  2. Symptoms may persist for months
  3. Surgery for resistant cases only

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Epicondylitis (C0014488)

Concepts Disease or Syndrome (T047)
SnomedCT 156659008, 268088003, 73583000
Italian Epicondilite, Epitrocleite
English Epicondylitis, epicondylitis, epicondylitis (diagnosis), Epitrochleitis, Epicondylitis (disorder), Epicondylitis, NOS, Epicondylitis NOS
Japanese 上顆炎, ジョウカエン, ナイソクジョウカエン, 内側上顆炎
Czech Epikondylitida, Epitrochleitis
Spanish Epitrocleitis, epicondilitis de húmero (trastorno), epicondilitis del húmero, epicondilitis del húmero (trastorno), epicondilitis de húmero, Epicondilitis
Portuguese Epitrocleíte, Epicondilite
Dutch epitrochleïtis, epicondylitis
French Epitrochléite, Epicondylite
German Epitrochleitis, Epikondylitis
Hungarian Epitrochleitis, Epicondylitis

Ontology: Tennis Elbow (C0039516)

Definition (MSH) A condition characterized by pain in or near the lateral humeral epicondyle or in the forearm extensor muscle mass as a result of unusual strain. It occurs in tennis players as well as housewives, artisans, and violinists.
Concepts Disease or Syndrome (T047)
MSH D013716
ICD9 726.32
ICD10 M77.1
SnomedCT 24133009, 268088003, 156659008, 202855006
English Elbows, Tennis, Epicondylitides, Lateral Humeral, Epicondylitis, Lateral Humeral, Humeral Epicondylitides, Lateral, Humeral Epicondylitis, Lateral, Lateral Humeral Epicondylitides, Lateral Humeral Epicondylitis, Tennis Elbows, Elbow, Tennis, TENNIS ELBOW, Tennis Elbow, lateral epicondylitis (diagnosis), lateral epicondylitis, tennis elbow, lateral epicondylitis (tennis elbow), Tennis Elbow [Disease/Finding], Epicondylitis;lateralis, radiohumeral bursitis, tennis elbows, epicondylitis lateralis, lateral humeral epicondylitis, Lateral epicondylitis of elbow joint (disorder), Tennis elbow - epicondylitis, Lateral epicondylitis, Tennis elbow, Lateral epicondylitis of elbow, Lateral epicondylitis (disorder), bursitis; radiohumeral, epicondylitis; lateral, lateral; epicondylitis, radiohumeral; bursitis, Lateral epicondylitis of elbow joint (disorder) [Ambiguous], Lateral Epicondylitis, lateralis epicondylitis
Dutch laterale epicondylitis, tenniselleboog, bursitis; radiohumeraal, epicondylitis; lateralis, lateralis; epicondylitis, radiohumeraal; bursitis, Epicondylitis lateralis, Elleboog, tennis-, Tenniselleboog
French Epicondylite externe, Épicondylite humérale latérale, Épicondylite, Tennis elbow, Épicondylite des joueurs de tennis
German Tennisellbogen, laterale Epikondylitis, Epicondylitis radialis humeri, Epicondylitis lateralis humeri, Tennisellenbogen
Italian Epicondilite, Epicondilite omero laterale, Gomito del tennista
Portuguese Cotovelo de ténis, Epicondilite externa, Cotovelo de Tenista, Epicondilite Lateral do Úmero
Spanish Epicondilitis lateral, Codo del tenista, epicondilitis externa, epicondilitis, epicondilitis externa de la articulación del codo (trastorno), Epicondilitis Lateral del Húmero, codo de tenista, epicondilitis externa de la articulación del codo (concepto no activo), epicondilitis lateral (trastorno), epicondilitis lateral del codo, epicondilitis lateral, Codo de Tenista, Epicondilitis Humeral Lateral
Japanese 外側上顆炎, ガイソクジョウカエン, テニスヒジ, 上腕骨外上顆炎, テニス肘, 上腕骨外側上顆炎
Swedish Tennisarmbåge
Czech tenisový loket, Laterální epikondylitida, Tenisový loket
Finnish Tenniskyynärpää
Korean 외측 상과염
Polish Łokieć tenisisty
Hungarian Teniszkönyök, Epicondylitis lateralis
Norwegian Tennisalbue, Epikondylitt, lateral, Lateral epikondylitt, Laterale epikondylsmerter, Epicondylitis lateralis humeri, Lateral epikondalgi

Ontology: Enthesopathy of elbow region (C0158307)

Concepts Pathologic Function (T046)
ICD9 726.30, 726.3
SnomedCT 202858008, 202854005, 35185008
English Elbow enthesopathy unspecified, Enthesopathy of elbow, unspecified, enthesopathy of elbow (diagnosis), enthesopathy of elbow, Elbow enthesopathy NOS, Elbow enthesopathy NOS (disorder), Elbow enthesopathy unspecified (disorder), Enthesopathy of elbow region, Enthesopathy of elbow, Enthesopathy of the elbow region, Enthesopathy of elbow region (disorder), elbow region; enthesopathy, enthesopathy; elbow region, Enthesopathy of elbow region, NOS, Enthesopathy of elbow, NOS
Dutch enthesopathie van elleboogstreek, niet-gespecificeerde enthesopathie van elleboog, elleboogstreek; enthesopathie, enthesopathie; elleboogstreek
French Enthésopathie de la région du coude, Enthésopathie du coude, non précisée
German Enthesiopathie des Ellbogens, unspezifisch, Enthesiopathie der Ellbogengegend
Italian Entesopatia della regione del gomito, Entesopatia non specificata della regione del gomito
Portuguese Entesopatia do cotovelo NE, Entesopatia da região do cotovelo
Spanish Entesopatía del codo, no especificada, Entesopatía de la región del codo, entesopatía de codo, no especificada, entesopatía de codo, no especificada (trastorno), entesopatía de codo, SAI (trastorno), entesopatía de codo, SAI, entesopatía de la región del codo (trastorno), entesopatía de la región del codo, entesopatía del codo
Japanese 肘部の腱付着部症, 詳細不明の肘部腱付着部症, ショウサイフメイノチュウブケンフチャクブショウ, チュウブノケンフチャクブショウ
Czech Entezopatie loketní oblasti, Entezopatie loketní oblasti, blíže neurčená
Hungarian Könyök enthesopathiája, nem meghatározott, Könyök régió enthesopathiája