Lateral Epicondylitis

Aka: Lateral Epicondylitis, Tennis Elbow, Epicondylitis, Elbow Enthesopathy, Radiohumeral Bursitis, Extensor Carpi Radialis Brevis Tendinopathy

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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

  1. Radial Tunnel Syndrome (or Posterior Interosseous Nerve Syndrome)
    1. Radial nerve Entrapment Neuropathy
  2. Radiocapitellar chondromalacia
  3. Osteochondritis Dissecans capitellum

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

  1. Corticosteroid Iontophoresis does not offer benefit
    1. Nirschl (2003) Am J Sports 31:189-95 [PubMed]
  2. Extracorporeal shock wave therapy is not beneficial
    1. Chung (2004) Am J Sports Med 32:1660-7 [PubMed]

XIII. Complications

  1. Elbow Ulnar Collateral Ligament Injury
  2. Ulnar Nerve instability

XIV. Prognosis

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

XV. References

  1. Childress (2013) Am Fam Physician 87(7): 486-90 [PubMed]
  2. Hay (1999) BMJ 319:964-8 [PubMed]
  3. Kane (2019) Am Fam Physician 100(3): 147-57 [PubMed]
  4. Kane (2014) Am Fam Physician 89(8): 649-57 [PubMed]

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