Lateral Elbow Tendinopathy

Definition

Pain at the tendon insertion or myotendinous junction is termed lateral elbow tendinopathy. It is also commonly called tennis elbow, lateral epicondylitis, lateral epicondylalgia, and elbow tendinosis/tendinitis.

Epidemiology

Lateral elbow tendinopathy is the most common cause of lateral elbow pain.

The prevalence was 1.3% in an observational study of 5871 working-age Finns

Risk Factors

Common risk factors are summarised below

• Smoking
• Obesity
• Age 45-54
• Repetitive movements especially wrist extension and supination for at least two hours daily
• Forceful activity (lifting loads over 20kg)
• New or sudden overuse of tendon (e.g. lifting a new baby, new exercise routine, new gardening, handling heavy tools or heavy load)
• Low job control
• Low social support

Doesn't increase risk: keyboard use, working with arms above shoulder-height, exposure to hand-transmitted vibrations

Poor prognostic factors

• High work physical strain
• Dominant side
• Neck pain
• Symptoms greater than 3 months
• Severe Pain

Note: Tennis is associated with the condition in less than 10 in 100 patients, and is more common in recreational players. See Hatch et al for discussion about racket grip sizes.

Pathogenesis

It is generally stated that the extensor carpi radialis brevis tendon is the structure most commonly implicated. The extensor digitorum or extensor carpi ulnaris may be the culprit if middle finger extension is more painful than wrist extension

Formal histopathological studies of lateral epicondylitis are limited to those patients who have undergone surgery, and who, by definition, must have been suffering from chronic and refractory disease, and who are patently not representative of either the acute or typical clinical situation.

The extensor radialis brevis muscle is the most commonly involved muscle.

Pathology Studies

• Card et al harvested 20 common extensor tendons in patients having a release procedure, and compared them to nine control biopsies, and performed an unblinded assessment. Common changes were glycosaminoglycan infiltration, new bone formation, fibrofatty change, partial rupture, and fibrocartilage formation. Inflammatory changes were only found in one sample.
• In a smaller study of similar design but with blinded assessment, Regan et al 12 again noted a paucity of chronic inflammatory infiltrates, but found evidence of hyaline degradation in 11 of 11 biopsies, vascular proliferation in 10 biopsies, fibroblastic proliferation in 7 and calcific debris in 3. Only two of the controls had evidence of vascular proliferation.
• The third controlled study also found no evidence of ongoing inflammation, but evidence of ongoing repair reference required.
• One study looked at using high definition ultrasound studies in patients with the syndrome of lateral epicondylitis 13. Forty-one tennis players with symptoms for an average of 2.2 months were investigated with high definition, real time ultrasound, and the images independently reported. Six ultrasonographic diagnoses were made. Fifteen of 41 had tendonitis; five each of bursitis and enthesiopathy; four of peritendonitis; two had intra-muscular hematomas. Seven had multiple lesions and 3 were normal to ultrasound. No controls were used.
• Zeisig et al in 2006 investigated the common extensor origin with grey-scale ultrasonography and colour doppler in 17 patients in a total of 22 elbows, and compared them to 11 controls with 22 pain-free elbows. In 21/22 of the painful elbows, vascularity was shown. This was in contrast to only 2/22 of pain-free elbows. This was thought to correspond to vasculo-neural growth.

In summary, the pathology of acute lateral epicondylitis remains unknown. It seems likely that a variety of pathological lesions, principally affecting the common extensor tendon and its surrounding tissues are responsible. In chronic lateral epicondylitis, the extant pathological studies indicate a chronic repair and degenerative process with very little in the way of an active inflammatory component.

Factors thought to be relevant:

• Repeated microtearing and healing attempts
• Non inflammatory angiofibroblastic hyperplasia
• Formation of nonfunctional blood vessels
• Collagen scaffold disrupted by fibroblasts and vascular granulation

Diagnosis

• Onset of pain is insidious
• Can be diagnosed using the "Southampton examination schedule"
  • All three of epicondylar pain, epicondylar tenderness, pain on resisted extension of the wrist
  • Fairly accurate - sensitivity 73%, specificity 97%, kappa = 0.75
• Often also get pain with supination of the forearm, resisted third finger extension (with an extended elbow), pain on lifting a chair with a pronated hand.
• Can get wrist extension weakness
• Range of motion usually normal
• Imaging usually unnecessary, and extend of tendon damage is not correlated with the amount of pain. May be considered if no improvement.

Differential Diagnoses

Lateral Elbow Pain

• Lateral Elbow Tendinopathy
• Referred pain (Cervical spine, Upper thoracic spine, Myofascial)
• Synovitis of the radiohumeral joint
• Radiohumeral bursitis
• Radial Head Fractures
• Radial Head Dislocation
• Capitellar Osteochondritis Dissecans (Capitellum, Radius in adolescents)
• Capitellar Osteochondrosis
• Lateral Condyle Fracture
• Capitellum Fracture
• Lateral Collateral Ligament Complex Injury
• Radial Head Subluxation (Nursemaid Elbow)
• Radiocapitellar Osteoarthrosis
• Bone Neoplasm
• Soft Tissue Neoplasm
• Posterolateral Rotary Instability
• Posterior Interosseous Nerve Entrapment or Radial Neuropathy at the Spiral Groove
• Posterolateral Plica Syndrome

Medial Elbow Pain

• Medial Elbow Tendinopathy
• Medial collateral ligament injury (acute and chronic)
• Ulnar neuritis
• Avulsion fracture of the medial epicondyle (children and adolescents)
• Apophysitis (children and adolescents)
• Referred pain (Cervical Radicular Pain, somatic referred myofascial pain)
• Myofascial pain
• Ulnar Neuropathy
• Little Leaguer's Elbow
• Triceps Tendinopathy and rupture
• Fractures (Olecranon Fracture, Pediatric Medial Epicondyle Avulsion, Coronoid Process Fracture, Medial Condyle Fracture)
• Medial epitrochlear lymphadenopathy (e.g. from cat-scratch disease)
• Anconeus Epitrochlearis
• Cyst, Mass, Foreign Body

Posterior Elbow Pain

• Olecranon bursitis
• Triceps Tendinopathy
• Posterior impingement
• Gout

Anterior Elbow Pain

• Biceps tendinopathy or rupture

Generalised

• Osteoarthritis
• If locking consider chondromalacia, osteochondritis, loose bodies

Treatment

Doing Nothing

• Most patients recover at one year with or without treatment

Exercises

Effective exercise programmes incorporate progressive eccentric and isometric strengthening. Flexibility training may also be required. Eccentric exercise can be performed by holding a weight or a taut resistance band with the wrist extended. The wrist is then flexed against resistance.

There are inconsistencies in the methodological quality of research into eccentric strengthening for this condition. High quality research in other tendinopathies, in particular achilles tendinopathy, has shown benefit for including eccentric strengthening in a rehabilitation programme. One systematic review in 2003 showed mixed results. . A more recent review in 2014 found three high quality studies, seven medium quality studies, and two low quality studies. They concluded that the evidence supports the inclusion of eccentric strengthening as part of a multimodal approach to rehabilitation

Some of the better quality studies:

• Standard physical therapy versus standard therapy plus eccentric stregnthening. Patients in the eccentric strengthening group had marked reductions in pain, disability, and improvement in tendon appearance on ultrasound at one month. At completion the eccentric training group had no strength deficit.
• A similar smaller study found better outcomes in the eccentric strengthening group when using a rubber bar: File:rubber bar lateral elbow.jpg .

Rest

• Rest, avoid or alter activities responsible for symptoms

Activity Modification

• For tennis players: lighter racket with smaller grip and less string tension, use 2 - handed backhand

Orthotics

• braces, forearm straps, wrist cock-up splints may reduce pain and improve function (level 2)
• Counter-force brace recommended as inexpensive and easy to use. Apply 6-10cm distal to elbow joint.

Medication

• topical NSAIDs may help, inconsistent evidence for oral NSAIDs (level 2)
• topical GTN may help for patients having physical therapy (level 2)

PRP

• Injection platelet rich plasma (level 2)

Steroid injections

Peritendinous steroid injections may provide short-term relief (up to 12 weeks), but result in increased pain and recurrence at one year (level 1)

Complete recovery or much improvement at	Normal	Steroid	Physio	Steroid+Physio
4 weeks	10%	71%	39%	68%
26 weeks	83%	56%	89%	54%
52 weeks	93%	84%	100%	82%
recurrence at 52w	20%	55%	5%	54%

Stretching

Bogduk wrote about stretching but this would not be a modern approach to treating this condition due to the compressive forces applied.

References

1. Allander E. Prevalence, incidence, and remission rates of some common rheumatic diseases or syndromes. Scand J Rheumatol 1974; 3:145-153. 2. Hamilton PG. The prevalence of humeral epicondylitis: a survey in general practice. J R Coll Gen Pract 1986; 36:464-465. 3. Dimberg L. The prevalence and causation of tennis elbow (lateral humeral epicondylitis) in a population of workers in an engineering industry. Ergonomics. 1987; 30:573-579. 4. Carroll R. Tennis elbow: incidence in local league players. Br J Sports Med 1981; 15:250-256. 5. Kurppa K, Viikari Juntura E, Kuosma E, Huuskonen M, Kivi P. Incidence of tenosynovitis or peritendinitis and epicondylitis in a meat-processing factory. Scand J Work Environ Health 1991; 17:32-37. 6. Roto P, Kivi P. Prevalence of epicondylitis and tenosynovitis among meatcutters. Scand J Work Environ Health 1984; 10:203-205. 7. Vender MI, Kasdan ML, Truppa KL. Upper extremity disorders: a literature review to determine work relatedness. J Hand Surg 1995; 20A:534-541. 8. Department of clinical epidemiology and biostatistics. How to read clinical journals: III to learn the clinical course and prognosis of disease. Can Med Assoc J 1981; 124:869-872. 9. Binder AI, Hazleman BL. Lateral humeral epicondylitis--a study of natural history and the effect of conservative therapy. Br J Rheumatol 1983; 22:73-76. 10. Coonrad RW, Hooper WR. Tennis elbow: its course, natural history and surgical management. J Bone Joint Surg 1973; 55A:1177-1182. 11. Chard MD, Cawston TE, Riley GP, Gresham GA, Hazleman BL. Rotator cuff degeneration and lateral epicondylitis: a comparative histological study. Ann Rheum Dis 1994; 53:30-34. 12. Regan W, Wold LE, Coonrad RW, Morrey BF. Microscopic histopathology of chronic refractory lateral epicondylitis. Am J Sports Med 1992; 20:746-749. 13. Maffulli N, Regine R, Carrillo F, Capasso G, Minelli S. Tennis elbow: an ultrasonographic study in tennis players. Br J Sports Med 1990; 24:151-155.