Lateral Elbow Tendinopathy
From WikiMSK
Epidemiology
- Prevalence of 1 to 3 in 100
- Aged 35 - 54
- Risk factors
- o Tennis associated with condition in less than 10 in 100 patients
- o Repetitive movements especially wrist extension and supination
- o New or sudden overuse of tendon (e.g. lifting a new baby, new exercise routine, new gardening, handling heavy tools or heavy load)
- o Low job control
- o Low social support
- o Doesn't increase risk: keyboard use, working with arms above shoulder-height, exposure to hand-transmitted vibrations
Pathogenesis
- 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
- 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 diagnosis of lateral elbow pain
- Osteomyelitis
- Arthritis
- Peripheral neuropathy
- Trauma
- Referred pain from neck,shoulder, wrist
- Posterior interosseous neuropathy
- Stress fracture
- Osteochondritis dissecans of capitellum and radius
Treatment
- Most patients recover at one year with or without treatment
- Rest, avoid or alter activities responsible for symptoms
- 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.
- topical NSAIDs may help, inconsistent evidence for oral NSAIDs (level 2)
- topical GTN may help for patients having physical therapy (level 2)
- Injection platelet rich plasma (level 2)
- Surgery
- 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% |
- Acupuncture (level 2)
- Physiotherapy
- May be no more effective or only slightly more effective than doing nothing at all, but studies are of poor quality.
- Expert opinion is to do daily eccentric isokinetic strengthening exercises
- Application of this technique for epicondylitis involves holding a weight or a taut resistance band with the wrist extended and then flexing the wrist while maintaining tension in the wrist extensors (ie, eccentrically contracting the wrist extensors)