Lateral Elbow Tendinopathy

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)