Lateral Epicondylitis

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Search Strategy

MeSH terms: Lateral Epicondylitis, Tennis Elbow.
Key words: Lateral Epicondylitis, Tennis Elbow, Elbow.
The university’s library and sites: Pubmed, Web of Knowledge and Google.

Definition/Description

Lateral epicondylitis is the most common overuse syndrome in the elbow. Lateral epicondylitis or tennis elbow is an injury involving the extensor muscles of the forearm. These muscles originate on the lateral epicondylar region of the distal of the humerus.

Clinically Relevant Anatomy

The elbow joint is made up of three bones: the humerus (upper arm bone), the radius and ulna (two bones in the forearm). At the distal end of the humerus there are two epicondyles, one lateral (on the outside) and one medial (on the inside). 

Musculature involved is most commonly the extensor carpi radialis brevis (ECRB), but this injury can also involve the extensor carpi radialis longus (ECRL), extensor digitorum, and extensor carpi ulnaris.

The radial nerve is also in close proximity to this region, and divides into the superficial radial nerve and the posterior interosseous nerve.

Epidemiology /Etiology

Lateral epicondylitis is classified as an overuse injury. Overuse of the muscles and tendons of the forearm and elbow together with repetitive gripping or manual tasks can put too much strain on the elbow tendons. These gripping or manual tasks require manipulation of the hand that causes maladaptions in tendon structure that lead to pain over the lateral epicondyle. Mostly, the pain is located anterior and distal from the lateral epicondyle.

Epicondylitis occurs at least five times more often and predominantly occurs on the lateral rather than on the medial aspect of the joint, with a 4:1 to 7:1 ratio.

This injury is often work-related, any activity involving wrist extension, pronation or supination during manual labour, housework and hobbies are considered as important causal factors.
A systematic review identified 3 risk factors: handling tools heavier than 1 kg, handling loads heavier than 20 kg at least 10 times per day, and repetitive movements for more than 2 hours per day.

Other risk factors are overuse, repetitive movements, training errors, misalignments, flexibility problems, aging, poor circulation, strength deficits or muscle imbalance and psychological factors.
There are several opinions concerning the cause of lateral epicondylitis:

Inflammation:
• Although the term epicondylitis implies the presence of an inflammatory condition, inflammation is present only in the earliest stages of the disease process.

Microscopic tearing:
• Nirschl and Pettrone attributed the cause to microscopic tearing with formation of reparative tissue (angiofibroblastic hyperplasia) in the origin of the extensor carpi radialis brevis (ECRB) muscle. This micro-tearing and repair response can lead to macroscopic tearing and structural failure of the origin of the ECRB muscle.
• That microscopic or macroscopic tears of the common extensor origin were involved in the disease process, was postulated by Cyriax in 1936.
• The first to describe macroscopic tearing in association with the histological findings were Coonrad and Hooper.
• Histology of tissue samples shows "collagen disorientation, disorganization, and fibre separation by increased proteoglycan content, increased cellularity, neovascularization, with local necrosis." Nirschl termed these histological findings bangiofibroblastic hyperplasia. The term has since been modified to bangiofibroblastic tendinosis. He noted that the tissue was characterized by disorganized, immature collagen formation with immature fibroblastic and vascular elements. This grey, friable tissue is found in association with varying degrees of tearing involving the extensor carpi radialis brevis.

Degenerative process:
The histopathological features of 11 patients who had lateral epicondylitis were examined by Regan et al. They determined that the cause of lateral epicondylitis was more indicative of a degenerative process than an inflammatory process. The condition is degenerative with increased fibroblasts, vascular hyperplasia, proteoglycans and glycosaminoglycans, and disorganized and immature collagen. Repetitive eccentric or concentric overloading of the extensor muscle mass is thought to be the cause of this angiofibroblastic tendinosis of the ECRB.

Hypovascularity:
Because this tendinous region contains areas that are relatively hypovascular, the tendinous unit is unable to respond adequately to repetitive forces transmitted through the muscle, resulting in declining functional tolerance.

Characteristics/Clinical Presentation

Lateral epicondylitis has an annual incidence of 1-3% within the general population.
The difference between men and women on lateral epicondylitis is still controversial.
Patients with lateral epicondylitis are typically 35 to 54 years. It’s less common in people under 30 years. Symptoms last, on average, from 6 months to 2 years. 89% of the patients recover within 1 year without any treatment except perhaps avoidance of the painful movements.

Patients often report weakness in their grip strength or difficulty carrying objects in their hand, especially with the elbow extended. They have complaints of pain just distal to and localized tenderness over the lateral epicondyle. Patients will commonly have pain with palpation of the lateral epicondyle, resisted wrist, or second or third finger extension (Cozen's sign).

Differential Diagnosis

Radial Tunnel Syndrome

Posterior Interosseous Nerve (PIN) Syndrome

Elbow osteoarthritisOsteoarthritis

• Pain
• Loss of range of motion

Fractures

• Distal Radial Fracture
• Radial Head Fracture
• Olecranon Fracture

Cervical Radiculopathy

• Radiating arm pain corresponding to the dermatomes 
• Neck pain
• Parasthesia
• Muscle weakness in myotome
• Reflex impairment/loss
• Headaches
• Scapular pain
• Sensory and motor dysfunction in upper extremities and neck

Diagnostic Procedures

The diagnosis of lateral epicondylitis is substantiated by tenderness over the ECRB or common extensor origin. By the following methods, the therapist or physiotherapist should be able to reproduce the typical pain:
1. Digital palpation on the facet of the lateral epicondyle
2. Resisted wrist extension or resisted middle-finger extension with the elbow in extension
3. Having the patient grip an object

Outcome Measures

add links to outcome measures here (also see Outcome Measures Database)

mASES

QuickDASH (reliability= .90, MCID not reported)

DASH_Outcome_Measure

PSFS (reliability= .82-.92, MCID=2.0)

PrTEEQ - Patient-Rated Tennis Elbow Evaluation Questionnaire (Pain ICC = 0.89-0.99, Function ICC = 0.83-0.99, Total ICC = 0.89-0.99)

Examination

• To examine the sincerity of the tennis elbow, there is a dynamometer and a Patient-rated Tennis Elbow Evaluation Questionnaire (PrTEEQ). The dynamometer measures grip strength. The PrTEEQ is a 15-item questionnaire, it’s designed to measure forearm pain and disability in patients with lateral epicondylitis. The patients have to rate their levels of tennis elbow pain and disability from 0 to 10, and consists of 2 subscales. There is the pain subscale (0 = no pain, 10 = worst imaginable) en the function subscale (0 = no difficulty, 10 = unable to do). 

• A positive sign is tenderness to palpation at the anterior epicondyle

• Cozen's sign:
The patient is positioned with the upper extremity relaxed. The examiner stabilizes the patient’s elbow with one hand and the patient is instructed to make a fist, pronate the forearm, and radially deviate the wrist. At last, the patient is instructed to extend the wrist against resistance that is provided by the examiner. An altenative is resisted extension of the middle finger that can cause pain at the extensor carpi radialis brevis origin. The test is positive if the patient experiences a sharp, sudden, severe pain over the lateral epicondyle.

• Chair test: The patient grasps the back of the chair while standing behind it and attempts to raise it by putting their hands on the top of the chair back. Pain reproduction at the lateral epicondyle is a positive test.

• Mill's Test: The patient is positioned in standing with the upper extremity relaxed at side and the elbow extended. The examiner passively stretches the wrist in flexion and pronation. Pain at the lateral epicondyle or proximal musculotendinous junction of wrist extensors is positive for lateral epicondylitis.

• The coffee cup test (by Coonrad and Hooper) where picking up a full cup of coffee is painful.

Medical Management

Medical management of lateral epicondylalgia has historically included NSAIDs, advice regarding rest, use of an elbow counterforce brace, and corticosteroid injection(s). Histologic research and the discovery of the true nature of this condition has led to more appropriate diagnosis and treatment in regard to the degeneration that is occurring at the site. Current medical treatment and research involves the use of interventions like prolotherapy, autologous blood injections, and even surgery (usually after failed conservative treatment for >6 mos)(Emedicine). Low level laser therapy has also been found to be an ineffective treatment modality for lateral epicondylalgia.

Physical Therapy Management

Physical therapy interventions including elbow joint mobilization with movement combined with exercise has been shown to have better results than corticosteroid injection at 6 weeks and to wait and see at 6 weeks but not 52 weeks. Recent research regarding cervicothoracic joint mobilization in conjunction with local treatment for lateral epicondylalgia has shown improvements in strength, pain, and tolerance to activity compared to local treatment alone.
Physical therapy management including only the use of ultrasound, massage, and exercise has been shown to be no better than a "wait and see" treatment method. Activity modification, when possible, can help prevent recurrent episodes of lateral epicondylalgia, as well as use of a counterforce brace as needed.

Key Research

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Resources

• Nirschl, RP, Pettrone FA, Tennis elbow and the surgical treatment of lateral epicondylitis. Journal of Bone and Joint Surgery. 61A:832, 1979.
• Wright JG. Evidence-based orthopaedics: the best answers to clinical questions. Philadelphia: Saunders Elsevier, 2008.
• Whaley AL, Baker CL. Lateral epicondylitis. Clin Sports Med 23 (2004) 677–691.
• Davenport TE, Kulig K, Matharu Y, Blanco CE. The EdUReP Model for Nonsurgical Management of Tendinopathy. Phys Ther. 2005;85(10):1093-103. http://ptjournal.apta.org/content/85/10/1093.long
• Sambrook P, Schrieber L, Taylor T, Ellis A. The musculoskeletal system. Churchill Livingstone, 2001
• Staples MP, Forbes A, Ptasznik R, Gordon J, Buchbinder R. A randomized controlled trial of extracorporeal shock wave therapy for lateral epicondylitis (tennis elbow). J Rheumatol. 2008;35(10):2038-46. A2  http://www.ncbi.nlm.nih.gov/pubmed/18792997 (accessed 17 Nov 2010)
• Rompe JD et al., Repetitive Low-Energy Shock Wave Treatment for Chronic Lateral Epicondylitis in Tennis Players, Am J Sports Med. 2004 Apr-May;32(3):734-43. A2 http://chroniccure.net/physicians/research/2004-03-11-AJSMRompe-Epicondylitis.pdf  (accessed 1 Nov 2010)

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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