Lateral Epicondylitis

 

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Clinically Relevant Anatomy

Lateral epicondylitis- more appropriately re-named lateral epicondylalgia- is a disorder affecting the wrist and finger extensor tendinous origin at the lateral epicondyle of the humerus at the elbow. Musculature involved is most commonly the extensor carpi radialis brevis (ECRB), but 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 n. and the posterior interosseous n. at the radiocapitellar joint. 

File:Lateral Elbow.jpg

Lateral Elbow

Mechanism of Injury / Pathological Process

Lateral epicondylalgia is classified as an overuse injury, usually due to repetitive gripping tasks. This disorder affects the extensor tendons at the musculotendinous junction, where excessive loading causes maladaptions in tendon structure that lead to pain. 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. Human biopsy samples do not show evidence of an active inflammatory response, hence the term "tendonopathy" is a better descriptor of pathology. Rather than showing the presence of inflammatory cellular markers, histologic tissue samples show "collagen disorientation, disorganization, and fiber separation by increased proteoglycan content, increased cellularity, neovascularization, with focal necrosis." (Davenport et al)

Clinical Presentation

Patients presenting with lateral epicondylalgia are typically in their 3rd to 5th decade of life, and havecomplaints of pain just distal to the lateral epicondyle, usually with gripping activities. Patients will commonly have pain with palpation of the lateral epicondyle, resisted wrist, or second or third finger extension (Cozen's sign). (Bisset et al) Grip strength will typically be weakened, especially with the elbow extended.

Diagnostic Procedures

• (+) tenderness to palpation at the anterior epicondyle
• Cozen's sign- The patient is positioned with the UE relaxed, elbow extended. The examiner resists supination and wrist extension OR resists middle finger extension; pain is positive for lateral epicondylalgia
• Chair test- patient grasps the back of the chair while standing behind it and attempts to lift it. Pain reproduction at the lateral epicondyle is a positive test
• Mill's Test- The patient is positioned in standing with the UE relaxed at side, 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 epicondylalgia

Plain film radiologic evaluation may be indicated if there is lack of elbow joint movement or if the patient's symptoms persist despite adequate treatment (eMedicine)

Outcome Measures

mASES

QuickDASH (reliability= .90, MCID not reported)

DASH

PSFS (reliability= .82-.92, MCID=2.0)

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Management / Interventions

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)(http://emedicine.medscape.com/article/1231903-overview). Low level laser therapy has been found to be an ineffective treatment modality for lateral epicondylalgia.
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 (Bisset et al 2006). 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. (Cleland et al)
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. (Bisset et al) Activity modification, when possible, can help prevent recurrent episodes of lateral epicondylalgia, as well as use of a counterforce brace as needed.

Differential Diagnosis

• Elbow osteoarthritis
• Fracture
• Radial tunnel syndrome
• Cervical Radiculopathy

Key Evidence

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