Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Tennis Elbow

Basics
Description
  • Lateral epicondylitis (tennis elbow) is a tendinopathy of the origin of the ECRB tendon.
  • The lateral epicondyle is the origin of the common wrist extensor tendon, including:
    • ECRL
    • ECRB
    • Extensor digitorum communis
    • Extensor carpi ulnaris
  • The ECRB lies beneath the ECRL.
  • These extensors stabilize the wrist and are used in sports (such as tennis) during a backhand stroke.
  • Lateral epicondylitis typically occurs from overuse in the nonathlete’s dominant arm during the 4th and 5th decades.
General Prevention
Use of good form while playing tennis (i.e., proper grip size, backhand technique)
Epidemiology
Occurs equally in males and females

Incidence
The peak incidence is in the 5th decade .
Risk Factors
  • Patients are susceptible with activities of repetitive supination and pronation of the forearm in which the elbow is near full extension (such as in tennis).
  • Although tennis elbow is its common name, lateral epicondylitis can be seen in other racket sports, fencing, and certain occupations with repetitive actions (e.g., plumbing, painting, knitting, and dentistry).
  • Associations have been made to poor stroke mechanics, improper racket grip size, racket weight, and racket stringing.
  • Harder playing surfaces produce more force on the ball and therefore create greater transmitted forces to the lateral epicondyle.
Etiology
  • Initiated as a microtear within the origin of ECRB.
  • The ECRL and extensor digitorum communis also are susceptible.
  • Insufficient healing response leaves the ECRB origin vulnerable to secondary injury.
Diagnosis
Signs and Symptoms
  • Patients usually have a history of repetitive activity.
  • Pain is present at the lateral epicondyle with resisted wrist extension that is made worse when the elbow is extended.
  • Symptoms are exacerbated with activity and improve with rest.
  • Patients report pain with grasping objects.
  • Elbow ROM usually is not compromised.
Physical Exam
  • Tenderness over the origin of the common wrist extensor tendons at the lateral epicondyle
  • Tenderness may extend distally.
  • Reproduction of pain with passive flexion of the wrist with the elbow extended
  • The clinician should check for radial tunnel syndrome, in which pain is reproduced with active middle finger extension against resistance.
  • A cervical spine examination is warranted for all patients, especially if symptoms are bilateral.
Tests
Imaging
  • Radiographs:
    • AP and lateral radiographs of the elbow are obtained to rule out fractures or other lesions in the elbow.
    • AP and lateral plain radiographs usually are negative, but 23% of patients may show calcifications in the local soft tissue .
    • Consider cervical spine radiographs if symptoms possibly originate from the neck.
  • CT may be warranted for detailed evaluation of the joint in cases of a loose body or arthritis.
  • MRI usually is not necessary, but it may show tendon thickening with increased T1 and T2 signals.
Diagnostic Procedures/Surgery
Electromyography may be helpful in distinguishing radial tunnel syndrome from lateral epicondylitis .

Pathological Findings
  • Microscopic tears within the substance of the ECRB
  • Histology shows replacement of tendon collagen fibers with vascular granulation-like tissue and fibroblasts, termed angioblastic proliferation.
Differential Diagnosis
  • Differential diagnosis includes cervical spine disease with radiculopathy.
  • Radial tunnel syndrome (5% coexistence reported, compression of posterior interosseous nerve as it enters the supinator muscle)
  • Olecranon bursitis
  • Medial epicondylitis
  • UCL strain/sprain
  • Intra-articular disease, such as arthritis, osteochondritis dissecans of the capitellum, or loose body
Treatment
General Measures
  • Nonoperative treatment includes rest, counterforce straps, wrist splint, activity modification, cryotherapy, NSAIDs, and physical therapy initially.
  • Athletes should improve technique and mechanics and modify equipment as detailed above.
  • If results are poor with initial therapy, then consider corticosteroid injection.
    • Caution should be used, because multiple injections or incorrectly given injections increase the risk of tendon rupture.
  • Nonoperative treatment is successful in 95% of patients .
  • Newer treatments, including low-level laser and extracorporeal shock wave, have not shown substantial benefit when compared with placebo treatment in a recent meta-analysis .
Activity
Patients should be instructed to rest the affected extremity and that activity can be resumed in a graduated fashion as symptoms improve.
Special Therapy
Physical Therapy
  • If pain continues, physical therapy (including ultrasound, iontophoresis, friction massage, and counterforce bracing [tennis elbow strap]) may be helpful.
  • Once symptoms have diminished, a stretching and strengthening program directed at forearm extensors may help to prevent recurrence.

Surgery

  • If nonoperative therapy fails over a 6-month period, operative treatment may be warranted.
  • Traditional surgery consists of resection of the degenerated ECRB origin.
  • The 5% coexistent radial tunnel syndrome also should be released .
  • Arthroscopic debridement of the ECRB origin represents a promising surgical procedure with quicker return to activity .
Follow-up
  • The splint is removed in 1 week, and ROM exercises are initiated.
  • Once the wound is well healed, strengthening exercises are added to the therapy program and pain-limited activity can be started.
  • Full activity usually is possible in ~3 months.
Prognosis
  • Lateral epicondylitis has the potential to be a chronic problem with periods of exacerbation and relief.
  • Patients usually (95%) have success with nonoperative treatment.
Complications
  • Few complications occur with nonoperative therapy.
  • Potential surgical complications include tendon rupture (retear), infection, decreased ROM, and stiffness.
Patient Monitoring
Repeat radiographs in 3 months if the pain persists.
Miscellaneous
Codes
ICD9-CM
726.32 Tennis elbow (lateral epicondylitis)
Patient Teaching
Lateral epicondylitis is typically a result of chronic overload of the wrist extensors.
Activity
Activity modification is an important element of treatment.
Prevention
  • Proper technique and grip size for playing tennis
  • 2-hand backhand eliminates strain on the ECRB.
FAQ
Q: What devices can one wear to relieve lateral epicondylitis?
A: Patients with lateral epicondylitis typically respond to counterforce strapping (placing a strap around the proximal forearm) and wrist splinting (immobilizing the wrist puts the wrist extensors at rest).
Q: When would injecting lateral epicondylitis with cortisone be considered?
A: If symptoms persist after activity modification, physical therapy, and bracing.

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