- Email: [email protected]
Lateral Epicondylitis
CHAPTER 22
Lateral Epicondylitis Lyn D. Weiss, MD Jay M. Weiss, MD
Symptoms
Synonyms
Patients usually report pain in the area just distal to the lateral epicondyle. They may complain of pain radiating proximally or distally. Patients may also complain of pain with wrist or hand movement, such as gripping a doorknob, carrying a briefcase, or shaking hands. Patients occasionally report swelling as well.
Tendinosis1 Lateral epicondylitis Tennis elbow
ICD-10 Codes M77.10 M77.11 M77.12
Lateral epicondylitis, unspecified elbow Lateral epicondylitis, right elbow Lateral epicondylitis, left elbow
Definition Epicondylitis is a general term used to describe inflammation, pain, or tenderness in the region of the medial or lateral epicondyle of the humerus. The actual nidus of pain and pathologic change has been debated. Lateral epicondylitis implies an inflammatory lesion with degeneration at the tendinous origin of the extensor muscles (the lateral epicondyle of the humerus). The tendon of the extensor carpi radialis brevis muscle is primarily affected. Other muscles that can contribute to the condition are the extensor carpi radialis longus and the extensor digitorum communis. Although the term epicondylitis implies an inflammatory process, inflammatory cells are not identified histologically. Instead, the condition may be secondary to failure of the musculotendinous attachment with resultant fibroplasia,2 termed tendinosis. Other postulated primary lesions include angiofibroblastic tendinosis, periostitis, and enthesitis.3 Overall the focus of injury appears to be the common extensor tendon origin. Symptoms may be related to failure of the repair process.4 Repetitive stress has been implicated as a factor in this condition.5 Overuse from a tennis backhand (especially a one-handed backhand with poor technique) can frequently lead to lateral epicondylitis (hence the term tennis elbow is frequently used synonymously with lateral epicondylitis, regardless of its etiology). Repetitive computer use (especially with a mouse) as well as golf, swimming, and baseball can cause or exacerbate epicondylitis. 124
Physical Examination On examination, the hallmark of epicondylitis is tenderness over the extensor muscle origin. The common origin of the extensor muscles can be located one fingerbreadth below the lateral epicondyle. With lateral epicondylitis, pain is increased with resisted wrist extension, especially with the elbow extended, the forearm pronated, the wrist radially deviated, and the hand in a fist. The middle finger test can also be used to assess for lateral epicondylitis. Here, the proximal interphalangeal joint of the long finger is resisted in extension and pain is elicited over the lateral epicondyle. Swelling is occasionally present. In cases of recalcitrant lateral epicondylitis, the diagnosis of radial nerve entrapment should be considered. The radial nerve can become entrapped just distal to the lateral epicondyle where the nerve pierces the intermuscular septum (between the brachialis and brachioradialis muscles). There may be localized tenderness along the course of the radial nerve around the radial head. Motor and sensory findings are usually absent.
Functional Limitations The patient may complain of an inability to lift or carry objects on the affected side secondary to increased pain. Typing, using a computer mouse, or working on a keyboard may recreate the pain. Even handshaking or squeezing may be painful in lateral epicondylitis. Athletic activities may cause pain, especially with an acute increase in repetition, poor technique, and equipment changes (frequently with a new racket or restringing).
Diagnostic Studies The diagnosis is usually made on clinical grounds. Magnetic resonance imaging (MRI), which is particularly useful for soft tissue definition, can be used to assess for tendinitis, tendinosis, degeneration, partial or complete tears, and detachment of the common extensor tendons at the lateral epicondyle.6
CHAPTER 22 Lateral Epicondylitis
125
MRI is rarely needed, however, except in recalcitrant epicondylitis, and it will not alter the treatment significantly in the early stages. The lateral collateral ligament complexes can be evaluated for tears as well as for chronic degeneration and scarring. Ultrasonography has been used to diagnose lateral epicondylitis.7 The common extensor tendon and the radial nerve may appear swollen on the affected side.8 Findings of radial nerve involvement may indicate that the pain was secondary to radial nerve entrapment. Arthrography may be beneficial if capsular defects and associated ligament injuries are suspected. Barring evidence of trauma, early radiographs are of little help in this condition but may be useful in cases of resistant tendinitis and to rule out occult fractures, arthritis, and an osteochondral loose body.
Differential Diagnosis Posterior interosseous nerve syndrome Bone infection or tumors Ulnar or median neuropathy around the elbow Osteoarthritis Acute calcification around the lateral epicondyle9 Osteochondral loose body Anconeus compartment syndrome10 Triceps tendinitis Degenerative arthrosis11 Elbow synovitis Lateral ligament instability12 Radial head fracture Bursitis Collateral ligament tears Hypertrophic synovial plica13
Treatment Initial Initial treatment consists of relative rest, avoidance of repetitive motions involving the wrist, activity modification to avoid stress on the epicondyle, anti-inflammatory medications, and thermal modalities such as heat and ice for acute pain. Patients who develop lateral epicondylitis from tennis should modify their stroke (especially improving the backhand stroke to ensure that the forearm is in midpronation and the trunk is leaning forward) and their equipment, usually by reducing string tension and enlarging the grip size.5 Frequently a two-handed backhand will relieve the stress sufficiently. In addition, a forearm band (counterforce brace) worn distal to the extensor muscle group origin can be beneficial (Fig. 22.1). The theory behind this device is that it will dissipate forces over a larger area of tissue than the lateral attachment site. Alternatively, the use of wrist immobilization splints may be helpful. A splint set in neutral can be helpful for lateral epicondylitis by relieving the tension on the flexors and extensors of the wrist and fingers. A splint set in 30 to 40 degrees of wrist extension will relieve the tension on the extensor tendons, including the extensor carpi radialis brevis muscle as well as other wrist and finger extensors.14,15 Dynamic extension bracing has also been proposed.16
FIG. 22.1 Forearm band (counterforce brace) used in patients with lateral epicondylitis.
Rehabilitation Rehabilitation may include physical or occupational therapy. Therapy should include two phases. The first phase is directed at decreasing pain by physical modalities (ultrasound, electrical stimulation, phonophoresis, cortisone iontophoresis,17 myofascial release,18 heat, ice, massage) and decreasing disability (education, reduction of repetitive stress, and preservation of motion). When the patient is pain free, a gradual program is implemented to improve strength and endurance of wrist extensors and stretching. This program must be carefully monitored to permit strengthening of the muscles and work hardening of the tissues without itself causing an overuse situation. The patient should start with static exercises and advance to progressive resistive exercises (with an emphasis on the eccentric phase of the exercise). Thera-Band, light weights, and manual (self) resistance exercises can be used. Work or activity restrictions or modifications may be required for a time.
Procedures Injections may be useful if therapy and exercise have not provided relief.19,20 Injection of corticosteroid, usually with a local anesthetic, into the area of maximum tenderness (approximately 1 to 5 cm distal to the lateral epicondyle) has been shown to be effective in the shortterm treatment of lateral epicondylitis (Fig. 22.2),21-23 although several studies have questioned the long-term efficacy of these injections.24,25 To confirm the diagnosis, a trial of lidocaine alone may be given. An immediate improvement in grip strength should be noted after injection. Postinjection treatment includes icing of the affected area both immediately (for 5 to 10 minutes) and thereafter (a reasonable regimen is 20 minutes two or three times per day for 2 weeks) and wearing of a wrist splint (particularly for activities that involve wrist movement). The wrist splint should be set in slight extension for lateral epicondylitis. Exacerbating activities are to be avoided. Plateletrich plasma injections have been shown to reduce pain and
126
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Potential Treatment Complications Analgesics and nonsteroidal anti-inflammatory drugs have well-known side effects that most commonly affect the gastric, hepatic, and renal systems. Local steroid injections may increase the risk for disruption of tissue planes, create highpressure tissue necrosis, rupture tendons,1 damage nerves, promote skin depigmentation or atrophy, or cause infection.42
References
FIG. 22.2 Under sterile conditions, with use of a 27-gauge needle and 1 to 2 mL of a local anesthetic combined with 1 to 2 mL of a corticosteroid preparation, inject the solution approximately 1 to 5 cm distal to the lateral epicondyle. The injected materials should flow smoothly. Resistance generally indicates that the solution is being injected directly into the tendon, which should be avoided.
to increase function in patients with lateral epicondylitis to be superior in the intermediate (12 weeks) and long term (6 months to a year).22,23,26-29 However, the optimal concentration of platelets, frequency of application, cell types, and optimal regimen for tissue repair remain unclear.30 Injection of botulinum toxin into the extensor digitorum communis muscles to the third and fourth digits has been reported to be beneficial in chronic treatment– resistant lateral epicondylitis.31,32 Injection of autologous blood has also been shown to improve pain but may pose a higher risk of adverse events.33 There are studies that support acupuncture as an effective modality in the short-term relief of lateral epicondylitis.34-36 Extracorporeal shock wave treatment may also be beneficial.37 A recent study investigated the effectiveness of microtenotomy using a radiofrequency probe in patients with chronic tendinosis of the elbow. Results showed improvement in pain self-reporting.38 In a small study of recalcitrant cases of lateral epicondylitis, pulsed radiofrequency has also been used on the radial nerve (under ultrasound guidance).39
Technology There is no specific technology for the treatment or rehabilitation of this condition.
Surgery Surgery may be indicated in those patients with continued severe symptoms who do not respond to conservative management. For lateral epicondylitis, surgery is aimed at excision and revitalization of the pathologic tissue in the extensor carpi radialis brevis and release of the muscle origin.40 Pinning may be done if the elbow joint is unstable.41
Potential Disease Complications Possible long-term complications of untreated epicondylitis include chronic pain, loss of function, and possible elbow contracture. In general, epicondylitis is more easily and successfully treated in the acute phase.
1. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow): clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999;81:259–278. 2. Nirschl RP, Pettrone FA. Tennis elbow. J Bone Joint Surg Am. 1979;61:832–839. 3. Nirschl RP. Elbow tendinosis/tennis elbow. Clin Sports Med. 1992;11:851–870. 4. Putnam MD, Cohen M. Painful conditions around the elbow. Orthop Clin North Am. 1999;30:109–118. 5. Cassvan A, Weiss LD, Weiss JM, et al. Cumulative trauma disorders. Boston: Butterworth-Heinemann; 1997:123–125. 6. Braddom RL. Physical medicine and rehabilitation. Philadelphia: WB Saunders; 1996:222. 7. Bodor M, Fullerton B. Ultrasonography of the hand, wrist, and elbow. Phys Med Rehabil Clin N Am. 2010;21:509–531. 8. Gürçay E, Karaahmet ÖZ Kara M, et al. Ultrasonographic evaluation of the radial nerves in patients with unilateral refractory lateral epicondylitis. Pain Med. 2016. pii: pnw181. 9. Hughes E. Acute deposition of calcium near the elbow. J Bone Joint Surg Br. 1950;32:30–34. 10. Abrahamsson S, Sollerman C, Soderberg T, et al. Lateral elbow pain caused by anconeus compartment syndrome. Acta Orthop Scand. 1987;58:589–591. 11. Brems JJ. Degenerative joint disease of the elbow. In: Nicholas JA, Hershman EB, eds. The upper extremity in sports medicine. St. Louis: Mosby; 1995:331–335. 12. Morrey BF. Anatomy of the elbow joint. In: Morrey BF, et al., eds. The elbow and its disorders. 2nd ed. Philadelphia: WB Saunders; 1993:16. 13. Kim DH, Gambardella RA, El Attrache NS, et al. Arthroscopic treatment of posterolateral elbow impingement from lateral synovial plicae in throwing athletes and golfers. Am J Sports Med. 2006;34:438–444. 14. Plancher KD. The athletic elbow and wrist, part I. diagnosis and conservative treatment. Clin Sports Med. 1995;15:433–435. 15. Derebery VJ, Devenport JN, Giang GM, Fogarty WT. The effects of splinting on outcomes for epicondylitis. Arch Phys Med Rehabil. 2005;86:1081–1088. 16. Faes M, van den Akker B, de Lint JA, et al. Dynamic extensor brace for lateral epicondylitis. Clin Orthop Relat Res. 2006;442:149–157. 17. Stefanou A, Marshall N, Holdan W, Siddiqui A. A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis. J Hand Surg [Am]. 2012;37:104–109. 18. Ajimsha MS, Chithra S, Thulasyammal RP. Effectiveness of myofascial release in the management of lateral epicondylitis in computer professionals. Arch Phys Med Rehabil. 2012;93:604–609. 19. Murtezani A, Ibraimi Z, Vllasolli TO, et al. Exercise and therapeutic ultrasound compared with corticosteroid injection for chronic lateral epicondylitis: a randomized controlled trial. Ortop Traumatol Rehabil. 2015;17(4):351–357. 20. Coombes BK, Connelly L, Bisset L, et al. Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial. Br J Sports Med. 2016;50(22):1400–1405. 21. Hay EH, Paterson SM, Lewis M, et al. Pragmatic randomized controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ. 1999;319:964–968. 22. Mi B, Liu G, Zhou W, et al. Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials. Phys Sportsmed. 2017:1–8. 23. Qian X, Lin Q, Wei K, Hu B, Jing P, Wang J. Efficacy and safety of autologous blood products compared with corticosteroid injections in the treatment of lateral epicondylitis: a meta-analysis of randomized controlled trials. PM R. 2016;8(8):780–791.
CHAPTER 22 Lateral Epicondylitis
24. Sirico F, Ricca F, DI Meglio F, et al. Local corticosteroid versus autologous blood injections in lateral epicondylitis: meta-analysis of randomized controlled trials. Eur J Phys Rehabil Med. 2016. 25. Claessen FM, Heesters BA, Chan JJ, et al. A meta-analysis of the effect of corticosteroid injection for enthesopathy of the extensor carpi radialis brevis origin. J Hand Surg Am. 2016;41(10):988–998. 26. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010;38:255–262. 27. Gosens T. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2011;39:1200–1208. 28. Hechtman KS, Uribe JW, Botto-vanDemden A, Kiebzak GM. Plateletrich plasma injection reduces pain in patients with recalcitrant epicondylitis. Orthopedics. 2011;34:92. 29. Khaliq A, Khan I, Inam M, et al. Effectiveness of platelets rich plasma versus corticosteroids in lateral epicondylitis. J Pak Med Assoc. 2015;65(11 suppl 3):S100–S104. 30. Halpern BC, Chaudhury S, Rodeo SA. The role of platelet-rich plasma in inducing musculoskeletal tissue healing. HSS J. 2012;8(2):137–145. 31. Morre HH, Keizer SB, van Os JJ. Treatment of chronic tennis elbow with botulinum toxin. Lancet. 1997;349:1746. 32. Wong SM, Jui AC, Tong PY, et al. Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2005;143:793–797. 33. Arirachakaran A, Sukthuayat A, Sisayanarane T, et al. Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis. J Orthop Traumatol. 2016;17(2):101–112.
127
34. Trinh KV, Phillips SD, Ho E, Damsma K. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology (Oxford). 2004;43:1085–1090. 35. Fink M, Wolkenstein E, Luennemann M, et al. Chronic epicondylitis: effects of real and sham acupuncture treatment: a randomised controlled patient- and examiner-blinded long-term trial. Forsch Komplementarmed Klass Naturheilkd. 2002;9:210–215. 36. Fink M, Wolkenstein E, Karst M, Gehrke A. Acupuncture in chronic epicondylitis: a randomized controlled trial. Rheumatology (Oxford). 2002;41:205–209. 37. Gunduz R, Malas FU, Borman P, et al. Physical therapy, corticosteroid injection, and extracorporeal shock wave treatment in lateral epicondylitis. clinical and ultrasonographical comparison. Clin Rheumatol. 2012;31:807–812. 38. Tasto JP, Richmond JM, Cummings JR, et al. Radiofrequency microtenotomy for elbow epicondylitis: midterm results. Am J Orthop (Belle Mead NJ). 2016;45(1):29–33. 39. Oh DS, Kang TH, Kim HJ. Pulsed radiofrequency on radial nerve under ultrasound guidance for treatment of intractable lateral epicondylitis. J Anesth. 2016;30(3):498–502. 40. Organ SW, Nirschl RP, Kraushaar BS, Guidi EJ. Salvage surgery for lateral tennis elbow. Am J Sports Med. 1997;25:746–750. 41. Brown D, Freeman E, Cuccurullo S. Elbow disorders. In: Cuccurullo S, ed. Physical medicine and rehabilitation board review. New York: Demos; 2004:163–173. 42. Nichols AW. Complications associated with the use of corticosteroids in the treatment of athletic injuries [review]. Clin J Sport Med. 2005;15:370–375.
Lateral Epicondylitis Lyn D. Weiss, MD Jay M. Weiss, MD
Symptoms
Synonyms
Patients usually report pain in the area just distal to the lateral epicondyle. They may complain of pain radiating proximally or distally. Patients may also complain of pain with wrist or hand movement, such as gripping a doorknob, carrying a briefcase, or shaking hands. Patients occasionally report swelling as well.
Tendinosis1 Lateral epicondylitis Tennis elbow
ICD-10 Codes M77.10 M77.11 M77.12
Lateral epicondylitis, unspecified elbow Lateral epicondylitis, right elbow Lateral epicondylitis, left elbow
Definition Epicondylitis is a general term used to describe inflammation, pain, or tenderness in the region of the medial or lateral epicondyle of the humerus. The actual nidus of pain and pathologic change has been debated. Lateral epicondylitis implies an inflammatory lesion with degeneration at the tendinous origin of the extensor muscles (the lateral epicondyle of the humerus). The tendon of the extensor carpi radialis brevis muscle is primarily affected. Other muscles that can contribute to the condition are the extensor carpi radialis longus and the extensor digitorum communis. Although the term epicondylitis implies an inflammatory process, inflammatory cells are not identified histologically. Instead, the condition may be secondary to failure of the musculotendinous attachment with resultant fibroplasia,2 termed tendinosis. Other postulated primary lesions include angiofibroblastic tendinosis, periostitis, and enthesitis.3 Overall the focus of injury appears to be the common extensor tendon origin. Symptoms may be related to failure of the repair process.4 Repetitive stress has been implicated as a factor in this condition.5 Overuse from a tennis backhand (especially a one-handed backhand with poor technique) can frequently lead to lateral epicondylitis (hence the term tennis elbow is frequently used synonymously with lateral epicondylitis, regardless of its etiology). Repetitive computer use (especially with a mouse) as well as golf, swimming, and baseball can cause or exacerbate epicondylitis. 124
Physical Examination On examination, the hallmark of epicondylitis is tenderness over the extensor muscle origin. The common origin of the extensor muscles can be located one fingerbreadth below the lateral epicondyle. With lateral epicondylitis, pain is increased with resisted wrist extension, especially with the elbow extended, the forearm pronated, the wrist radially deviated, and the hand in a fist. The middle finger test can also be used to assess for lateral epicondylitis. Here, the proximal interphalangeal joint of the long finger is resisted in extension and pain is elicited over the lateral epicondyle. Swelling is occasionally present. In cases of recalcitrant lateral epicondylitis, the diagnosis of radial nerve entrapment should be considered. The radial nerve can become entrapped just distal to the lateral epicondyle where the nerve pierces the intermuscular septum (between the brachialis and brachioradialis muscles). There may be localized tenderness along the course of the radial nerve around the radial head. Motor and sensory findings are usually absent.
Functional Limitations The patient may complain of an inability to lift or carry objects on the affected side secondary to increased pain. Typing, using a computer mouse, or working on a keyboard may recreate the pain. Even handshaking or squeezing may be painful in lateral epicondylitis. Athletic activities may cause pain, especially with an acute increase in repetition, poor technique, and equipment changes (frequently with a new racket or restringing).
Diagnostic Studies The diagnosis is usually made on clinical grounds. Magnetic resonance imaging (MRI), which is particularly useful for soft tissue definition, can be used to assess for tendinitis, tendinosis, degeneration, partial or complete tears, and detachment of the common extensor tendons at the lateral epicondyle.6
CHAPTER 22 Lateral Epicondylitis
125
MRI is rarely needed, however, except in recalcitrant epicondylitis, and it will not alter the treatment significantly in the early stages. The lateral collateral ligament complexes can be evaluated for tears as well as for chronic degeneration and scarring. Ultrasonography has been used to diagnose lateral epicondylitis.7 The common extensor tendon and the radial nerve may appear swollen on the affected side.8 Findings of radial nerve involvement may indicate that the pain was secondary to radial nerve entrapment. Arthrography may be beneficial if capsular defects and associated ligament injuries are suspected. Barring evidence of trauma, early radiographs are of little help in this condition but may be useful in cases of resistant tendinitis and to rule out occult fractures, arthritis, and an osteochondral loose body.
Differential Diagnosis Posterior interosseous nerve syndrome Bone infection or tumors Ulnar or median neuropathy around the elbow Osteoarthritis Acute calcification around the lateral epicondyle9 Osteochondral loose body Anconeus compartment syndrome10 Triceps tendinitis Degenerative arthrosis11 Elbow synovitis Lateral ligament instability12 Radial head fracture Bursitis Collateral ligament tears Hypertrophic synovial plica13
Treatment Initial Initial treatment consists of relative rest, avoidance of repetitive motions involving the wrist, activity modification to avoid stress on the epicondyle, anti-inflammatory medications, and thermal modalities such as heat and ice for acute pain. Patients who develop lateral epicondylitis from tennis should modify their stroke (especially improving the backhand stroke to ensure that the forearm is in midpronation and the trunk is leaning forward) and their equipment, usually by reducing string tension and enlarging the grip size.5 Frequently a two-handed backhand will relieve the stress sufficiently. In addition, a forearm band (counterforce brace) worn distal to the extensor muscle group origin can be beneficial (Fig. 22.1). The theory behind this device is that it will dissipate forces over a larger area of tissue than the lateral attachment site. Alternatively, the use of wrist immobilization splints may be helpful. A splint set in neutral can be helpful for lateral epicondylitis by relieving the tension on the flexors and extensors of the wrist and fingers. A splint set in 30 to 40 degrees of wrist extension will relieve the tension on the extensor tendons, including the extensor carpi radialis brevis muscle as well as other wrist and finger extensors.14,15 Dynamic extension bracing has also been proposed.16
FIG. 22.1 Forearm band (counterforce brace) used in patients with lateral epicondylitis.
Rehabilitation Rehabilitation may include physical or occupational therapy. Therapy should include two phases. The first phase is directed at decreasing pain by physical modalities (ultrasound, electrical stimulation, phonophoresis, cortisone iontophoresis,17 myofascial release,18 heat, ice, massage) and decreasing disability (education, reduction of repetitive stress, and preservation of motion). When the patient is pain free, a gradual program is implemented to improve strength and endurance of wrist extensors and stretching. This program must be carefully monitored to permit strengthening of the muscles and work hardening of the tissues without itself causing an overuse situation. The patient should start with static exercises and advance to progressive resistive exercises (with an emphasis on the eccentric phase of the exercise). Thera-Band, light weights, and manual (self) resistance exercises can be used. Work or activity restrictions or modifications may be required for a time.
Procedures Injections may be useful if therapy and exercise have not provided relief.19,20 Injection of corticosteroid, usually with a local anesthetic, into the area of maximum tenderness (approximately 1 to 5 cm distal to the lateral epicondyle) has been shown to be effective in the shortterm treatment of lateral epicondylitis (Fig. 22.2),21-23 although several studies have questioned the long-term efficacy of these injections.24,25 To confirm the diagnosis, a trial of lidocaine alone may be given. An immediate improvement in grip strength should be noted after injection. Postinjection treatment includes icing of the affected area both immediately (for 5 to 10 minutes) and thereafter (a reasonable regimen is 20 minutes two or three times per day for 2 weeks) and wearing of a wrist splint (particularly for activities that involve wrist movement). The wrist splint should be set in slight extension for lateral epicondylitis. Exacerbating activities are to be avoided. Plateletrich plasma injections have been shown to reduce pain and
126
PART 1 MSK Disorders
Potential Treatment Complications Analgesics and nonsteroidal anti-inflammatory drugs have well-known side effects that most commonly affect the gastric, hepatic, and renal systems. Local steroid injections may increase the risk for disruption of tissue planes, create highpressure tissue necrosis, rupture tendons,1 damage nerves, promote skin depigmentation or atrophy, or cause infection.42
References
FIG. 22.2 Under sterile conditions, with use of a 27-gauge needle and 1 to 2 mL of a local anesthetic combined with 1 to 2 mL of a corticosteroid preparation, inject the solution approximately 1 to 5 cm distal to the lateral epicondyle. The injected materials should flow smoothly. Resistance generally indicates that the solution is being injected directly into the tendon, which should be avoided.
to increase function in patients with lateral epicondylitis to be superior in the intermediate (12 weeks) and long term (6 months to a year).22,23,26-29 However, the optimal concentration of platelets, frequency of application, cell types, and optimal regimen for tissue repair remain unclear.30 Injection of botulinum toxin into the extensor digitorum communis muscles to the third and fourth digits has been reported to be beneficial in chronic treatment– resistant lateral epicondylitis.31,32 Injection of autologous blood has also been shown to improve pain but may pose a higher risk of adverse events.33 There are studies that support acupuncture as an effective modality in the short-term relief of lateral epicondylitis.34-36 Extracorporeal shock wave treatment may also be beneficial.37 A recent study investigated the effectiveness of microtenotomy using a radiofrequency probe in patients with chronic tendinosis of the elbow. Results showed improvement in pain self-reporting.38 In a small study of recalcitrant cases of lateral epicondylitis, pulsed radiofrequency has also been used on the radial nerve (under ultrasound guidance).39
Technology There is no specific technology for the treatment or rehabilitation of this condition.
Surgery Surgery may be indicated in those patients with continued severe symptoms who do not respond to conservative management. For lateral epicondylitis, surgery is aimed at excision and revitalization of the pathologic tissue in the extensor carpi radialis brevis and release of the muscle origin.40 Pinning may be done if the elbow joint is unstable.41
Potential Disease Complications Possible long-term complications of untreated epicondylitis include chronic pain, loss of function, and possible elbow contracture. In general, epicondylitis is more easily and successfully treated in the acute phase.
1. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow): clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999;81:259–278. 2. Nirschl RP, Pettrone FA. Tennis elbow. J Bone Joint Surg Am. 1979;61:832–839. 3. Nirschl RP. Elbow tendinosis/tennis elbow. Clin Sports Med. 1992;11:851–870. 4. Putnam MD, Cohen M. Painful conditions around the elbow. Orthop Clin North Am. 1999;30:109–118. 5. Cassvan A, Weiss LD, Weiss JM, et al. Cumulative trauma disorders. Boston: Butterworth-Heinemann; 1997:123–125. 6. Braddom RL. Physical medicine and rehabilitation. Philadelphia: WB Saunders; 1996:222. 7. Bodor M, Fullerton B. Ultrasonography of the hand, wrist, and elbow. Phys Med Rehabil Clin N Am. 2010;21:509–531. 8. Gürçay E, Karaahmet ÖZ Kara M, et al. Ultrasonographic evaluation of the radial nerves in patients with unilateral refractory lateral epicondylitis. Pain Med. 2016. pii: pnw181. 9. Hughes E. Acute deposition of calcium near the elbow. J Bone Joint Surg Br. 1950;32:30–34. 10. Abrahamsson S, Sollerman C, Soderberg T, et al. Lateral elbow pain caused by anconeus compartment syndrome. Acta Orthop Scand. 1987;58:589–591. 11. Brems JJ. Degenerative joint disease of the elbow. In: Nicholas JA, Hershman EB, eds. The upper extremity in sports medicine. St. Louis: Mosby; 1995:331–335. 12. Morrey BF. Anatomy of the elbow joint. In: Morrey BF, et al., eds. The elbow and its disorders. 2nd ed. Philadelphia: WB Saunders; 1993:16. 13. Kim DH, Gambardella RA, El Attrache NS, et al. Arthroscopic treatment of posterolateral elbow impingement from lateral synovial plicae in throwing athletes and golfers. Am J Sports Med. 2006;34:438–444. 14. Plancher KD. The athletic elbow and wrist, part I. diagnosis and conservative treatment. Clin Sports Med. 1995;15:433–435. 15. Derebery VJ, Devenport JN, Giang GM, Fogarty WT. The effects of splinting on outcomes for epicondylitis. Arch Phys Med Rehabil. 2005;86:1081–1088. 16. Faes M, van den Akker B, de Lint JA, et al. Dynamic extensor brace for lateral epicondylitis. Clin Orthop Relat Res. 2006;442:149–157. 17. Stefanou A, Marshall N, Holdan W, Siddiqui A. A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis. J Hand Surg [Am]. 2012;37:104–109. 18. Ajimsha MS, Chithra S, Thulasyammal RP. Effectiveness of myofascial release in the management of lateral epicondylitis in computer professionals. Arch Phys Med Rehabil. 2012;93:604–609. 19. Murtezani A, Ibraimi Z, Vllasolli TO, et al. Exercise and therapeutic ultrasound compared with corticosteroid injection for chronic lateral epicondylitis: a randomized controlled trial. Ortop Traumatol Rehabil. 2015;17(4):351–357. 20. Coombes BK, Connelly L, Bisset L, et al. Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial. Br J Sports Med. 2016;50(22):1400–1405. 21. Hay EH, Paterson SM, Lewis M, et al. Pragmatic randomized controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ. 1999;319:964–968. 22. Mi B, Liu G, Zhou W, et al. Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials. Phys Sportsmed. 2017:1–8. 23. Qian X, Lin Q, Wei K, Hu B, Jing P, Wang J. Efficacy and safety of autologous blood products compared with corticosteroid injections in the treatment of lateral epicondylitis: a meta-analysis of randomized controlled trials. PM R. 2016;8(8):780–791.
CHAPTER 22 Lateral Epicondylitis
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