Lateral Epicondylitis Case File

Lateral Epicondylitis Case File

Eugene C. Toy, MD, Andrew J. Rosenbaum, MD, Timothy T. Roberts, MD, Joshua S. Dines, MD

CASE 33

A 43-year-old dentist presents to the clinic with debilitating left elbow pain and stiffness. He states that his left elbow has been bothering him on and off for several weeks but has recently been getting worse. He states that he has been having trouble grasping and gripping objects and feels as if his hand is not working properly. The patient is concerned because the pain and stiffness are beginning to limit him in what he can do in his practice. On physical exam, he is found to have pain on palpation of his lateral elbow and pain with resisted wrist extension and radial deviation. There is minimal swelling present. All motor and sensory findings are normal. His past medical history and review of systems are otherwise unremarkable.

► What is the most likely diagnosis?

► What is the initial treatment?

► Should the patient receive a steroid injection?

ANSWER TO CASE 33:

Lateral Epicondylitis                              

Summary: A 43-year-old otherwise healthy dentist presents with left elbow pain localized to its lateral aspect. The pain has progressively worsened over the last several weeks, and he now reports stiffness and difficulty with grasping objects. The patient is found to have tenderness with palpation of the lateral epicondyle, specifically at the origin of the forearm extensors, as well as pain with resisted wrist extension and pain with resisted radial deviation. All motor and sensory findings are normal. Radiographs of the elbow are negative for any pathology.

• Most likely diagnosis: Lateral epicondylitis (tennis elbow).
• Initial treatment: Rest and activity modifications designed to avoid repetitive movements that stress the wrist and forearm extensor tendons. Nonsteroidal anti-inflammatory medications (NSAIDs) can be prescribed, and icing may provide symptomatic relief. A forearm band or “counterforce brace” that is worn distal to the origin of the extensor group could be worn. Once pain has subsided, stretching and strengthening of the forearm extensors should be performed to prevent recurrence of symptoms.
• Utility of a steroid injection: Corticosteroids, usually administered concurrently with a local anesthetic, into the area of maximal tenderness, have been shown to be beneficial in achieving transient pain relief. However, multiple corticosteroid injections may be associated with rupture of the extensor tendon origin and/or lateral collateral ligament, both devastating complications.

ANALYSIS

Objectives

1. Know the causes of lateral epicondylitis and the populations most affected.
2. Be familiar with the differential diagnosis for lateral epicondylitis.
3. Know the treatment options for lateral epicondylitis.

Considerations

This 43-year-old dentist presents with left elbow pain localized to the extensor origin at the lateral elbow. His history and physical exam are concerning for lateral epicondylitis, more commonly known as tennis elbow. However, this diagnosis is one of exclusion, and it is essential to rule out other possible injuries, such as a radial and posterior interosseous nerve (PIN) entrapment syndromes, occult fractures, radial head arthritis, C6 and C7 nerve root compression, posterolateral plica, and osteochondral loose bodies. Plain radiographs and physical exam are effective at evaluating for such pathology. In this patient, exam findings that make the diagnosis of lateral epicondylitis more likely include localized elbow tenderness at the origin of the forearm extensors, pain with resisted wrist extension, and pain with resisted radial deviation.

APPROACH TO:

Lateral Epicondylitis                                

DEFINITIONS

LATERAL EPICONDYLITIS: An overuse syndrome or tendinosis affecting the lateral humeral epicondyle. It most commonly involves the extensor carpi radialis brevis (ECRB) but may also involve the extensor digitorum communis (EDC). Lateral epicondylitis is more commonly referred to as tennis elbow.

MAUDSLEY TEST: A test used to evaluate for tennis elbow. It is positive when the patient experiences pain in the region of the lateral epicondyle during resisted extension of the middle finger.

CLINICAL APPROACH

Etiology

Lateral epicondylitis is a condition that typically affects middle-aged men and women, resulting in mild to severe discomfort and functional impairment. Although it is also known as tennis elbow because of the vulnerability of tennis players to this injury, javelin throwers, bowlers, swimmers, golfers, and pitchers are also susceptible because of the stress that is placed on the forearm and wrist extensor tendons in those sports. Individuals whose vocational demands include repetitious upper extremity movements, such as carpenters, plumbers, shoemakers, surgeons, and musicians (ie, violinists), are also at risk of developing lateral epicondylitis. The ECRB is most often implicated, but EDC involvement also occurs.

    Although epicondylitis is commonly thought of as an inflammatory process, this is a misconception; histology reveals neither acute nor chronic inflammatory changes, but instead hyaline degeneration and vascular proliferation, typically at the ECRB origin ( Figure 33–1 ). These histologic findings have been termed angiofibroblastic dysplasia. One proposed mechanism by which this occurs involves repetitive microtrauma to the ECRB with an incomplete healing and regenerative response.

Clinical Presentation and Diagnosis

On presentation, patients complain of pain and sometimes stiffness around the lateral aspect of the elbow. They may also describe subjective feelings of tightness in the forearm. It is usually the dominant arm that is affected, and it is rarely seen bilaterally. Physical exam should include evaluation of range of motion at the wrist and elbow, motor strength of the forearm extensor muscles, and palpation of the radial head. Tenderness localized to the lateral epicondyle, where the extensor muscles originate, is present on palpation, especially when the elbow is held in extension, the forearm held in pronation, and the wrist held in flexion. Additionally, both resisted wrist extension and resisted radial deviation may cause pain in the region of the lateral epicondyle. The Maudsley test should also be performed and is positive when the patient complains of pain in the region of the lateral epicondyle during resisted extension of the middle finger. A lidocaine injection test can be used to differentiate between tennis elbow and posterior interosseous nerve (PIN) syndrome, an entrapment neuropathy that is commonly misdiagnosed as lateral epicondylitis as a result of a similar constellation of symptoms. In the case of radial tunnel syndrome, an injection given 4 fingerbreadths distal to the lateral epicondyle will result in a temporary PIN palsy and in the setting of radial tunnel syndrome, a temporary relief in pain. If the injection fails to provide relief, the diagnosis of lateral epicondylitis is more likely and can be confirmed with transient pain relief from a lidocaine injection at the origin of the ECRB tendon.

Figure 33–1. (A) Lateral view of the forearm. (B) Superficial and (C) deep muscles of the posterior

forearm. (Reproduced, with permission, from Morton DA, Foreman KB, Albertine KH. The Big Picture: Gross Anatomy. New York, NY: McGraw-Hill; 2011:Fig. 32-2.)

Imaging has limited utility in the diagnosis of lateral epicondylitis and is most beneficial for ruling out other processes, such as arthritis or fractures. Plain radiographs only rarely show soft-tissue calcification near the lateral epicondyle, which if present would be suggestive of tennis elbow. Ultrasound and magnetic resonance imaging can be used to visualize the extensor tendons and elbow joint, but are only indicated if the patient’s symptoms fail to improve after 3 months of conservative treatment.

TREATMENT

Conservative, nonoperative treatment modalities are always attempted first, with operative interventions reserved for refractory cases. Pain reduction is the first treatment goal, and NASIDs, rest, and splinting are often trialled. Patients should be advised to attempt to reduce performing strenuous activities that exacerbate their symptoms for at least 6 weeks. Wrist splints are particularly useful if the elbow tenderness is exacerbated by resisted wrist extension. A counterforce brace can also be used and functions as an inelastic cuff around the proximal forearm against the extensor compartment that reduces the forces generated by the muscles. Other conservative measures that may relieve pain include corticosteroid injections adjacent to the ECRB tendon and extracorporeal shock wave therapy. More recently, injection of platelet-rich plasma has also shown some promise in providing symptomatic relief. Once pain relief is achieved, extensor compartment stretching and strengthening exercises should commence and will help to prevent symptom recurrence.

    Cases in which symptoms fail to resolve with 6 to 12 months of conservative treatment can be treated with operative intervention, in which any degenerative, angiofibrotic tissue is debrided, and the ERCB, common extensor tendon, and its aponeurosis are repaired if torn. Both open and arthroscopic techniques have been described. Surgery is followed by a period of rest followed by progressive rehabilitation and strengthening. The major complication following this procedure is posterolateral elbow instability, which results from excessive debridement of collateral ligament and extensor muscle origins on the lateral epicondyle.

COMPREHENSION QUESTIONS

33.1 A 45-year-old carpenter has chronic pain and stiffness over the lateral aspect of the elbow, especially when using a hammer. On exam, Maudsley test is positive. Which muscle attachment is likely to be involved?

A. Extensor carpi radialis longus

B. Brachioradialis

C. Extensor carpi radialis brevis

D. Supinator

33.2 A 65-year-old tennis player presents to your office complaining of pain localized over the insertion of the extensor carpi radialis brevis. On exam, you also note pain with resisted wrist extension and subsequently diagnosis the patient with lateral epicondylitis. What is the histologic term used to describe tennis elbow?

A. Reactive hyperemia

B. Lateral epicondylitis

C. Angiofibroblastic dysplasia

D. Apoptosis

33.3 A 40-year-old woman who you have recently diagnosed with lateral epicondylitis wants to know her treatment options. Which of the following are considered first-line interventions?

A. NSAIDs

B. Wrist splinting

C. ECRB debridement

D. Counterforce brace

E. A, B, D

ANSWERS

33.1 C. The extensor carpi radialis brevis is the most common forearm extensor associated with lateral epicondylitis. The extensor digitorum communis has also been implicated. The extensor carpi radialis longus and extensor carpi ulnaris can also be involved, but it is very rare.

33.2 C. The histologic term used to describe tennis elbow is angiofibroblastic dysplasia. This is because tennis elbow results from hyaline degeneration and vascular proliferation at the ECRB origin. Microscopic evaluation shows fibroblast hypertrophy, disorganized collagen, and vascular hyperplasia. Although tennis elbow is named lateral epicondylitis, it is not due to inflammatory processes.

33.3 E. Conservative measures used in the treatment of lateral epicondylitis include rest, ice, NSAIDs, physical therapy, bracing, steroid injections, extracorporeal shock wave therapy, and platelet-rich plasma. ECRB debridement with possible tendon repair is only performed after 6 to 12 months of failed conservative treatment.

    CLINICAL PEARLS    

► Lateral epicondylitis, or tennis elbow, is a diagnosis of exclusion. ► The ECRB is most often implicated, but EDC involvement also occurs in tennis elbow. ► Exam findings consistent with lateral epicondylitis include point tenderness at the forearm extensor origin on the lateral epicondyle, pain with resisted wrist extension, pain with resisted radial deviation, and a positive Maudsley test. ► Imaging rarely has a role in the diagnosis of tennis elbow. ► Conservative treatment modalities should always be tried first, with operative intervention reserved for refractory cases. ► Despite its name, lateral epicondylitis is not technically the result of an inflammatory response, but rather a pathological process of hyaline degeneration and vascular proliferation termed angiofibroblastic dysplasia.

REFERENCES

De Smedt T, et al. Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment. Br J Sports Med . 2007;41:816-819. 

Faro F, Wolf JM. Lateral epicondylitis: review and current concepts. J Hand Surg Am . 2007;32: 1271-1279.

HomeOrthopaedic Surgery Case FileLateral Epicondylitis Case File