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Lateral Epicondylitis

Peter B. J. Wu, M.D. / June 21, 1996

Incidence:

• 1-3% in the general population, work-related cases 59 per 10,000 workers per year, 7.4% of industrial workers in the USA at some time are affected by it.
• Not related to tennis in at least 95% of patients. Most cases are caused by occupational stress rather than racket sports. However, tennis players have a reported incidence from 10 to 50%.
• The younger group has a sports-related injury. The older group has epicondylitis as a result of a work-related injury or overuse syndrome. A work-related overuse syndrome is much more difficult to treat.
• Most often in white male between 30 and 60 years of age. The dominant side of the body is more frequently affected. (70-87%)

Etiology:

Natural History:

Histopathology:

• periostitis, subtendinous granulation tissue, or bursitis.
• Nirschl: invasion of fibroblasts and vascular granulation tissue---angiofibroblastic hyperplasia. Calcification at the tendon origin, granulation tissue, and avascularity of the tendon were noted.
• Regan W et al (1992): 11 patients with symptom duration from 7 to 96 months, vascular and fibroblastic proliferation accompanied by focal hyaline degeneration of the aponeurotic origin of the ECRB tendon. This may explain the lack of response to rest and anti-inflammatory medication. The ECRB origin has been cited by many authors as the primary sited of abnormalities.

Symptoms and Signs:

• Aching may increase in the evening, with elbow stiffness in the morning on awakening a frequent complaint. There is usually no visible swelling. If swelling is present, arthritis, synovitis, infection, trauma and tumor should be diagnostic considerations.
• It is not uncommon for patients to develop symptoms after either adopting a new activity or increasing the duration or intensity of an established one.
• Coffee-cup sign

Diagnosis:

• X-ray: to rule out radiocapitellar arthritis, malignant lesion, rare diseases like epiphysiolysis, osteochondritis dissecans, osteonecrosis, loose bodies, or arthrosis of the elbow joint.
• MR: The definition of tendon degeneration and degree of tear, as depicted on MR images, correlate well with surgical and histologic findings. Areas of signal hyperintensity on MR images correlated with findings of neovascularization and/or mucoid degeneration at histopathologic examination.

Differential Diagnosis:

Neuropathic

Radial tunnel syndrome
Entrapment of posterior interosseous nerve
Entrapment of musculocutaneous nerve
Entrapment of median nerve (pronator syndrome)
Ulnar entrapment syndrome

Inflammatory

Radiocapitellar arthritis
Synovitis
Gouty arthritis
Joint space infection

Trauma

Radial neck fracture
Distal humerus fracture

Referred pain

Cervical radiculopathy
Shoulder arthritis
Carpal tunnel syndrome
Angina pectoris

Other

Medial epicondylitis
Tumor (primary or secondary)
Bone cyst

Treatment:

• Phase I: Acute Management
  • Reducing inflammation
  • Rest
  • Passive ROM
  • Cold therapy
  • Splinting (Cock-up splint) for 2 weeks, and to maintain the wrist in 20° of extension.
  • NSAIDs
• Phase II: Post-acute management
  • Return of normal muscular strength and endurance. This is also the stage where specific inciting factors are identified and modified.
  • Patient education, protection of the painful elbow, avoidance or modification of aggravating actions.
  • Active wrist exercises are performed with increasing repetitions. Specific attention is directed to the wrist and finger extensors and supinator. The use of a wrist roll and a weighted rod.
  • Transverse friction massage
  • Steroid phonophoresis
  • Ultrasound
  • Cold therapy
  • High Voltage Galvanic Stimulation
  • TENS
  • Corticosteroid injection. collagen healing may be effected adversely by the presence of corticosteroids, worsening of pain in half of the patients, in some case lasting for days. The injection should be spaced at least 1 month apart, with no more than three injections administered to the same region within a 1-year period.
  • Tennis elbow band: static and counterforce--- preventing full muscular expansion, decreasing the force of the muscle contraction, creating a new functional origin, and broadening the area of applied stress. The force may be partially transferred to the brace itself. A statistically significant increase in strength with the strap was found at 120°/sec but not 30°/sec with isokinetic testing. Nirschl reported that 1000 patients experienced relief or decrease of symptoms through use of the armband. Wadsworth found use of the armband increased in wrist extension and grip strength. They postulated that the armband disperses stresses generated by muscle contraction, thereby reducing painful inhibition and allowing the subject to contract more forcefully. The armband may also facilitate muscle contraction by sensory skin stimulation and/or muscle belly pressure.
  • Acupuncture.
• Phase III: Conditioning
  • Functional rehabilitation designed to return the patient to the desired level of activity. Progressive, controlled exercise is the key to stimulating the biological healing process. Human pain thresholds vary so widely that pain is unreliable in many cases.
  • Strengthening
  • Technique modification
  • Equipment modification
  • Gradual return to activity
  • Rehabilitation is crucial to prevent recurrence.
  • Surgery: severe pain for at least 6 months, no response to two weeks of immobilization and no response to two local injections of corticosteroids. The percentage of cases that prove resistant to conservative care or the passage of time ranges from 4 to 10%.
  • Intra-articular procedures
  • Extra-articular procedures
       Incise the extensor origin with subsequent excision of any underlying abnormal granulation tissue followed by repair of the extensor tendon after appropriate lateral epicondylar bony decortication. a posterior elbow splint at 90 degrees with the inclusion of the wrist at 30 to 45 degrees of extension postoperatively for a total 3-5 days to 3 weeks. At 6 weeks postoperatively, all splinting is discontinued with gentle and controlled strengthening being started on the extensor muscle mass.
       The technique most commonly used that seems to give the most consistent results is excision of the ECRB.

  • Labelle H et al (1992): There is not enough scientific evidence to favor any particular type of treatment for acute lateral epicondylitis.

REFERENCES

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