Lateral Epicondylitis Flashcards
Background
The most common overuse syndrome is related to excessive wrist extension and commonly referred to as “tennis elbow,” but it is actually more common in non-tennis players.
It is also commonly referred to as lateral epicondylitis, but this is usually a misnomer because, in general, microscopic evaluation of the tendons does not show signs of inflammation, but rather angiofibroblastic degeneration and collagen disarray.
Light microscopy reveals both an excess of fibroblasts and blood vessels that are consistent with neovessels or angiogenesis.
The tendons are relatively hypovascular proximal to the tendon insertion. This hypovascularity may predispose the tendon to hypoxic tendon degeneration and has been implicated in the etiology of tendinopathies.
Most typically, the primary pathology is tendinosis of the extensor carpi radialis brevis (ECRB) tendon 1-2 cm distal to its attachment on the lateral epicondyle
Epidemiology
The annual incidence is 1-3% of the U.S. population. Men and women are equally affected.
- Typically, lateral epicondylitis affects individuals greater than age 40 years.
- There is usually a history of repetitive activity aggravating the extensor tendons of the forearm. Repetitive, eccentric motion of the wrist extensor muscles may increase risk of injury. Individuals with a current or prior history of tobacco use were also noted to be at increased risk.
Functional Anatomy
The area of maximal tenderness is usually an area just distal to the origin of the extensor muscles of the forearm at the lateral epicondyle. Most typically, the ECRB is involved, but others may include the extensor digitorum and extensor carpi ulnaris.
The radial nerve splits into the superficial radial and posterior interosseus nerve (PIN) at the radiocapitellar joint. The PIN may become entrapped by pericapsular structures, causing radial tunnel syndrome.
Sport-Specific Biomechanics
Long Summary
Tennis is the most common sport to cause lateral epicondylitis, but the condition can also be seen in those who play squash and badminton. Symptoms can occur after an improper backhand hitting technique, which can occur when the athlete attempts to increase power by increasing forearm force rather than relying on core, rotator cuff, and scapular power. This results in snapping the wrist with supination and irritation of the extensor tendons. Symptoms can also occur with improper technique when an athlete does not get his or her feet into position and hits the ball late or when the athlete strikes the ball with a bent “leading” elbow. The power of the hit is again generated from the forearm instead of the core. This condition has also been observed more frequently in novice players when compared with more experienced players. This may be secondary to the ability of experienced players to decrease the impact forces from the racquet to the wrist.
In comparing one-handed versus two-handed backhand stroke, electromyography (EMG) results demonstrated reduced amplitude with a two-handed backhand versus a one-handed backhand stroke. [6]
Other causes of extensor tendinopathy in tennis are using new racquet, using a racquet that is strung too tightly, or using a racquet that is too heavy, as well as hitting wet or heavy balls or hitting into the wind. It is unclear if a grip that is sized too small or too large contributes to the development of lateral epicondylitis. However a recent, very small study by Rossi et al revealed that there may be an optimal grip size to reduce grip forces as well as reduce extensor tendon loading during a tennis stroke. In addition, string vibration dampeners have not been shown to decrease the incidence of lateral epicondylitis.
Industrial athletes have certain occupational and leisure activities that lead to overuse injuries of the forearm wrist extensors, causing pain at the lateral epicondyle. These include carpenters, bricklayers, seamstresses and tailors, politicians (excessive handshaking), and musicians (eg, pianists, drummers). Such injuries can also be seen in individuals who perform a lot of computer work, a lot of typing, and a lot of mouse work for their occupations.
Clinical History for Lateral Epicondilitis
- The typical age of those affected is 40 to 50 years.
Patients most typically report an insidious onset, but they will often relate a history of overuse without specific trauma. - Symptom onset generally occurs 24-72 hours after repeated wrist extension activity.
- Delayed symptoms are probably due to microscopic tears in the tendon.
- The patient complains of pain over the lateral elbow that worsens with activity and improves with rest. The patient will also often describe aggravating conditions such as a backhand stroke in tennis or the overuse of a screwdriver.
- Pain may radiate down the posterior aspect of the forearm.
- The patient can often pinpoint pain 1.5 cm distal to the origin of the ECRB.
- Pain can vary from being mild (eg, with aggravating activities like tennis or the repeated use of a hand tool), or it can be such severe pain that simple activities like picking up and holding a coffee cup (ie, “coffee cup sign”) will act as a trigger for the pain.
Physical Exam on Lateral Epicondilitis
- Inspection: Very rarely does one notice swelling or ecchymosis.
* 2. Palpation: Maximal tenderness is elicited 1-2 cm distal to the origin of the ECRB at the lateral epicondyle.
* 3. Pain is increased with resisted wrist extension, with the wrist radially deviated and pronated and the elbow extended - Pain may also increase when the patient attempts to lift the back of a chair with the elbow extended and the wrist maximally pronated.
- Resisted extension of the middle finger is also painful secondary to stress placed on the ECRB tendon, as it is preferentially stressed in this position when it must contract synergistically to anchor the third metacarpal, such that extension can take place at the digits. [9]
- Increased pain is noted with resisted supination, gripping hand shaking.
- Always examine ROM of the shoulder, elbow, and wrist on the affected side.
- Examine ROM and test for crepitus at the radiohumeral joint of the affected limb to evaluate for radiohumeral bursitis, osteochondritis of the capitellum, or PIN entrapment.
- If decreased ROM if noted on physical examination, consider obtaining an x-ray to further evaluate the joint.
Lateral Epicondylitis Causes
- Poor general conditioning leads to fatigue of the core and shoulder muscles, which puts an overemphasis on the extensor muscles of the forearm.
- Improper training (eg, poor positioning when striking a tennis ball)
- Improper technique (eg, hitting a tennis ball late on the backhand)
- Poor or improper equipment (eg, a racquet that is strung too tightly)
- Scapular dyskinesis will lead to a compensatory increased load placed on the ipsilateral wrist extensors.
Lateral Epicondylitis Differential Diagnoses
Cervical Radiculopathy
Elbow and Forearm Overuse Injuries
Little League Elbow Syndrome
Medial Epicondylitis
Plica Syndrome
Radial Nerve Entrapment
Lateral Epicondylitis Workup
Laboratory Studies
-Laboratory studies are typically not useful in the workup of lateral epicondylitis.
Imaging Studies
i. Imaging studies are rarely needed in the initial workup of lateral elbow pain.
ii. Consider pain film radiologic evaluation if the patient’s symptoms persist despite adequate treatment or to evaluate for osteophytes, degenerative joint disease, or OCD
iii. Plain films may reveal osteophytes or calcifications along the lateral epicondyle.
iv. Consider magnetic resonance imaging (MRI), bone scanning, and/or computed tomography (CT) scanning to evaluate for OCD or stress fractures.
v. Musculoskeletal ultrasound is emerging as a useful modality to characterize areas of tendinosis, partial tearing, or calcifications and may assist with treatment options.
Other Tests
A local anesthetic block may lead to symptom resolution and confirmation of the diagnosis.
Lateral Epicondylitis Treatment & Management
Watchful waiting
Smidt et al noted a greater improvement in pain symptoms from lateral epicondylitis at 52 weeks when employing watchful waiting relative to the administration of corticosteroid injections. [10] In addition, watchful waiting was about equally as effective as physiotherapy at 52 weeks. However, corticosteroid injections were significantly better than both watchful waiting and physiotherapy at 6 weeks.
In 2006, Bisset et al investigated treating lateral epicondylitis with physiotherapy, corticosteroid injection, or watchful waiting in 198 individuals with symptoms for greater than 6 weeks. [1] Outcomes were global improvement in symptoms, pain-free grip force, and assessment of severity of complaints. There were significant reductions in all outcomes measured for corticosteroid injections over watchful waiting at 6 weeks. In the corticosteroid group, 78% reported success, versus 27% for those in the watchful waiting group. Corticosteroid injections also outperformed physiotherapy at 6 weeks, with 65% of the physiotherapy group having success versus 78% of the corticosteroid group. Physiotherapy was superior to watchful waiting at 6 weeks. However, the improvement in symptoms with corticosteroid injections was not sustained at 52 weeks.
At 52 weeks, the injection group was significantly worse on all outcomes compared with the physiotherapy group and worse on 2 of 3 measures compared with watchful waiting. Finally, at 52 weeks, there was not much of a difference in comparing physiotherapy to watchful waiting. Fifty-nine of 63 much improved or completely recovered in the physiotherapy group, versus 56 of 62 in the watchful waiting group. This study again elucidates that corticosteroid injections may have some benefit in the short term, but the long-term benefits are definitely lacking in the treatment of lateral epicondylitis. Physiotherapy demonstrated improvement versus watchful waiting at 5 weeks, with only slight improvement at 52 weeks
Lateral Epicondylitis Treatment & Management
Nonsteroidal anti-inflammatory drugs ( NSAIDS)
Topical NSAIDS such as diclofenac may offer some short-term relief. [11, 12] In a study with oral diclofenac, this agent improved short-term pain and function, but there was no difference noted when comparing naproxen and placebo for pain reduction in lateral epicondylitis. Corticosteroid injection demonstrated greater benefit at 4 weeks when compared with NSAIDS, but no long-term differences were seen.
A Cochrane review in 2013 looked at 17 comparisons of 759 participants and noted that “There remains limited evidence from which to draw firm conclusions about the benefits or harms of topical or oral NSAIDs in treating lateral elbow pain. Although data from five placebo-controlled trials suggest that topical NSAIDs may be beneficial in improving pain (for up to 4 weeks), non-normal distribution of data and other methodological issues precluded firm conclusions.”
Lateral Epicondylitis Treatment & Management
Corticosteroid injection
*In summary, administering a corticosteroid injection is effective in reducing pain from lateral epicondylitis in the short term, but this procedure may not be as effective in the long term.
One study demonstrated administering a corticosteroid injection as having superior efficacy in pain relief at 6 weeks when compared with physiotherapy that consisted of ultrasound, massage, and exercise. However, the authors noted that corticosteroid injection was not as effective as physiotherapy at 12 weeks. [10] Smidt et al found that administering a corticosteroid injection decreased pain in lateral epicondylitis at 6 weeks but not beyond that period.
A 2012 study looked at 297 patients with lateral epicondylitis and found that individuals treated with structured physical therapy had less pain than patients treated with corticosteroid injections or NSAIDs and experienced better function than those treated with corticosteroid injections. The intervention group had a lower recurrence and fewer sick leave days at the time of the visit to the healthcare center. [14]
In another study, when corticosteroid injection was compared with arm bracing, the use of a corticosteroid injection demonstrated decreased pain at 2 weeks, but there was no difference noted at 6 weeks. [15] There was also no significant difference noted in the type of steroid that was injected.
Lateral Epicondylitis Treatment & Management
Counterforce bracing
Counterforce braces are used in an attempt to reduce the tension forces on the wrist extensor tendons, and these orthotics may be superior to lateral epicondyle bandages in reducing resting pain. [17] The brace should be applied firmly approximately 10 cm distal to the elbow joint. Use of a counterforce brace may decrease pain and increase grip strength at 3 weeks in individuals with lateral epicondylitis. [18] However, some authors believe that no firm conclusions can be drawn from the use of orthotics in the treatment of lateral epicondylitis. [19] Counterforce braces are possibly inferior in the treatment of lateral epicondylitis when compared with topical NSAIDS and corticosteroid injections.
Jafarian et al compared 3 common types of orthoses for their effect on grip strength in patients with lateral epicondylosis. [20] In a randomized controlled laboratory study in 52 patients, maximum and pain-free grip strength were assessed with the patient wearing an elbow strap orthosis, an elbow sleeve orthosis, a wrist splint, or a placebo orthosis. Use of the elbow strap and sleeve orthoses resulted in an immediate and equivalent increase in pain-free grip strength (P < 0.02); consequently, the researchers suggest that either of these types of orthosis may be used. [20] The wrist splint provided no immediate improvement in either pain-free or maximum grip strength.
At 6 weeks, significant improvement was noted in all parameters with the implementation of counterforce bracing. The wrist splint group demonstrated improvement in all parameters measured at 2 and 6 weeks except for sensitivity at 2 weeks. Comparison of the 2 groups showed significant improvement in resting pain at 2 weeks for the wrist splint group over the counterforce brace group. No other significant differences were noted between the 2 groups. This study was limited by lack of a control, nonbraced, group. In summary, all patients improved with either counterforce elbow bracing or wrist splint bracing at 2 and 6 weeks. Wrist splint bracing, however, demonstrated an advantage on some measured subjective and objective parameters.
Huge list of other treatments for Lateral Epicondilitis
Extracorporeal shock wave therapy (ECSWT)
There has been no significant benefit demonstrated in using ECSWT to treat patients with lateral epicondylitis.
Ultrasound-guided percutaneous radiofrequency thermal lesioning
In August of 2011, Lin et al published a study looking at a novel method of treating chronic refractory lateral epicondylitis with ultrasound-guided percutaneous radiofrequency thermal lesioning (RTL). [9] They enrolled 34 patients (35 elbows) with symptoms of lateral epicondylitis for greater than 6 months in whom previous interventions had failed. Patients were examined at baseline and then at 1, 3, and 6 months after the index procedure. Outcomes measures were VAS at rest and activity, QuickDASH scores, and the Modified Mayo Clinic Performance Index (MMCPI) for the elbow.
Significant pain reductions were noted at the 1, 3, and 6 months of follow up. Grip strength improved significantly at 3 and 6 months of follow up but not significantly at the 1 month of follow up. DASH and MMCPI scores improved significantly at all follow-up measurements. Eighty-five percent of the patients reported pain relief at the 1-month follow-up. Ninety-one percent of the subjects reported good-to-excellent satisfaction results at 6 months. Five patients needed a repeat procedure because of unsatisfactory symptom relief, and, of these, 4 reported satisfactory results after the second procedure. No change was noted on ultrasound in the thickness of the origin of the extensor tendon. [9]
Laser therapy
Low-level laser treatments have not been proven to be an effective method to treat patients with pain from lateral epicondylitis. [23]
Acupuncture
Systemic reviews and meta-analyses have demonstrated some evidence of short-term improvement in pain reduction at 2 to 8 weeks in patients suffering from lateral epicondylar pain. [19, 24] However, other studies demonstrated insufficient evidence to recommend its use. [12]
Autologous blood
Autologous blood injections are thought to initiate an inflammatory process and promote improved healing of degenerative tissue via the relatively atraumatic injection itself as well as providing necessary cellular and humoral mediators to induce a healing cascade. Edwards and Calandruccio studied 28 people in whom conservative therapy had failed to resolve symptoms from their lateral epicondylitis. [25] They were given a cock-up wrist splint and told to avoid any other bracing or physical therapy for 3 weeks. A home exercise program was initiated at week 3. The study demonstrated 22 (79%) of 28 of the patients had a reduction in Nirschl pain scores over 9.5 months after autologous blood injection therapy. [25] Most often, this occurred after only one injection. However, this study is limited as it lacked a control group. [10]
A study by Connnell et al in 2005 looked at ultrasound-guided autologous blood injections as a treatment for 35 individuals with lateral epicondylitis confirmed on MRI. These patients had symptoms for a median of almost 14 months and conservative therapy had not been successful. Outcomes were measured as reduction in VAS and Nirschl pain scores at 4 weeks and 6 months. No formal physical therapy or home exercise program was recommended. Autologous blood injections demonstrated significant improvements in VAS and Nirschl pain measurements at 4 weeks and at 6 months. Autologous blood injections also demonstrated statistical improvements in tendon thickness, interstitial cleft formation, echoic foci, hyperechoic change, and neovascularity. [11]
A small study was recently published comparing autologous blood, corticosteroid, and saline injection in the treatment of lateral epicondylitis of less than 6 months’ duration in 28 individuals. Patients were followed for 6 months after the injections, and the outcomes measured were reduction in DASH scores and pain- and disease-specific functional scores. Participants were not given any formal physical therapy regimen or orthotics. They were simply given a standard sheet of stretching exercises to which compliance was not measured. All 3 injections caused a decrease in DASH scores at 2 weeks and 2 months and a significant decrease at 6 months; however, there were no significant differences between the 3 groups. In addition, patient reported scores of pain and function also improved among all 3 groups. [12]
An August 2010 study by Kazremi et al performed a single blinded randomized clinical trial comparing autologous blood injections to corticosteroid injection in 60 individuals with lateral elbow tendinopathy during the past year. [15] Bracing, physical therapy, or anti-inflammatory medications were not allowed during the duration of the study.
Outcomes were measurement of VAS pain scale, DASH questionnaire, modified Nirschl pain scores, maximum grip strength, and pain pressure threshold. Short-term follow-up was ascertained at 4- and 8-week intervals. Corticosteroid injections demonstrated improvements at 4 weeks in all outcome scores except pain pressure threshold. There was no significant improvement from 4-8 weeks in the steroid group for any of the outcomes except a decrease in limb pain and a worsening of grip strength. The autologous blood group demonstrated statistically significant improvements in all outcomes measured at 4 and 8 weeks. Autologous blood injections demonstrated superiority to corticosteroid injections at 4 and 8 weeks in all parameters measured.
In 2010, Ozturan et al performed a 3-armed randomized trial of 60 patients with symptoms consistent with lateral epicondylitis for greater than 6 months with no previous physical therapy in the past 3 months to a corticosteroid injection, autologous blood injection, or extracorporeal shock wave therapy (ESWT). [26] Outcomes measured were Thomsen provocative test scores, upper extremity functional scores, and maximal grip strength. Assessment was at 4, 12, 26, and 52 weeks. Sixteen of the 20 patients in the autologous blood group received a second injection at 6 weeks.
In this study, at 4 weeks, the corticosteroid group had a significant improvement in a functional score and Thomsen provocative tests over both the autologous blood group and the ESWT group. There was no difference between the autologous blood group and the ESWT at 4 weeks. There was no significant difference in these tests at the 12-week mark. Following patterns from other studies, the corticosteroid group performed less well the longer that the patients were followed. There was a statistically significant improvement for the autologous blood and ESWT groups compared with the corticosteroid groups at the 26- and 52-week follow-up appointments for functional scores and Thomsen provocative tests.
Grip strength was also assessed at the same time intervals and noted an improvement for the corticosteroid group at 4 weeks compared with autologous blood and ESWT. There was no difference noted in grip strength at 12 weeks between the three groups. ESWT performed better at the 26-week follow-up with respect to grip strength when compared with autologous blood and corticosteroid injections. At 52 weeks, there was no significant difference between the three groups with respect to grip strength. At 52 weeks, the success rate for corticosteroid injections was 50%, compared with 83% for autologous blood injections and 89% for ESWT treatments.
This study supported the idea the corticosteroid injections can be helpful for temporary and short term improvement in chronic lateral epicondylitis patients, but that autologous blood and ESWT tend to have more lasting improvements. [27]
A very small study in 2013 also demonstrated effectiveness of autologous blood injections for the treatment of chronic lateral epicondylitis. However, the patients were placed in a long arm cast for three weeks after the injection. Long arm cast immobilization is not the standard of care after proinflammatory injections.
Platelet rich plasma (PRP)
Another study demonstrated significantly reduced pain when treating chronic elbow tendinosis with buffered platelet rich plasma. Mishra and Pavelko evaluated 140 patients with elbow epicondylar pain; 20 patients continued to consider surgical intervention after conservative therapy failed to resolve their symptoms. [29] These patients were then administered either a single percutaneous injection of platelet-rich plasma or bupivacaine (control group). At 8 weeks after therapy, the authors demonstrated a 60% pain improvement in the group who received the platelet-rich plasma compared with a 16% pain improvement in the control group. [29] At 6 months and final follow-up (mean, 25.6 mo; range, 12-38 mo), the patients who had received the platelet-rich plasma continued to report significant pain reduction.
A study was published in August 2011 comparing PRP therapy injections to autologous blood injections in 28 patients who had symptoms of lateral epicondylitis for greater than 3 months. Patients were instructed on home physical therapy consisting of eccentric exercises. Reevaluation was done at 6 weeks, 3 months, and 6 months to assess symptoms on a VAS pain scale and a Liverpool elbow score, which measured range of motion, activity level, and ulnar nerve function. On the VAS scale, both groups demonstrated improvements at all follow-up appointments. The PRP group had better results at each visit, with statistically better results at 6 weeks. Both groups also showed improvements on the Liverpool elbow score at all visits, with no significant differences noted. [16]
Also in 2011, Creany et al compared PRP injections to autologous blood injections in 130 individuals with refractory symptoms of lateral epicondylitis in whom conservative physical therapy had failed. These injections were performed under ultrasound guidance, and each group had two injections, initial visit and then 1 month later. The outcome measured was the Patient-Related Tennis Elbow Evaluation (PRTEE) score. Success was defined as a 25-point improvement in this score. Measurements were obtained a 0, 1, 3, and 6 months. At 6 months, there was a 66% success rate in the PRP group and a 72% success rate in the autologous blood group. However, 20% of the autologous blood group went on to have surgery, versus 10% of the PRP group. [30]
More recently in 2013, Raeisadat et al performed a randomized clinical trial involving 40 patients who had symptoms consistent with lateral epicondylitis for greater than 3 months. They looked at improvement in pain and function when comparing PRP with autologous blood. Both groups were given a counterforce brace and a home exercise program. At 4 weeks, Mayo and visual analogue scale (VAS) scores significantly improved in both the PRP and the autologous blood groups. However, only the PRP group demonstrated significant improvement at 8 weeks with respect to the VAS and Mayo scores. [31]
Krogh et al examine whether a single injection of platelet-rich plasma (PRP) is more effective than placebo (saline) or glucocorticoid in reducing pain in adults with LE after 3 months. The authors conclude that either injection of PRP nor glucocorticoid was superior to saline with regard to pain reduction in LE at the primary end point at 3 months. However, injection of glucocorticoid had a short-term pain-reducing effect at 1 month in contrast to the other therapies. Injection of glucocorticoid in LE reduces both color Doppler activity and tendon thickness compared with PRP and saline. [32]
Mishra et al evaluate the clinical value of tendon needling with PRP in patients with chronic tennis elbow compared with an active control group. No significant differences were found at 12 weeks in this study, however, at 24 weeks, clinically meaningful improvements were found in patients treated with leukocyte-enriched PRP compared with an active control group. [33]
Hyaluronate (HA) injections
A novel approach to the treatment of chronic lateral epicondylitis is HA injections. Petrella et al looked at treating 331 individuals with lateral elbow pain of greater than 3 months with either 1% sodium HA or saline. This was a double-blinded study, and each group received an injection at baseline and then 1 week later. Participants had not had any recent injections. They were instructed on postinjection care of rest, ice, compression, elevation (RICE) and no formal physical therapy was prescribed. Primary outcomes were improvement on VAS at rest and after elbow grip testing. VAS pain at rest and after grip testing was significantly better in the HA group versus the saline group. There was also improvement in secondary outcomes of grip strength, patient global satisfaction, and assessment of normal elbow function in the HA group versus the saline group. These differences persisted at the 90-day and 365-day follow-up appointments. [34]
Polidocanol
Polidocanol is a vascular sclerosant. Zeisig et al looked at 32 patients with symptoms of chronic lateral epicondylitis in whom conservative therapy had failed. [35] Some patients had previously had injections (cortisone = 24, botulism = 5). Eccentric strengthening was previously used in 22 participants and 2 participants had tendon-lengthening surgery. Symptoms were present for more than 3 months and there had been no previous treatment in the past 3 months. Groups were randomized to either an ultrasound-guided blinded injection of polidocanol or lidocaine plus epinephrine.
Patients were followed for 3 months for primary endpoints of satisfaction with treatment and elbow pain during grip activities of daily life. At 3 months, if they still had pain, they were offered another injection of polidocanol. They were then followed for a total of 12 months. At 3 and 12 months, there was a significant improvement in patient satisfaction and in VAS grip pain from baseline for both groups. However, there was no significant difference between the groups.
Botulinum toxin (BTX) In a study by Wong et al, the authors demonstrated that an injection of BTX decreased patients' pain from lateral epicondylitis at 4-12 weeks when compared with saline injection; however, there was an increased incidence of side effects in the BTX treated group, which included digit paresis and weakness of finger extension. [36] In addition, the trial was small (60 patients), most of the patients were women, and the blinding of the study may have been affected by some of the patients possibly knowing which treatment they received (4 patients experienced digit paresis and may have correctly deduced they received the BTX injection). A study by Placzek et al also demonstrated improvement in painful symptoms arising from lateral epicondylitis when BTX injections were used compared with saline. [37] However, another randomized controlled trial demonstrated no significant difference when comparing injections of BTX and saline in the treatment of lateral epicondylitis. [38]
Topical nitrates
Topical nitrates are thought to stimulate collagen synthesis and improve healing. Paolini et al demonstrated that application of topical nitrates to be an effective method of treating pain from lateral epicondylitis.
