Disclosure Lateral epicondylitis, or tennis elbow, is a commonly encountered problem in orthopedic practice. History of the Procedure: The first description of lateral epicondylitis generally is attributed to Runge in 1873. Since this initial report, much controversy over the pathophysiology and treatment of this disorder has existed. Problem: Lateral epicondylitis is an overuse injury involving the extensor/supinator muscles that originate on the lateral epicondylar region of the distal humerus. Frequency: Lateral epicondylitis has been demonstrated to occur in up to 50% of tennis players. However, this condition is not limited to tennis players and has been reported to be the result of overuse from many activities. Lateral epicondylitis is extremely common in today's active society. Etiology: Any activity involving wrist extension and/or supination can be associated with overuse of the muscles originating at the lateral epicondyle. Tennis has been the activity most commonly associated with the disorder. The risk of overuse injury is increased 2-3 times in players with more than 2 hours of play per week and 2-4 times in players older than 40 years. Several risk factors have been identified, including improper technique, size of racquet handle, and racquet weight. Pathophysiology: Many proposed etiologies for this condition have involved inflammatory processes of the radial humeral bursa, synovium, periosteum, and the annular ligament. However, in 1979, Nirschl and Pettrone attributed the cause to microscopic tearing with formation of reparative tissue (ie, angiofibroblastic hyperplasia) in the origin of the extensor carpi radialis brevis (ECRB) muscle. This microtearing and repair response can lead to macroscopic tearing and structural failure of the origin of the ECRB muscle. Concomitant intra-articular lesions (eg, loose bodies, synovitis, ulnohumeral osteophytes, chondral lesions) have been visualized during elbow arthroscopy in patients with lateral epicondylitis. However, while concomitant intra-articular pathology has been noted, this process is currently considered an extra-articular process. Clinical: Patients present complaining of lateral elbow and forearm pain exacerbated by use. The typical patient is a man or woman aged 35-55 years who either is a recreational athlete or one who engages in rigorous daily activities. Upon examination, the patient has a point of maximal tenderness just distal (5-10 mm) to the lateral epicondyle in the area of the ECRB muscle. Wrist extension or supination (but not flexion or pronation) against resistance with the elbow extended should provoke the patient's symptoms. Another helpful test is the chair raise test. The patient stands behind their chair and attempts to raise it by putting their hands on the top of the chair back and lifting. In patients with lateral epicondylitis, pain results over the lateral elbow.
Approximately 90-95% of patients respond to conservative measures and do not require surgical intervention. Patients who are recalcitrant to 6 months of conservative therapy (including corticosteroid injections) are candidates for surgery.
Relevant Anatomy: The ECRB muscle arises from the lateral epicondyle. The ECRB muscle lies deep to the extensor carpi radialis longus (ECRL) muscle and superficial to the joint capsule. The annular and collateral ligaments are located beneath and just distal to the origin of the ECRB muscle. Contraindications: No absolute contraindications to lateral epicondylitis surgery exist. Relative contraindications include any comorbidities that would place the patient at a more serious level of surgical risk. |
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Imaging Studies:
Other Tests:
Diagnostic Procedures:
Staging: Nirschl defined the following progressive stages:
Medical therapy: Nonsurgical treatment is the mainstay of care for patients with lateral epicondylitis. The goal of initial treatment is cessation of the offending activity. Rest, use of a counterforce brace, and nonsteroidal anti-inflammatory drugs (NSAIDs) often provide relief of symptoms. Often, wrist splinting and/or corticosteroid injections are necessary. When the patient is free of pain through a full range of motion, begin strengthening therapy in a very slow and progressive way. When the patient regains strength and nears resumption of activity, place the emphasis on preventing future irritation (eg, correct technique or address equipment concerns in athletes who participate in racquet sports, modify jobs or activities in patients who are not athletes). Despite some excitement about the use of extracorporeal shock wave therapy, a recent prospective, randomized, blinded, multicenter European trial showed no benefit of this intervention over placebo. Surgical therapy: A myriad of surgical procedures has been described for the treatment of lateral epicondylitis. However, most surgical procedures involve debridement of the diseased tissue of the ECRB muscle with decortication of the lateral epicondyle. This procedure has been performed through open, percutaneous, endoscopic, and arthroscopic approaches. While the classic open approach provides excellent reproducible results, the mentioned minimally invasive approaches are reported to allow earlier rehabilitation and resumption of activities. Preoperative details: Note the length of time of the patient's symptoms. Also note the conservative therapeutic course that has been implemented, including any corticosteroid injections. Consider the patient's worker's compensation status, as these patients may not respond as well to intervention. A full evaluation should be performed on patients with lateral epicondylitis so that any other associated conditions can be detected. Some authors have noted a relatively high incidence of concomitant intra-articular pathology. Intraoperative details: As described by Nirschl, the patient is positioned supine in the classic open-release procedure for lateral epicondylitis. A 3-cm longitudinal incision is made over the lateral epicondyle. An incision is made through the extensor aponeurosis. The ECRL muscle is retracted medially, revealing the degenerative origin of the ECRB. All pathologic tissue is excised. The lateral epicondyle is decorticated with an osteotome or by drill holes. The ECRL is sewn to the extensor aponeurosis in an attempt to repair the defect. (See Images 5-9.) When performing elbow arthroscopy and viewing through the proximal medial portal, the lateral capsule and undersurface of the ECRB tendon is easily visualized and evaluated. By advancing the 30° arthroscope past the radial head, the ECRB tendon is visualized directly in front of the camera and can be followed to its origin on the lateral epicondyle. Associated synovitis may be noted at this location. The capsule is adherent to the undersurface of the ECRB tendon. Often the capsule is torn with the ECRB tendon or is thin and translucent. A 4.5-mm synovial resector then is introduced through the proximal lateral portal. If the capsule is present, it is debrided to reveal the undersurface of the ECRB muscle. The release of the ECRB tendon is begun at the site of pathology and is continued back to its origin on the lateral epicondyle. After release of the visible ECRB origin, a 4.5-mm round burr is used to decorticate the lateral epicondyle and distal portion of the lateral condylar ridge in the area of the ECRB muscle origin. A cadaveric study showed that this release removed an average of 23 mm of ECRB tendon and 22 mm of lateral epicondyle. While more aggressive resection may be possible with the 70° arthroscope, this potentially can injure the lateral collateral ligament complex. Resection to the limit of the visualization provided by the 30° arthroscope produced adequate release while protecting the lateral collateral ligaments. (See Images 1-4.) Postoperative details: Surgical treatment of lateral epicondylitis is an outpatient surgical procedure. If the open approach is used, the patient is usually protected with a splint or brace at 90° initially. Follow-up care: Early motion in a brace may be initiated at 3-5 days, with strengthening exercises usually started by 3 weeks, depending on the patient's symptoms. Return to racquet sports can be expected by 4-6 months. Depending on the specific job requirements, patients can return to work in 6-12 weeks, although job modification or persistent use of a counterforce brace during work activities may be necessary. Patient Education: For excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center. Also, see eMedicine's patient education article Tennis Elbow.
The major complications of lateral epicondylitis surgery are weakness of wrist extension and recurrence of symptoms. One of the most concerning complications of aggressive surgical debridement is lateral elbow instability. The proximity of the lateral collateral ligaments and the annular ligament makes them susceptible to injury. In addition, when using the arthroscopic technique, the radial nerve is put at risk.
Surgical treatment of lateral epicondylitis has yielded predictably favorable results, with approximately 85% of patients reporting complete pain relief. Some patients may have persistent symptoms despite surgical treatment, and these patients may benefit from a more aggressive debridement.
While much of the controversy regarding the pathology has been discussed, the surgical treatment options described have all yielded excellent results. While some less invasive approaches have been proposed and have shown excellent results, large prospective studies have not been performed to provide conclusive evidence of significant benefit of a particular procedure over another.
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