AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Editors: Daniel D Scott, MD, MA, BS, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver and Health Sciences Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, University of Medicine and Dentistry of New Jersey, New Jersey Medical School; Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center; Rene Cailliet, MD, Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
tennis elbow, lateral elbow tendinitis, lateral elbow tendonitis, elbow overuse syndrome
Background
Lateral epicondylitis, or tennis elbow, is the most common overuse injury of the elbow and is observed up to 10 times more frequently than medial epicondylitis. Lateral epicondylitis is usually precipitated by repetitive contraction of the wrist extensors and is characterized by aching pain that is worsened with activity. Early conservative management is the key to symptom resolution, which eventually allows return to vocational and avocational activities without restriction.1, 2, 3
Related eMedicine topics:
Elbow and Forearm Overuse Injuries
Lateral Epicondylitis [Orthopedic Surgery]
Lateral Epicondylitis [Sports Medicine]
Overuse Injury
Tendonitis
Related Medscape topics:
CME/CE Guidelines Issued for Overuse Injuries in Child and Adolescent Athletes
Resource Center Exercise and Sports Medicine
Pathophysiology
Lateral epicondylitis is a result of inflammation, or enthesitis, at the muscular origin of the extensor carpi radialis brevis (ECRB). This inflammation leads to microtears of the tendon, with subsequent fibrosis and, ultimately, tissue failure. Less commonly, the attachments of the extensor carpi radialis longus (ECRL), extensor digitorum communis (EDC), or extensor carpi ulnaris (ECU) are involved.4, 5, 6
Sex
The condition affects men and women with equal frequency.
Age
Lateral epicondylitis most often occurs between the third and fifth decades of life.
History
The patient usually describes a gradual onset of lateral elbow pain, which is characterized as follows:
- The aching pain generally increases with activity. The patient may describe symptoms occurring during simple activities of daily living (ADL), such as picking up a cup of coffee or a gallon of milk.
- Pain may be present at night.
- Symptoms are typically unilateral.
Physical
Most commonly, the examination reveals localized tenderness to palpation just distal and anterior to the lateral epicondyle. Other symptoms include the following7:
- Pain increases with resisted wrist extension, especially with the elbow in extension.
- The patient may have a weakened grip on the affected side.
- Elbow range of motion (ROM) is typically normal.
- In chronic, refractory cases, be sure to fully assess shoulder integrity and scapular stability. Weakness or instability of the scapular stabilizers may perpetuate lateral epicondylitis by leading to overuse of the wrist extensors.
Causes
- Lateral epicondylitis is an overuse syndrome generally caused by repetitive use of the wrist extensors or sustained power gripping.8
- Lateral epicondylitis can be associated with an imbalance secondary to muscle weakness and soft-tissue inflexibility.
Cervical Disc Disease
Cervical Myofascial Pain
Cervical Radiculopathy
Cervical Spondylosis
Fibromyalgia
Medial Epicondylitis
Other Problems to Be Considered
Radial tunnel syndrome
Synovitis of the radiohumeral joint
Posterior interosseous nerve palsy
Neuralgic amyotrophy
Lab Studies
- Laboratory studies generally are not indicated for the diagnosis of lateral epicondylitis.
Imaging Studies
- Imaging studies usually are not necessary, but tendinopathies can be visualized with magnetic resonance imaging (MRI) and with ultrasonography.9
Other Tests
- Electrodiagnostic studies may help to determine whether other causes of lateral elbow pain, such as cervical radiculopathy or posterior interosseous nerve palsy, are present.
Histologic Findings
Findings can include collagen disorientation, collagen disorganization, fiber separation by increased mucinoid substance, an increased prominence of cells and vascular spaces (with or without neovascularization), and focal necrosis or calcification. Superimposed evidence of a tear, including fibroblastic proliferation, hemorrhage, and organizing granulation tissue, may be revealed.
Rehabilitation Program
Physical Therapy
Acutely, the goals of treatment are to reduce pain and inflammation. Anti-inflammatory modalities include ice, ultrasonography, and iontophoresis. Iontophoresis with topical nonsteroidal anti-inflammatory drugs (NSAIDs) has been shown to help reduce pain. The use of iontophoresis with corticosteroids is not supported. A wrist splint used during activities can be helpful, because it places the extensor muscles in a position of rest and prevents maximal muscle contraction. Counterforce bracing (tennis elbow strap) is another orthotic alternative that can be used to unload the area of muscle origin at the elbow. A splint or brace should not be used in isolation but should be employed only as an adjunct to modalities and exercise/stretching.10 Deep-tissue and friction massage help to release underlying adhesions and promote improved circulation to the area.
In the subacute stage, emphasis is placed on the restoration of function of the involved muscle group. Flexibility, strength, and endurance of the wrist extensor muscle group can be achieved through a graded program. ROM for wrist flexion/extension and pronation/supination should be achieved prior to proceeding with a strengthening program. Strength and grip training should progress from isometric to concentric to eccentric contractions of the forearm muscles, especially the wrist extensors.11, 12 In chronic refractory cases of lateral epicondylitis, scapular stabilization should be addressed to prevent overuse of the wrist extensors during activities. Sports-specific training should also be included in the rehabilitation program, if appropriate.
Occupational Therapy
As activities are resumed, the patient's vocational and avocational pursuits must be considered. Job and recreational tools and/or equipment may need to be modified, especially if repetitive gripping is required. Gradual resumption of activities is recommended to improve tolerance and prevent recurrence.
Medical Issues/Complications
The so-called radial tunnel syndrome should be considered for refractory cases of lateral epicondylitis. Criteria for diagnosis of radial tunnel syndrome are controversial in the literature.13 There exist cases of posterior interosseous nerve palsy associated with weakness in muscles that are innervated by that nerve. However, syndromes of forearm pain without associated weakness in muscles that are innervated by the posterior interosseous nerve are also seemingly labeled as radial tunnel syndrome.7 Electrodiagnostic studies should be helpful in demonstrating nerve injury in cases of radial tunnel syndrome, thereby differentiating this entity from a forearm pain syndrome. In compression of the posterior interosseous nerve, patients report pain at the lateral aspect of the elbow and weakness in the wrist and hand, but no sensory symptoms. Electrodiagnostic findings in posterior interosseous nerve compression may include denervation in radial-supplied muscles distal to the supinator, and possibly slowing across the area of entrapment. Surgical intervention for radial tunnel syndrome or persistent tennis elbow should be approached with caution and only after a thorough workup and extensive conservative management.
Surgical Intervention
For cases of refractory lateral epicondylitis, surgical resection of the lateral extensor aponeurosis might be considered.14, 15
Consultations
An orthopedic hand specialist may be consulted.
Other Treatment
Topical NSAIDs may provide short-term pain relief, but evidence is conflicting on the use of oral NSAIDs.
If a patient does not seem to be responding to conservative care, a steroid injection about the lateral epicondyle using local anesthetic can be performed.9, 16, 17, 18, 19, 20 However, the role of corticosteroid injection in tendinopathy remains controversial. Most lateral epicondylitis is degenerative rather than inflammatory, and injecting steroid around a tendon can inhibit collagen repair; therefore, steroid injections should be used on a limited basis. Additionally, injecting a corticosteroid directly into a tendon can be deleterious. Nonetheless, steroid injections in some cases can bring about dramatic, albeit short-term, relief. When employing steroid injections, the following steps should be taken:
- Palpate the lateral epicondyle to locate the painful area (usually inferior and radial to the lateral epicondyle).
- Using a 25- or 30-gauge needle, inject 0.5-1 mL of triamcinolone (20 mg/mL) and 1-2 mL of 1% lidocaine. Infiltrate the area, distributing small aliquots of medication in a fanlike fashion. To avoid tissue rupture, take care not to inject directly into the origin of the extensor muscle group.
- Heavy lifting or repetitive activity by the patient should be minimized for 48-72 hours after the injection.
Other substances used for injection include local anesthetics and botulinum toxin. However, studies have provided conflicting evidence as to whether botulinum toxin injection has positive long-term benefits for lateral epicondylitis.21, 22, 23 Other types of treatment have included acupuncture and extracorporeal shockwave therapy.24, 25 However, there is insufficient evidence to support acupuncture as a treatment for epicondylitis. Likewise, reviews of trials using shockwave therapy have found reasons not to support this as a treatment option.
The goal of drug treatment in cases of lateral epicondylitis is pain control, in order to facilitate the performance of ADL.
Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
| Drug Name | Diclofenac (Solaraze) |
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| Description | Designated chemically as 2-[(2,6-dichlorophenyl) amino] benzeneacetic acid, monosodium salt, with an empirical formula of C14H10Cl2NO2NA. Diclofenac is one of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacologic studies. It is believed to inhibit the activity of COX, which is essential in the biosynthesis of prostaglandins. |
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| Adult Dose | Apply topically to affected area(s) bid |
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| Pediatric Dose | Not indicated |
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| Contraindications | Documented hypersensitivity |
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| Interactions | None reported |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
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| Precautions | May cause hypersensitivity, caution in those predisposed (eg, aspirin allergy); may cause contact dermatitis, rash, pruritus, or exfoliation at application sites |
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| Drug Name | Ibuprofen (Motrin, Ibuprin, Advil, Excedrin IB) |
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| Description | DOC for patients with mild to moderate pain. Ibuprofen inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. |
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| Adult Dose | 400-800 mg PO qid |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding |
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| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
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| Precautions | Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy |
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| Drug Name | Naproxen (Naprosyn, Naprelan, Anaprox, Aleve) |
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| Description | For relief of mild to moderate pain. Naproxen inhibits inflammatory reactions and pain by decreasing the activity of COX, which is responsible for prostaglandin synthesis. |
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| Adult Dose | 250-500 mg PO bid; may increase to 1.5 g/d for limited periods |
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| Pediatric Dose | <2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d |
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| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency |
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| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
|
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| Precautions | Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug |
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| Drug Name | Celecoxib (Celebrex) |
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| Description | Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, being induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient. |
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| Adult Dose | 200 mg/d PO qd; alternatively, 100 mg PO bid |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration with rifampin may decrease celecoxib plasma concentrations |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
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| Precautions | May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, and conditions predisposing to fluid retention; caution in severe heart failure and hyponatremia because celecoxib may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or laboratory results suggest liver dysfunction |
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Drug Category: Corticosteroids
The medications have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
| Drug Name | Triamcinolone (Amcort, Aristospan Intra-articular) |
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| Description | For inflammatory dermatosis responsive to steroids. This agent decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and by reversing capillary permeability. |
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| Adult Dose | 0.5-1 mL (20 mg/mL formulation) IM |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity; fungal, viral, and bacterial skin infections |
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| Interactions | Coadministration with barbiturates, phenytoin, and rifampin decreases effects of triamcinolone |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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| Precautions | Multiple complications (eg, severe infections, hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression) may occur; abrupt discontinuation of glucocorticoids may cause adrenal crisis |
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Drug Category: Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who experience pain.
| Drug Name | Acetaminophen (Tylenol, Aspirin-Free Anacin, Tempra, Feverall) |
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| Description | DOC for pain in patients who have documented hypersensitivity to aspirin or NSAIDs, who have upper GI disease, or who are taking PO anticoagulants. |
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| Adult Dose | 1000 mg PO tid/qid |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity; known G-6-PD deficiency |
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| Interactions | Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
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| Precautions | Hepatotoxicity possible in persons with long-term alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP (acetaminophen) is contained in many OTC products, and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose |
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In/Out Patient Meds:
Deterrence/Prevention:
- To avoid a recurrence of lateral epicondylitis, the etiology of the condition must be considered. Job modifications may be necessary and may be facilitated by a job site evaluation. Investigation into avocational activities also is necessary, because contributing factors to this condition may be identified. In addition, adherence to a home exercise program is important in preventing a recurrence of lateral epicondylitis.
Prognosis:
- Patients who present acutely (<3 mo) generally respond well to treatment. Chronic cases that are refractory to treatment may take months to resolve.
Patient Education:
Medical/Legal Pitfalls
- When proceeding with a corticosteroid injection, be sure to obtain informed consent. The potential complications must be fully explained to the patient, especially the risk of tendon rupture, as well as of subcutaneous atrophy, bleeding, infection, allergic reaction, and skin discoloration.
- If treating a work-related injury, be sure that the alleged mechanism of injury is plausible and is indeed work-related. Always include a history of vocational and avocational activities that could contribute to the person's symptomatology.
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Lateral Epicondylitis excerpt Article Last Updated: Jun 27, 2008
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