AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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.

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.

Age

Lateral epicondylitis most often occurs between the third and fifth decades of life.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The patient usually describes lateral elbow pain of gradual onset.

• 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.

• 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.
• Lateral epicondylitis can be associated with an imbalance secondary to muscle weakness and soft tissue inflexibility.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Cervical radiculopathy
Radial tunnel syndrome
Synovitis of the radiohumeral joint
Posterior interosseous nerve palsy
Neuralgic amyotrophy

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Laboratory studies are not generally indicated for the diagnosis of lateral epicondylitis.

Imaging Studies

• Imaging studies usually are not necessary, but tendinopathies can be visualized with both MRI and ultrasonography.

Other Tests

• Electrodiagnostic studies may assist in determining other causes of lateral elbow pain, such as cervical radiculopathy or posterior interosseous nerve palsy.

Histologic Findings

Findings can include collagen disorientation, collagen disorganization, fiber separation by increased mucinoid substance, 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.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Rehabilitation Program

Physical Therapy

Acutely, the goals of treatment are to reduce pain and inflammation. Anti-inflammatory modalities include ice, ultrasound, and phonophoresis. Use of a wrist splint 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 during activity to unload the area of muscle origin at the elbow. Deep tissue and friction massage helps release underlying adhesions and promotes 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.

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 modifications, 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 are controversial in the literature. Cases of posterior interosseous nerve palsy associated with weakness in those muscles innervated by that nerve definitely exist; however, syndromes of forearm pain without associated weakness in those muscles innervated by the posterior interosseous nerve are also seemingly labeled as radial tunnel syndrome.

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 interosseus nerve, patients report pain at the lateral aspect of the elbow, weakness in the wrist and hand, but no sensory symptoms. Electrodiagnostic findings in posterior interosseus 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 thorough workup and extensive conservative management.

Surgical Intervention

For those cases of refractory lateral epicondylitis, surgical resection of the lateral extensor aponeurosis might be considered.

Consultations

An orthopedic hand specialist may be consulted.

Other Treatment

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. 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. That being said, steroid injections in some cases can bring about dramatic, albeit short-term, relief.

• 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. Take care not to inject directly into the origin of the extensor muscle group to avoid tissue rupture.
• Heavy lifting or repetitive activity should be minimized for 48-72 hours after the injection.
• Other substances used for injection include local anesthetics and botulinum toxin. Recently published studies have provided conflicting evidence as to whether or not botulinum toxin injection has positive benefits for lateral epicondylitis.
• In recent years, other types of treatment have included acupuncture and extracorporeal shockwave therapy.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goal of drug treatment in cases of lateral epicondylitis is pain control 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 cyclo-oxygenase (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	Naproxen (Naprosyn, Naprelan, Anaprox, Aleve)
Description	For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of COX, which is responsible for prostaglandin synthesis.
Adult Dose	250-500 mg PO bid; may increase to 1.5 g/d for limited periods
Pediatric Dose	<2 years: Not established >2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
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
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; 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

Drug Name	Celecoxib (Celebrex)
Description	Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, 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 lowest dose of celecoxib for each patient.
Adult Dose	200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
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
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; 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

Drug Category: Corticosteroids

Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

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.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

In/Out Patient Meds:

• See Medication.

Deterrence/Prevention:

• To avoid recurrence, 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. Adherence to a home exercise program also is important in preventing 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:

• Education regarding proper use of tools, good body mechanics, and the importance of flexibility and strength of the involved musculature should be emphasized to the patient.
• For excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center and Muscle Disorders Center. Also, see eMedicine's patient education articles Tennis Elbow, Repetitive Motion Injuries, and Sprains and Strains.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• If one proceeds 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 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 both vocational and avocational activities that could contribute to the person's symptomatology.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. Jul 2005;39(7):411-22; discussion 411-22.
• Chumbley EM, O''Connor FG, Nirschl RP. Evaluation of overuse elbow injuries. Am Fam Physician. Feb 1 2000;61(3):691-700. [Medline].
• Downs DG. Nonspecific work-related upper extremity disorders. Am Fam Physician. Mar 1997;55(4):1296-302. [Medline].
• Genovese MC. Joint and soft-tissue injection. A useful adjuvant to systemic and local treatment. Postgrad Med. Feb 1998;103(2):125-34. [Medline].
• Haake M, König IR, Decker T, et al. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis : a randomized multicenter trial. J Bone Joint Surg Am. Nov 2002;84-A(11):1982-91. [Medline].
• Hayton MJ, Santini AJ, Hughes PJ. Botulinum toxin injection in the treatment of tennis elbow. A double-blind, randomized, controlled, pilot study. J Bone Joint Surg Am. Mar 2005;87(3):503-7.
• Khan KM, Cook JL, Taunton JE. Overuse tendinosis, not tendinitis. The Physician and Sports Medicine. 2000;28:38-48.
• Lewis M, Hay EM, Paterson SM, Croft P. Local steroid injections for tennis elbow: does the pain get worse before it gets better?: Results from a randomized controlled trial. Clin J Pain. Jul-Aug 2005;21(4):330-4.
• Nadler S, Nadler JM. Cumulative trauma disorders. In: Rehabilitation Medicine: Principles and Practice. 3rd ed. Philadelphia, Pa:. Lippincott Williams & Wilkins;1998:1661-1676.
• O'Connor FG, Howard TM, Fieseler CM. Managing overuse injuries. A systematic approach. The Physician and Sportsmedicine. 1997;25:88-113.
• Pettrone FA, McCall BR. Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg Am. Jun 2005;87(6):1297-304.
• Rifat SF, Moeller JL. Site-specific techniques of joint injection. Useful additions to your treatment repertoire. Postgrad Med. Mar 2001;109(3):123-6, 129-30, 135-6. [Medline].
• Roberts WO. Lateral epicondylitis injection. The Physician and Sports Medicine. 2000;28:93-94.
• Rosenbaum R. Disputed radial tunnel syndrome. Muscle Nerve. Jul 1999;22(7):960-7. [Medline].
• Sheon RP. Repetitive strain injury. 1. An overview of the problem and the patients. The Goff Group. Postgrad Med. Oct 1997;102(4):53-6, 62, 68. [Medline].
• Sheon RP. Repetitive strain injury. 2. Diagnostic and treatment tips on six common problems. The Goff Group. Postgrad Med. Oct 1997;102(4):72-8, 81, 85 passim. [Medline].
• Wong SM, Hui AC, Tong PY. Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. Dec 6 2005;143(11):793-7.
• Yassi A. Repetitive strain injuries. Lancet. Mar 29 1997;349(9056):943-7. [Medline].

Article Last Updated: Jan 17, 2007