Practice Essentials

Lateral epicondylitis (commonly referred to as “tennis elbow”) is related to excessive wrist extension. It is the most common overuse syndrome. Patients typically report pain over the lateral elbow that worsens with activity and improves with rest. The symptoms tend to improve in 9-18 months; however, refractory cases may require surgery (see the image below).

Representation of the relationships in arthroscopic release for lateral epicondylitis.

Signs and symptoms of lateral epicondylitis

Pain generally occurs 24-72 hours after repeated wrist extension activity. Maximal tenderness on palpation is elicited 1-2 cm distal to the origin of the extensor carpi radialis brevis at the lateral epicondyle.

See Presentation for more detail.

Diagnosis of lateral epicondylitis

Imaging studies are rarely needed in the initial workup of lateral elbow pain. Consider plain film radiologic evaluation if the patient's symptoms persist despite adequate treatment or to evaluate for osteophytes, degenerative joint disease, or osteochondritis dissecans (OCD). Consider magnetic resonance imaging (MRI), bone scanning, and/or computed tomography (CT) scanning to evaluate for OCD or stress fractures. Musculoskeletal ultrasonography is emerging as a useful modality to characterize areas of tendinosis, partial tearing, or calcifications and may assist with treatment options.

See Workup for more detail.

Treatment of lateral epicondylitis

Among the numerous treatment options are the following:

Watchful waiting
Nonsteroidal anti-inflammatory drugs
Corticosteroid injection
Counterforce bracing
Extracorporeal shock wave therapy
Ultrasound-guided percutaneous radiofrequency thermal lesioning
Acupuncture
Autologous blood injection
Platelet-rich plasma injection
Hyaluronate injection
Polidocanol
Botulinum toxin
Topical nitrates
Bone marrow injection
Autologous tenocyte injection
Allogenic adipose-derived mesenchymal stem cells
Percutaneous tenotomy
High-intensity laser therapy

Surgical intervention can be very effective for refractory cases of lateral epicondylitis. However, surgical intervention is only indicated after 6 months of conservative care has failed to relieve symptoms.

See Treatment and Medication for more detail.

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.^[1]

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.^[2]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.^{[2, 3]}

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

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.^[4]

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.^[5]In addition, string vibration dampeners have not been shown to decrease the incidence of lateral epicondylitis.^[6]

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 great deal of computer work, typing, and mouse work for their occupations.

Etiology

The causes of lateral epicondylitis include the following:

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

United States statistics

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.

A study reported the age- and sex-adjusted annual incidence of lateral elbow tendinosis decreased from 4.5 per 1000 people in 2000 to 2.4 per 1000 in 2012. The recurrence rate within 2 years was 8.5% and the proportion of surgically treated cases within 2 years of diagnosis tripled from 1.1% during the 2000-2002 time period to 3.2% after 2009. The study also added that about 1 in 10 patients with persistent symptoms at 6 months required surgery.^[7]

International statistics

Herquelot et al conducted a study that aimed to estimate the association between repeated measures of occupational risk factors and the incidence of lateral epicondylitis in a large working population. The study highlights the importance of temporal dimensions for occupational risk factors on the incidence of lateral epicondylitis. The authors conclude that further research should evaluate the risk associated with the duration and repetition of occupational exposure on the incidence of lateral epicondylitis.^[8]

Prognosis

Although most patients with lateral epicondylitis tend to improve in 9-18 months, they need to be made aware that successful treatment may be a prolonged course. Refractory cases may need surgical intervention.

Complications

The most serious complication is complete tendon rupture. Such an injury often causes a palpable defect in the extensors, which results in weakness on attempted wrist extension. Frequently, the treatment of this complication is surgical repair.

Patient Education

Advise the athlete on proper technique and equipment. Formal sport lessons may be beneficial to prevent individuals from acquiring bad habits.

For patient education resources, see the Hand, Wrist, Elbow, and Shoulder Center, as well as Tennis Elbow.

Clinical Presentation

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