Synonyms for this term are tennis elbow and lateral epicondylitis
Definition:
Painful inflammation of the extensor carpi radialis brevis and the extensor digitorum communis at their aponeurotic origin on the lateral epicondyle.
Aetiology, pathogenesis:
Changes can arise as a result of a cumulative effect, mechanical overload and metabolic changes. Recreational and amateur players are affected much more frequently than professional tennis players. The condition rarely occurs in players under 30.
Pathophysiology
The cause of the symptoms is a fibroblastic tendinosis of a degenerative nature, given the absence of acute inflammatory cells.
History
Typical complaints include pain and tenderness at the lateral epicondyle radiating into the upper arm and forearm, clear dependence on loading and functional impairment: weakness in the wrist with the simplest movements.
Previous conditions: previous conservative or surgical treatment, accidents, joint diseases, sport-specific history.
Occupation with specific strain on the wrist extensor muscles.
Clinical diagnosis
o Inspection usually unremarkable, occasionally a protective posture
o Tenderness at the lateral epicondyle and along the extensor muscles
o Pain on movement
o Weakness in the wrist
o Positive provocation tests (pronation and wrist extension against resistance, chair test, cup test)
o In classic tennis elbow, the extensor carpi radialis brevis muscle is affected first and the extensor digitorum communis muscle second. With the extensor carpi radialis brevis, dorsiflexion of the whole wrist is more painful than the middle finger test
o In symptoms acquired more through occupational activity, the extensor digitorum communis muscle predominates. Pain on extending the middle finger against resistance is typical
o Simultaneous examination of the cervical spine, shoulder and hand
o Assessment of circulation, motor function and sensation, including signs of nerve entrapment
Diagnostic imaging and tests
o An X-ray of the elbow joint in 2 planes should be carried out to rule out other conditions such as loose bodies, osteochondritis dissecans, occasional secondary ossification at the tendon origin or osteoarthritis.
o MRI of the elbow joint
o Ultrasound
Further investigations useful in individual cases
o X-ray of the cervical spine
o Electromyography and nerve conduction velocity
Common differential diagnoses
o Cervical syndrome (C6/C7)
o Compression neuropathy of the radial nerve
o Supinator (radial tunnel) syndrome
o Pronator teres syndrome
o Subacromial pain syndrome
o Osteoarthritis of the elbow joint
o Osteonecrosis
o Osteochondritis dissecans
o Loose bodies
o Humeroradial plica
o Posteroulnar impingement
o Instability of the elbow joint
o Olecranon bursitis
o Rheumatoid arthritis
The goals of the possible therapies are freedom from symptoms, pain reduction and improved function.
Conservative treatment
Advice and information about the condition, its natural course and treatment options
Information about ways of reducing and avoiding overexertion and incorrect loading in everyday life, work and sport
Drug therapy
Systemic and locally applied substances are available to reduce pain:
o Anti-inflammatory drugs (NSAIDs)
o Topical diclofenac
o Infiltration therapy with local anaesthetics
o Infiltration therapy with steroids followed by immobilisation for 1–2 weeks (caution: fat necrosis; no more than 2–3 repetitions)
o Botulinum toxin injection at the main pain point and into the affected muscles
Physical therapy
o Cryotherapy in the acute stage
o Heat in the chronic stage
o Transverse friction, stretching exercises
o Muscle-relaxing massage
o Electrotherapy
o Immobilisation
o Sonophoresis
o Transcutaneous nerve stimulation
o Ultrasound
o Laser treatment (low evidence)
o Extracorporeal shock wave therapy (low evidence)
o Low-dose radiotherapy (no evidence)
Orthopaedic aids
o Kinesio tape
o Epicondylitis brace
o Bandages and reminder straps
Surgical treatment
The general indication criterion is persistence of symptoms despite conservative treatment, with corresponding distress.
Common surgical procedures are
– open or endoscopic release of the affected extensor tendons close to their origin according to Hohmann
– open or endoscopic removal of the angiofibroblastic tendon tissue according to Nirschl
– open or endoscopic denervation at the lateral epicondyle according to Wilhelm
– additional decompression of the supinator canal if irritation is present
Possible consequences and complications
o General risks and complications: wound healing problems,
wound infection, haematoma, vascular injury, nerve injury,
instability of the elbow joint
o Persistent pain, recurrence
Postoperative measures/rehabilitation
o Early functional treatment, wound checks
o Return to sport after 8–10 weeks
o In individual cases, recovery over months to more than a year
Stepwise treatment approach
Guiding criteria
Subjective pain, distress, extent of functional and load-bearing impairment, resistance to treatment
Stage 1: conservative
Advice, medication, immobilisation, physical therapy,
orthopaedic aids, infiltration therapy, extracorporeal shock wave therapy
Stage 2: surgical, outpatient/inpatient
Advice, endoscopic or open surgery
Prognosis
The prognosis with regard to the natural course is favourable, although painful restriction of movement and loading often lasting several months must be expected. In the majority of cases, symptoms can be eliminated with drug and physical therapy and infiltration treatment.
The literature is contradictory regarding the effectiveness of conservative treatment methods, and there are few controlled studies. Only a few cases of lateral epicondylopathy become chronic. The spontaneous course of medial epicondylopathy is less favourable.
Prevention
Avoiding overload and incorrect loading; enabling and optimising ergonomic working conditions.
