REVIEW ARTICLE
Epicondylitis: Lateral Jared Brummel, DO,* Champ L. Baker III, MD,* Rob Hopkins, PT, SCS,* and Champ L. Baker, Jr, MD*w
Abstract: Lateral epicondylitis is the most common cause of lateral elbow pain in adults. Although it is typically a self-limiting process, there are many nonsurgical and surgical treatment options available if lateral epicondylitis becomes chronic and continues to cause pain. Its common name, tennis elbow, is somewhat of a misnomer because the condition is often work-related and occurs in athletes and nonathletes alike. Acute onset of symptoms occurs more often in young athletes; chronic, recalcitrant symptoms typically occur in older patients. In this review, we describe the pathogenesis and clinical presentation and the nonsurgical and surgical treatment options currently available. Key Words: lateral epicondylitis, elbow injuries, tennis elbow, tendinosis, lateral elbow pain
(Sports Med Arthrosc Rev 2014;22:e1–e6)
L
ateral epicondylitis is more commonly known as tennis elbow, however, many of those who are affected do not play a racquet sport. It occurs in 1% to 3% of adults.1 It has been estimated that 10% to 50% of people who play tennis regularly develop the condition at some time during their careers.2–7 Male tennis players are more often affected than women, but, in the general population, the incidence is equal among men and women. It is also believed that the backhand swing is the major contributing factor. One investigation identified a decrease in electromyographic findings in the backhand stroke in experienced players compared with that in novice players,8 suggesting the development of lateral epicondylitis is likely related to improper technique.9 The lateral-sided pain associated with lateral epicondylitis occurs more frequently than medialsided elbow pain, and it commonly affects the dominant extremity.5–8 Acute onset of symptoms occurs more often in young athletes; chronic recalcitrant symptoms typically occur in older patients. Although it is often thought of as a sports-related injury, lateral epicondylitis is more commonly the result of repetitive work-type conditions, such as prolonged computer typing.2,7 Of occupational risk factors, forceful activities, high force combined with high repetition or awkward posture are associated with epicondylitis.
CAUSES Although the term epicondylitis implies that inflammation is present, it is only present during the very early stages of the disease. Researchers have come to prefer the From *The Hughston Foundation, The Hughston Clinic, Columbus, GA; and wDepartment of Orthopaedic Surgery, Medical College of Georgia, Augusta, GA. Disclosure: The authors declare no conflict of interest. Reprints: Champ L. Baker, Jr, MD, The Hughston Foundation, The Hughston Clinic, PC, 6262 Veterans Parkway, P.O. Box 9517, Columbus, GA 31908-9517. Copyright r 2014 by Lippincott Williams & Wilkins
Sports Med Arthrosc Rev
term tendinosis over tendinitis to describe tennis elbow. Tendinosis is defined by the presence of vascular hyperplasia and active fibroblasts.10,11 In 1936, Cyriax12 postulated that microscopic or macroscopic tears of the common extensor origin were involved in the disease process. Subsequently, other investigators showed that the disease process is actually a degenerative tendinopathy.3,10,13–15 Goldie13 described granulation tissue found at the origin of the extensor carpi radialis brevis (ECRB). He found this to be a result of cumulative microtrauma resulting from repetitive wrist extension and alternating forearm supination and pronation. The ECRB origin has been the most commonly implicated as the specific site of pathology.10,14 Coonrad and Hooper15 were the first to describe macroscopic tearing in association with the histologic findings. Nirschl3,16 later termed these histologic findings “angiofibroblastic hyperplasia.” The term has since been modified to angiofibroblastic tendinosis. He noted that it was characterized by disorganized, immature collagen formation with immature fibroblastic and vascular elements. Chen et al17 further recognized that increased rates of apoptosis and cellular autophagy have been observed in tenocytes, resulting in disruption of extracellular collagen matrix and weakening of the tendon. Biomechanical analysis by Riek et al18 showed that eccentric contractions of the ECRB muscle during backhand tennis swings, especially in novice players, cause repetitive microtrauma that result in tears to the origin of the tendon and resultant lateral epicondylitis. Bunata et al19 studied the bony and tendinous anatomy of the elbow joint in 85 cadavers and showed that the origin of the ECRB tendon impinges on the lateral edge of the capitellum during elbow extension and flexion. They also identified varying morphology in the capitellum shape and tendon attachment among the cadavers and postulated that these variations may contribute to the reason some individuals develop lateral epicondylitis and others do not.
CLINICAL PRESENTATION Patients often describe pain at the lateral aspect of the elbow, and the pain often radiates down the forearm. Occasionally, the pain is proximal to the elbow. Symptoms also include weakness in grip strength that affects sports performance, work activities, and even activities of daily living. Patients usually experience insidious onset and gradual progression of the pain and weakness. The pain also varies in each patient from an intermittent ache to constant severe sharp pain. Although the patient’s symptoms may be centered in the forearm, it is important to begin with a cervical spine examination, followed by an examination of the entire upper extremity and comparison with the unaffected, contralateral extremity. A thorough shoulder examination should be included because patients are sometimes
Volume 22, Number 3, September 2014
www.sportsmedarthro.com |
e1
Sports Med Arthrosc Rev
Brummel et al
compensating for a dysfunctional shoulder. The examination should then proceed to the elbow and hand. Palpation of the elbow elicits tenderness at the lateral epicondyle and often along the extensor muscle mass just distal to it. Pain can be further elicited with passive wrist flexion and by resisting active wrist extension. The Thomsen test is performed with the patient’s shoulder flexed to 60 degrees, the elbow extended, the forearm pronated, and the wrist extended to 30 degrees. The examiner then applies pressure, which the patient resists, to the dorsum of the hand and third metacarpal to stress the ECRB and extensor carpi radialis longus (ECRL). The elbow examination is completed with a systemic evaluation of elbow stability, rangeof-motion, strength testing, and neurovascular function. The history and physical examination in the patient presenting with lateral elbow pain can help differentiate among the many possible causes. The differential diagnosis for lateral elbow pain includes lateral epicondylitis, synovial plica, osteochondritis dissecans of the capitellum, radiocapitellar arthrosis, radial tunnel syndrome, cervical radiculopathy, and posterolateral rotatory instability.
IMAGING Plain elbow radiographs are obtained at the initial evaluation. X-rays may demonstrate calcifications in the soft tissue at or near the insertion of the ECRB on the lateral epicondyle. Although commonly normal, they are helpful to rule out other potential causes of pain. Magnetic resonance imaging (MRI) can also help to determine the presence of osteochondral defects, intra-articular loose bodies, or ligamentous injuries. Although not usually necessary, MRI can help to confirm diagnoses involving the extensor tendon origin. Abnormally high signal intensity in a thickened common extensor tendon origin on T2-weighted and short T1 inversion recovery sequences is the typical finding of isolated lateral epicondylitis.20 These findings are consistent with the histologic findings of mucoid degeneration and neovascularization of lateral epicondylitis.10 If the common extensor tendon itself appears normal, adjacent soft-tissue edema usually predominates on T2-weighted sequences.21,22 MRI has 90% to 100% sensitivity and 83% to 100% specificity for detecting epicondylitis.23
NONSURGICAL TREATMENT In most patients, lateral epicondylitis can be treated successfully with nonoperative measures—rest, nonsteroidal anti-inflammatory medication, bracing, and physical therapy. The importance of rest from inciting activity should be emphasized first. In the active patient, activity modifications need to be addressed. If necessary, other nonsurgical treatments, such as various injections, acupuncture, extracorporeal shock wave therapy, and iontophoresis, can be used. Before treatment begins, the physician should discuss at length the cause and pathoanatomy of the disease and the expected outcomes as part of the patient’s education. Physical therapy includes such modalities as friction massage,12 manipulation,24 and stretching and strengthening the extensor wad when the pain subsides. In combination with oral analgesics, therapy can be effective. Our therapy program, consisting of 3 stages of treatment, includes a combination of oral nonsteroidal anti-inflammatory medications, rest, activity modification, strengthening exercises, and counterforce bracing (Table 1).25 There is general agreement that exercise is beneficial to treatment
e2 | www.sportsmedarthro.com
Volume 22, Number 3, September 2014
TABLE 1. Nonoperative Treatment Protocol for Lateral Epicondylitis Initial phase Reduce pain, inflammation, edema Rest from aggravating activities Anti-inflammatory medication, phonophoresis, iontophoresis Deep friction massage (2-3 min, 2 times a day) Ice massage (5 min, 2 times a day) Stretching (30 s, 5 repetitions; 3 times a day) Elbow flexion/extension Wrist flexion/extension Forearm pronation/supination Grip strengthening (2-3 min, 2 times a day) Counterforce bracing Assess mechanics in kinetic chain and correct Intermediate phase Continue stretching, appropriate modalities, and bracing Initiate progressive pain-free resistive strengthening (3 sets of 15, 2 times a day) Wrist curls (0-2 lbs progressing to 3-5 lbs) Elbow flexion/extension (2-3 lbs progressing to 5-10 lbs) Forearm pronation/supination (0-2 lbs progressing to 3-5 lbs) Shoulder strengthening to prevent disuse atrophy Final phase Continue stretching and strengthening Functional training paying attention to correct mechanics Ice after activity Gradual return to sport Maintenance stretching and strengthening program 3 times a week
outcome and eccentric exercises have been a staple in physical therapy protocols; however, eccentric exercise has not been shown to be superior to other types of exercise programs.26 Other therapeutic modalities can include cryotherapy, electrical stimulation, ultrasound,27 and iontophoresis.28 Acetaminophen and a variety of oral or topical nonsteroidal anti-inflammatory medications can be helpful in relieving pain in some patients.29,30 Bracing has proven to be an effective means of reducing the pain of lateral epicondylitis. Counterforce braces worn about the elbow work by distributing the tension on the ECRB tendon to other areas, thereby decreasing the tension at the site of pathoanatomy. Other types of braces, such as elbow straps and sleeves and wrist splints, are also available. Several studies have shown their efficacy in improving symptoms when used and compared with placebo braces.31,32 It is important to exclude radial tunnel compression syndrome from the differential diagnosis before using an elbow strap because of the risk of further compressing the symptomatic nerve at the site of entrapment. Patients with radial tunnel compression syndrome usually present with pain along the dorsoradial aspect of the proximal forearm. Localized tenderness over the posterior interosseous nerve in these patients may cause radial tunnel compression syndrome to be confused with lateral epicondylitis because of the proximity of the site of tenderness to the lateral epicondyle.33 Extracorporeal shock wave therapy has been investigated as to its efficacy in treating lateral epicondylitis. This treatment is performed using a generator to transmit sound waves to the affected area. The sound waves create a vibration that reinjures the diseased tendon as a means of restarting the healing cascade. The results have been mixed with regard to the efficacy of the treatment.34 Of concern, however, are the reported side effects, such as transient r
2014 Lippincott Williams & Wilkins
Sports Med Arthrosc Rev
Volume 22, Number 3, September 2014
reddening of the skin, pain at the site of the treatment, small hematomas, migraines, and syncope, that result from the treatment.35 There are numerous injection therapies that can be used to treat lateral epicondylitis. Although some injections are considered alternative methods of treatment, corticosteroid injections have become a mainstay in the treatment of epicondylitis. Considering that epicondylitis is less of an inflammatory process than initially suspected, the mechanism of action remains somewhat unclear. The many studies that have been performed on this topic show conflicting results. In a meta-analysis of 10 studies, only 6 of the 10 studies showed that corticosteroid injection was a more effective short-term therapeutic agent than its reference therapy.36 Altay et al37 found that technique was ultimately more important than the actual injection when treating lateral epicondylitis. In their study, they compared peppering an injection of lidocaine alone with peppering lidocaine with triamcinolone at the affected site and found both were equally useful in treating the disease at 1-year follow-up. Wolf et al38 demonstrated a better shortterm improvement at 4 weeks with corticosteroids than with nonsteroidal anti-inflammatory medications, but they found them to be equivocal at long-term follow-up. The risks of corticosteroid injections including skin hypopigmentation and fat atrophy should be explained to the patient. Considering the bony prominence of the lateral epicondyle, tissue breakdown can be a serious complication. Many alternative injection therapies are currently being studied for the treatment of epicondylitis. Among them is the use of botulinum toxin injected into the affected tendon. Although a recent meta-analysis of 4 randomized control studies did not show a consensus in the results, overall, the analysis showed a positive effect from the injection.39 Among the multiple variables, location of the injection may have played a role in the effectiveness versus ineffectiveness of the injection. In a study by Wong et al40 in which the injection was placed 1 cm from the pain source, investigators reported significant improvement; however, in another study by Hayton et al41 in which the injection was placed 5 cm from the pain source, investigators noticed no improvement over placebo. Further research is necessary in this field. Reports of the use of blood products, such as autologous blood and various concentrations of platelet-rich plasma (PRP), have been introduced into the literature. Most studies evaluating these products are in patients with chronic lateral epicondylitis. PRP has received increasing interest across many musculoskeletal disciplines and has been widely applied clinically to stimulate tissue healing.42 PRP is obtained from an autologous blood sample that has been centrifuged down to obtain the high concentration of platelets and growth factor-rich plasma. In one of the few studies to investigate PRP in lateral epicondylitis, Peerbooms et al43 published a randomized-controlled trial comparing the effects of peppered PRP injections with peppered steroid injections for tennis elbow; at 1 year, they found that patients injected with PRP had significantly improved pain and functional scores when compared with those who were injected with steroids. They then followed up their patients at 2 years and reported that both groups significantly improved over time in VAS scores, and although the corticosteroid group returned to baseline in average disabilities of the arm, shoulder and hand score, the PRP group significantly improved.44 Although this treatment appears promising, it remains an expensive treatment, r
2014 Lippincott Williams & Wilkins
Lateral Epicondylitis
because it is not covered by most insurance plans. Although interest in PRP continues to flourish, unfortunately the scientific understanding and general consensus on dosing, preparations, and injection schedules remain unclear. Autologous blood injections serve as a less expensive and natural treatment option that too is considered investigational in its early use. It offers another treatment that is intended to stimulate an inflammatory response at the site of the injury by injecting freshly drawn autologous blood often mixed with a local anesthetic. Kazemi et al45 performed a randomized-controlled study with 60 patients comparing treatment of lateral epicondylitis with either a corticosteroid injection or autologous blood injection. Short-term outcomes favored the autologous blood injection at 4 and 8 weeks. Creaney et al46 investigated patients whose symptoms were recalcitrant to previous conservative measures and compared further treatment with autologous blood injections versus PRP injections. They found similar improvement between both the study groups at 72% and 66%, respectively. Much like PRP injections, many questions remain as to the appropriate administration of these injections, including dosing, preparations, and injection schedules. Multiple topical agents are also available to treat epicondylitis. Patients with gastrointestinal comorbidities or sensitivities to oral nonsteroidal anti-inflammatory medications can benefit from the lessened systemic effects of topical treatments. Multiple companies also offer personalized compounding creams to be specially formulated for patients often containing multiple active ingredients including diclofenac among others. Nitric oxide has been reported to be an important factor in tendon healing. Animal studies and cell culture support the theory that nitric oxide enhances extracellular matrix production, improving mechanical properties.47 Paoloni et al48 described the clinical use of nitric oxide, or nitroglycerin, by investigating equivalent cohorts of patients with lateral epicondylitis receiving standard rehabilitation and nitroglycerin patches or rehabilitation and placebo patches. Patients in the nitroglycerin group had significantly reduced elbow pain with activity at 2 weeks and reduced epicondylar tenderness at 6 and 12 weeks. Patients receiving nitroglycerin patches also showed increased wrist extensor strength at 24 weeks. At 6 months, 81% of treated patients were asymptomatic during activities of daily living, compared with 60% of patients who had tendon rehabilitation alone. In a later publication, the investigators reported that, at 5 years after discontinuation of the therapy, the glyceryl trinitrate no longer offered any clinical benefits when compared with the patients who underwent physical therapy alone.30
SURGICAL TREATMENT Although lateral epicondylitis can be managed effectively without surgery in the majority of patients, 4% to 11% of patients ultimately require surgical treatment for relief of their symptoms.14,15,49 The scientific literature includes a wide variety of surgical options for lateral epicondylitis ranging from percutaneous50,51 to open,12,15,52–55 to arthroscopic treatment.53,56–64 Regardless of the procedure chosen, the key to a good outcome is proper patient selection with the appropriate pathology. Surgery is reserved for those with continued symptoms and disability despite all other treatments. www.sportsmedarthro.com |
e3
Brummel et al
In 1982, Baumgard and Schwartz50 discussed very successful results with a percutaneous surgical procedure performed in the office. Thirty-two of 35 patients had excellent results with less pain and improved strength at
Epicondylitis: Lateral Jared Brummel, DO,* Champ L. Baker III, MD,* Rob Hopkins, PT, SCS,* and Champ L. Baker, Jr, MD*w
Abstract: Lateral epicondylitis is the most common cause of lateral elbow pain in adults. Although it is typically a self-limiting process, there are many nonsurgical and surgical treatment options available if lateral epicondylitis becomes chronic and continues to cause pain. Its common name, tennis elbow, is somewhat of a misnomer because the condition is often work-related and occurs in athletes and nonathletes alike. Acute onset of symptoms occurs more often in young athletes; chronic, recalcitrant symptoms typically occur in older patients. In this review, we describe the pathogenesis and clinical presentation and the nonsurgical and surgical treatment options currently available. Key Words: lateral epicondylitis, elbow injuries, tennis elbow, tendinosis, lateral elbow pain
(Sports Med Arthrosc Rev 2014;22:e1–e6)
L
ateral epicondylitis is more commonly known as tennis elbow, however, many of those who are affected do not play a racquet sport. It occurs in 1% to 3% of adults.1 It has been estimated that 10% to 50% of people who play tennis regularly develop the condition at some time during their careers.2–7 Male tennis players are more often affected than women, but, in the general population, the incidence is equal among men and women. It is also believed that the backhand swing is the major contributing factor. One investigation identified a decrease in electromyographic findings in the backhand stroke in experienced players compared with that in novice players,8 suggesting the development of lateral epicondylitis is likely related to improper technique.9 The lateral-sided pain associated with lateral epicondylitis occurs more frequently than medialsided elbow pain, and it commonly affects the dominant extremity.5–8 Acute onset of symptoms occurs more often in young athletes; chronic recalcitrant symptoms typically occur in older patients. Although it is often thought of as a sports-related injury, lateral epicondylitis is more commonly the result of repetitive work-type conditions, such as prolonged computer typing.2,7 Of occupational risk factors, forceful activities, high force combined with high repetition or awkward posture are associated with epicondylitis.
CAUSES Although the term epicondylitis implies that inflammation is present, it is only present during the very early stages of the disease. Researchers have come to prefer the From *The Hughston Foundation, The Hughston Clinic, Columbus, GA; and wDepartment of Orthopaedic Surgery, Medical College of Georgia, Augusta, GA. Disclosure: The authors declare no conflict of interest. Reprints: Champ L. Baker, Jr, MD, The Hughston Foundation, The Hughston Clinic, PC, 6262 Veterans Parkway, P.O. Box 9517, Columbus, GA 31908-9517. Copyright r 2014 by Lippincott Williams & Wilkins
Sports Med Arthrosc Rev
term tendinosis over tendinitis to describe tennis elbow. Tendinosis is defined by the presence of vascular hyperplasia and active fibroblasts.10,11 In 1936, Cyriax12 postulated that microscopic or macroscopic tears of the common extensor origin were involved in the disease process. Subsequently, other investigators showed that the disease process is actually a degenerative tendinopathy.3,10,13–15 Goldie13 described granulation tissue found at the origin of the extensor carpi radialis brevis (ECRB). He found this to be a result of cumulative microtrauma resulting from repetitive wrist extension and alternating forearm supination and pronation. The ECRB origin has been the most commonly implicated as the specific site of pathology.10,14 Coonrad and Hooper15 were the first to describe macroscopic tearing in association with the histologic findings. Nirschl3,16 later termed these histologic findings “angiofibroblastic hyperplasia.” The term has since been modified to angiofibroblastic tendinosis. He noted that it was characterized by disorganized, immature collagen formation with immature fibroblastic and vascular elements. Chen et al17 further recognized that increased rates of apoptosis and cellular autophagy have been observed in tenocytes, resulting in disruption of extracellular collagen matrix and weakening of the tendon. Biomechanical analysis by Riek et al18 showed that eccentric contractions of the ECRB muscle during backhand tennis swings, especially in novice players, cause repetitive microtrauma that result in tears to the origin of the tendon and resultant lateral epicondylitis. Bunata et al19 studied the bony and tendinous anatomy of the elbow joint in 85 cadavers and showed that the origin of the ECRB tendon impinges on the lateral edge of the capitellum during elbow extension and flexion. They also identified varying morphology in the capitellum shape and tendon attachment among the cadavers and postulated that these variations may contribute to the reason some individuals develop lateral epicondylitis and others do not.
CLINICAL PRESENTATION Patients often describe pain at the lateral aspect of the elbow, and the pain often radiates down the forearm. Occasionally, the pain is proximal to the elbow. Symptoms also include weakness in grip strength that affects sports performance, work activities, and even activities of daily living. Patients usually experience insidious onset and gradual progression of the pain and weakness. The pain also varies in each patient from an intermittent ache to constant severe sharp pain. Although the patient’s symptoms may be centered in the forearm, it is important to begin with a cervical spine examination, followed by an examination of the entire upper extremity and comparison with the unaffected, contralateral extremity. A thorough shoulder examination should be included because patients are sometimes
Volume 22, Number 3, September 2014
www.sportsmedarthro.com |
e1
Sports Med Arthrosc Rev
Brummel et al
compensating for a dysfunctional shoulder. The examination should then proceed to the elbow and hand. Palpation of the elbow elicits tenderness at the lateral epicondyle and often along the extensor muscle mass just distal to it. Pain can be further elicited with passive wrist flexion and by resisting active wrist extension. The Thomsen test is performed with the patient’s shoulder flexed to 60 degrees, the elbow extended, the forearm pronated, and the wrist extended to 30 degrees. The examiner then applies pressure, which the patient resists, to the dorsum of the hand and third metacarpal to stress the ECRB and extensor carpi radialis longus (ECRL). The elbow examination is completed with a systemic evaluation of elbow stability, rangeof-motion, strength testing, and neurovascular function. The history and physical examination in the patient presenting with lateral elbow pain can help differentiate among the many possible causes. The differential diagnosis for lateral elbow pain includes lateral epicondylitis, synovial plica, osteochondritis dissecans of the capitellum, radiocapitellar arthrosis, radial tunnel syndrome, cervical radiculopathy, and posterolateral rotatory instability.
IMAGING Plain elbow radiographs are obtained at the initial evaluation. X-rays may demonstrate calcifications in the soft tissue at or near the insertion of the ECRB on the lateral epicondyle. Although commonly normal, they are helpful to rule out other potential causes of pain. Magnetic resonance imaging (MRI) can also help to determine the presence of osteochondral defects, intra-articular loose bodies, or ligamentous injuries. Although not usually necessary, MRI can help to confirm diagnoses involving the extensor tendon origin. Abnormally high signal intensity in a thickened common extensor tendon origin on T2-weighted and short T1 inversion recovery sequences is the typical finding of isolated lateral epicondylitis.20 These findings are consistent with the histologic findings of mucoid degeneration and neovascularization of lateral epicondylitis.10 If the common extensor tendon itself appears normal, adjacent soft-tissue edema usually predominates on T2-weighted sequences.21,22 MRI has 90% to 100% sensitivity and 83% to 100% specificity for detecting epicondylitis.23
NONSURGICAL TREATMENT In most patients, lateral epicondylitis can be treated successfully with nonoperative measures—rest, nonsteroidal anti-inflammatory medication, bracing, and physical therapy. The importance of rest from inciting activity should be emphasized first. In the active patient, activity modifications need to be addressed. If necessary, other nonsurgical treatments, such as various injections, acupuncture, extracorporeal shock wave therapy, and iontophoresis, can be used. Before treatment begins, the physician should discuss at length the cause and pathoanatomy of the disease and the expected outcomes as part of the patient’s education. Physical therapy includes such modalities as friction massage,12 manipulation,24 and stretching and strengthening the extensor wad when the pain subsides. In combination with oral analgesics, therapy can be effective. Our therapy program, consisting of 3 stages of treatment, includes a combination of oral nonsteroidal anti-inflammatory medications, rest, activity modification, strengthening exercises, and counterforce bracing (Table 1).25 There is general agreement that exercise is beneficial to treatment
e2 | www.sportsmedarthro.com
Volume 22, Number 3, September 2014
TABLE 1. Nonoperative Treatment Protocol for Lateral Epicondylitis Initial phase Reduce pain, inflammation, edema Rest from aggravating activities Anti-inflammatory medication, phonophoresis, iontophoresis Deep friction massage (2-3 min, 2 times a day) Ice massage (5 min, 2 times a day) Stretching (30 s, 5 repetitions; 3 times a day) Elbow flexion/extension Wrist flexion/extension Forearm pronation/supination Grip strengthening (2-3 min, 2 times a day) Counterforce bracing Assess mechanics in kinetic chain and correct Intermediate phase Continue stretching, appropriate modalities, and bracing Initiate progressive pain-free resistive strengthening (3 sets of 15, 2 times a day) Wrist curls (0-2 lbs progressing to 3-5 lbs) Elbow flexion/extension (2-3 lbs progressing to 5-10 lbs) Forearm pronation/supination (0-2 lbs progressing to 3-5 lbs) Shoulder strengthening to prevent disuse atrophy Final phase Continue stretching and strengthening Functional training paying attention to correct mechanics Ice after activity Gradual return to sport Maintenance stretching and strengthening program 3 times a week
outcome and eccentric exercises have been a staple in physical therapy protocols; however, eccentric exercise has not been shown to be superior to other types of exercise programs.26 Other therapeutic modalities can include cryotherapy, electrical stimulation, ultrasound,27 and iontophoresis.28 Acetaminophen and a variety of oral or topical nonsteroidal anti-inflammatory medications can be helpful in relieving pain in some patients.29,30 Bracing has proven to be an effective means of reducing the pain of lateral epicondylitis. Counterforce braces worn about the elbow work by distributing the tension on the ECRB tendon to other areas, thereby decreasing the tension at the site of pathoanatomy. Other types of braces, such as elbow straps and sleeves and wrist splints, are also available. Several studies have shown their efficacy in improving symptoms when used and compared with placebo braces.31,32 It is important to exclude radial tunnel compression syndrome from the differential diagnosis before using an elbow strap because of the risk of further compressing the symptomatic nerve at the site of entrapment. Patients with radial tunnel compression syndrome usually present with pain along the dorsoradial aspect of the proximal forearm. Localized tenderness over the posterior interosseous nerve in these patients may cause radial tunnel compression syndrome to be confused with lateral epicondylitis because of the proximity of the site of tenderness to the lateral epicondyle.33 Extracorporeal shock wave therapy has been investigated as to its efficacy in treating lateral epicondylitis. This treatment is performed using a generator to transmit sound waves to the affected area. The sound waves create a vibration that reinjures the diseased tendon as a means of restarting the healing cascade. The results have been mixed with regard to the efficacy of the treatment.34 Of concern, however, are the reported side effects, such as transient r
2014 Lippincott Williams & Wilkins
Sports Med Arthrosc Rev
Volume 22, Number 3, September 2014
reddening of the skin, pain at the site of the treatment, small hematomas, migraines, and syncope, that result from the treatment.35 There are numerous injection therapies that can be used to treat lateral epicondylitis. Although some injections are considered alternative methods of treatment, corticosteroid injections have become a mainstay in the treatment of epicondylitis. Considering that epicondylitis is less of an inflammatory process than initially suspected, the mechanism of action remains somewhat unclear. The many studies that have been performed on this topic show conflicting results. In a meta-analysis of 10 studies, only 6 of the 10 studies showed that corticosteroid injection was a more effective short-term therapeutic agent than its reference therapy.36 Altay et al37 found that technique was ultimately more important than the actual injection when treating lateral epicondylitis. In their study, they compared peppering an injection of lidocaine alone with peppering lidocaine with triamcinolone at the affected site and found both were equally useful in treating the disease at 1-year follow-up. Wolf et al38 demonstrated a better shortterm improvement at 4 weeks with corticosteroids than with nonsteroidal anti-inflammatory medications, but they found them to be equivocal at long-term follow-up. The risks of corticosteroid injections including skin hypopigmentation and fat atrophy should be explained to the patient. Considering the bony prominence of the lateral epicondyle, tissue breakdown can be a serious complication. Many alternative injection therapies are currently being studied for the treatment of epicondylitis. Among them is the use of botulinum toxin injected into the affected tendon. Although a recent meta-analysis of 4 randomized control studies did not show a consensus in the results, overall, the analysis showed a positive effect from the injection.39 Among the multiple variables, location of the injection may have played a role in the effectiveness versus ineffectiveness of the injection. In a study by Wong et al40 in which the injection was placed 1 cm from the pain source, investigators reported significant improvement; however, in another study by Hayton et al41 in which the injection was placed 5 cm from the pain source, investigators noticed no improvement over placebo. Further research is necessary in this field. Reports of the use of blood products, such as autologous blood and various concentrations of platelet-rich plasma (PRP), have been introduced into the literature. Most studies evaluating these products are in patients with chronic lateral epicondylitis. PRP has received increasing interest across many musculoskeletal disciplines and has been widely applied clinically to stimulate tissue healing.42 PRP is obtained from an autologous blood sample that has been centrifuged down to obtain the high concentration of platelets and growth factor-rich plasma. In one of the few studies to investigate PRP in lateral epicondylitis, Peerbooms et al43 published a randomized-controlled trial comparing the effects of peppered PRP injections with peppered steroid injections for tennis elbow; at 1 year, they found that patients injected with PRP had significantly improved pain and functional scores when compared with those who were injected with steroids. They then followed up their patients at 2 years and reported that both groups significantly improved over time in VAS scores, and although the corticosteroid group returned to baseline in average disabilities of the arm, shoulder and hand score, the PRP group significantly improved.44 Although this treatment appears promising, it remains an expensive treatment, r
2014 Lippincott Williams & Wilkins
Lateral Epicondylitis
because it is not covered by most insurance plans. Although interest in PRP continues to flourish, unfortunately the scientific understanding and general consensus on dosing, preparations, and injection schedules remain unclear. Autologous blood injections serve as a less expensive and natural treatment option that too is considered investigational in its early use. It offers another treatment that is intended to stimulate an inflammatory response at the site of the injury by injecting freshly drawn autologous blood often mixed with a local anesthetic. Kazemi et al45 performed a randomized-controlled study with 60 patients comparing treatment of lateral epicondylitis with either a corticosteroid injection or autologous blood injection. Short-term outcomes favored the autologous blood injection at 4 and 8 weeks. Creaney et al46 investigated patients whose symptoms were recalcitrant to previous conservative measures and compared further treatment with autologous blood injections versus PRP injections. They found similar improvement between both the study groups at 72% and 66%, respectively. Much like PRP injections, many questions remain as to the appropriate administration of these injections, including dosing, preparations, and injection schedules. Multiple topical agents are also available to treat epicondylitis. Patients with gastrointestinal comorbidities or sensitivities to oral nonsteroidal anti-inflammatory medications can benefit from the lessened systemic effects of topical treatments. Multiple companies also offer personalized compounding creams to be specially formulated for patients often containing multiple active ingredients including diclofenac among others. Nitric oxide has been reported to be an important factor in tendon healing. Animal studies and cell culture support the theory that nitric oxide enhances extracellular matrix production, improving mechanical properties.47 Paoloni et al48 described the clinical use of nitric oxide, or nitroglycerin, by investigating equivalent cohorts of patients with lateral epicondylitis receiving standard rehabilitation and nitroglycerin patches or rehabilitation and placebo patches. Patients in the nitroglycerin group had significantly reduced elbow pain with activity at 2 weeks and reduced epicondylar tenderness at 6 and 12 weeks. Patients receiving nitroglycerin patches also showed increased wrist extensor strength at 24 weeks. At 6 months, 81% of treated patients were asymptomatic during activities of daily living, compared with 60% of patients who had tendon rehabilitation alone. In a later publication, the investigators reported that, at 5 years after discontinuation of the therapy, the glyceryl trinitrate no longer offered any clinical benefits when compared with the patients who underwent physical therapy alone.30
SURGICAL TREATMENT Although lateral epicondylitis can be managed effectively without surgery in the majority of patients, 4% to 11% of patients ultimately require surgical treatment for relief of their symptoms.14,15,49 The scientific literature includes a wide variety of surgical options for lateral epicondylitis ranging from percutaneous50,51 to open,12,15,52–55 to arthroscopic treatment.53,56–64 Regardless of the procedure chosen, the key to a good outcome is proper patient selection with the appropriate pathology. Surgery is reserved for those with continued symptoms and disability despite all other treatments. www.sportsmedarthro.com |
e3
Brummel et al
In 1982, Baumgard and Schwartz50 discussed very successful results with a percutaneous surgical procedure performed in the office. Thirty-two of 35 patients had excellent results with less pain and improved strength at
