Epicondylitis (tennis and golfers' elbow)
Syndrome characterized by epicondylar pain and tenderness and related disability.
AKA epicondylitis or epicondylalgia
Nirschl in his Current Concepts Review describes epicondylitis as a misnomer because there are no histological findings of acute inflammation; he prefers the term epicondylosis.
Lateral epicondylitis was first described in 1873.
Much more common in non-athletes than in tennis players, who make up around 5-10% of patients with lateral epicondylitis.
Usually affects patients in 30s to 50s; median age is 41
10 times more common on lateral than medial side.
Lateral epicondylitis: activities that increase tension in wrist extensors, and supinators eg tennis
Medial epicondylitis: activities that increase tension in wrist flexors and pronators eg baseball pitching, tennis serve and freestyle swimming; hammering.
Tear in ECRB (LE) or common flexor origin, particularly pronator teres, FCR and occasionally FCU (ME), produced by mechanical overload in degenerating muscle fibres. In lateral epicondylitis 1/3 of patients also have EDC involved. Supinator and ECRL may be involved, and inflammation of the lateral collateral and annular ligaments may be seen.
On histological examination of material taken at surgery there is no evidence of large numbers of macrophages, lymphocytes or neutrophils. Rather, there is vascular hyperplasia with dense fibroblast populations and disorganized collagen, termed angiofibroblastic hyperplasia.
Tenderness and pain over the lateral epicondyle. The area of maximal discomfort is most commonly found 5mm distal and anterior to the lateral epicondyle. The pain is aggravated by wrist extension and is reproduced by passive flexion of the wrist and fingers with the elbow in full extension, and the forearm pronated.
Gardner 's chair test is said (by him) to be the most important physical finding; it involves picking up a chair with one hand in a position of forearm pronation and wrist palmar flexion. Severe pain is felt in the region of the lateral epicondyle in patients with lateral epicondylitis. This has not been scientifically verified.
Pain over the medial elbow which may radiate down the forearm
The pain is reproduced by resisted wrist flexion and pronation.
Grip strength is reduced.
Medial epicondylitis is commonly (60%) associated with ulnar nerve compression symptoms, and the ulnar nerve must be examined.
Radial tunnel syndrome
-Much less common
-In tennis elbow the maximal tenderness is at the lateral epicondyle; in radial tunnel syndrome the maximal tenderness is distal to this, in the mobile wad distal to the radial head
-If the diagnosis is entertained can be investigated with NCS
Entrapment of the musculocutaneous nerve
In medial epicondylitis rupture of the ulnar collateral ligament needs to be ruled out.
X-rays are not indicated initially but should be taken if there is resistance to non-surgical therapy or there are inconsistent or unusual features in the presentation.
X-rays if taken will show calcifications in the soft tissue overlying the affected epicondyle in around 30%.
Most authors agree there is no need for further imaging; however, MRI shows decreased signal on T1 and T2 (consistent with fact this is not an inflammatory condition).
EPS (electrophysiological) may be considered if there is any indication of ulnar nerve involvement or in the differential diagnosis of radial tunnel syndrome.
Injection of local anaesthetic into the common extensor origin should relieve the pain of lateral epicondylitis but will not help radial tunnel syndrome.
Nonsurgical treatment is trialled initially and surgical treatment is resorted to in the case of failure. Boyer and Hastings say there is little evidence to support any of the nonsurgical or surgical treatment options. The natural history of the condition is for resolution within a year in 70-80% of cases and there is no evidence that any of the nonsurgical treatment options alter this.
Physiotherapy is prescribed most often and entails rest during the period of acute pain then strengthening exercises for the forearm and hand muscles; in particular the wrist and finger extensors. If other upper limb muscles are weak, eg rotator cuff or parascapular muscles, these must also be rehabilitated.
Other physical therapy modalities include use of forearm support bands (counterforce braces) – these inhibit full muscular contraction and thus decrease the forces on the injured muscle origins; and change in racquet size (oversize head, bigger grip, looser strings, slower playing surfaces).
• Heat therapy eg ultrasound – no evidence of any lasting benefit
• Steroid and local anaesthetic injections in the area of maximal tenderness. Multiple randomized trials show no lasting benefit in corticosteroid injection, but 90% of patients will gain short-term pain relief. SFX of injection include tendon rupture, skin atrophy and hypopigmentation. More than 3 injections in one year should be avoided
• Glycosaminoglycan injection – no lasting benefit and causes local pain in a significant proportion
• Acupuncture – may give fleeting benefit
• Extra corporeal shock wave therapy – no evidence of benefit
A success rate of around 90% can be expected with non-operative treatment.
Around 10% of patients will have a recurrence.
Surgical treatment involves excision of the abnormal tissue and repair of the defect. An incision is made posterior to the lateral epicondyle to avoid the branches of the lateral antebrachial cutaneous nerve. ECRL is retracted anteriorly to expose the origin of ECRB. The pathological material (often the whole of the origin of ECRB) is removed and the area drilled or decorticated to encourage healing. ECRL is then repaired to the extensor aponeurosis, side to side.
Some have advocated percutaneous release of the extensor fascia or the extensor mass but other authors have found that this causes a significant decrease in wrist extensor strength.
Some surgeons routinely arthroscope the elbow concurrently, citing an intra-articular pathology rate of 69%.
The approach to medial epicondylitis is similar. Ulnar nerve pathology may need to be addressed concurrently. If a medial epicondylectomy is performed, no more than 20% of the epicondyle should be removed to avoid violation of the UCL. The most common complication of medial release is medial elbow instability.
Immobilize for several days postoperatively in an elbow immobilizer at 90 degrees, and then commence gentle ROM activities and progressive strengthening.
Back to sports at around 6 –12 weeks.
Weakness of wrist extensors
Synovial fistula and ganglion formation
Varus instability of the elbow
Results of surgical treatment
12% some pain but able to participate in sports
3% no improvement
The results in medial epicondylitis are not as predictable.
Aids to decision making
Nirschl describes the handshake test: the patient performs a firm handshake with the elbow extended and supinates the forearm against resistance. This is repeated with the elbow flexed to 90 degrees. If the pain is decreased in the flexed position then operative treatment is less likely to be necessary.
Nirschl advises a year of non-surgical treatment, unless the patient is greatly incapacitated.
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