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Epicondylitis


BASICS


DESCRIPTION


  • Tendinopathy of the elbow characterized by pain and tenderness at the origins of the wrist flexors/extensors at the humeral epicondyles
  • May be acute (traumatic) or chronic (overuse)
  • Two types
    • Medial epicondylitis ("golfer's elbow")
      • Involves the wrist flexors and pronators, which originate at the medial epicondyle
    • Lateral epicondylitis ("tennis elbow")
      • Involves the wrist extensors and supinators, which originate at the lateral epicondyle
  • May be caused by many different athletic or occupational activities
  • Common in carpenters, plumbers, gardeners, and athletes
  • Usually involves the dominant arm
  • Lateral epicondylitis is more common.

EPIDEMIOLOGY


  • Predominant age: >40 years
  • Predominant sex: male = female

Incidence
  • Common overuse injury
  • Lateral > medial
  • Estimated between 1% and 3%

Prevalence
  • Lateral epicondylitis: 1.3%
  • Medial epicondylitis: 0.4%

ETIOLOGY AND PATHOPHYSIOLOGY


  • Acute (tendonitis)
    • Inflammatory response to injury
  • Chronic (tendinosis)
    • Overuse injury
    • Tendon degeneration, fibroblast proliferation, microvascular proliferation, lack of inflammatory response
  • Repetitive wrist flexion or extension places strain across enthesis of flexor/extensor group
  • Tool/racquet gripping
  • Shaking hands
  • Sudden maximal muscle contraction
  • Direct blow

RISK FACTORS


  • Repetitive wrist motions
    • Flexion/pronation: medial
    • Extension/supination: lateral
  • Smoking
  • Obesity
  • Upper extremity forceful activities

GENERAL PREVENTION


  • Limit overuse of the wrist flexors, extensors, pronators, and supinators.
  • Use proper techniques when working with hand tools or playing racquet sports.
  • Use lighter tools and smaller grips.

DIAGNOSIS


HISTORY


  • Pain typically localized to lateral or medial elbow.
  • Occupational activities
  • Sports participation
  • Direct trauma
  • Duration and location of symptoms
  • Prior treatments or medication use
  • Pain with gripping
  • Sensation of mild forearm weakness

PHYSICAL EXAM


  • Localized pain just distal to the affected epicondyle
  • Increased pain with wrist flexion/pronation (medial)
  • Increased pain with wrist extension/supination (lateral)
  • Medial epicondylitis
    • Tenderness at origin of wrist flexor tendons
    • Increased pain with resisted wrist flexion and pronation
    • Normal elbow range of motion
    • Increased pain with gripping
  • Lateral epicondylitis
    • Tenderness at origin of wrist extensors
    • Increased pain with resisted wrist extension/supination
    • Normal elbow range of motion
    • Increased pain with gripping

DIFFERENTIAL DIAGNOSIS


  • Elbow osteoarthritis
  • Epicondylar fractures
  • Posterior interosseous nerve entrapment (lateral)
  • Ulnar neuropathy (medial)
  • Synovitis
  • Medial collateral ligament injury
  • Referred pain from shoulder or neck

DIAGNOSTIC TESTS & INTERPRETATION


Initial Tests (lab, imaging)
No imaging is required for initial evaluation and treatment of a classic overuse injury.  
Follow-Up Tests & Special Considerations
  • Anterior-posterior/lateral radiographs if decreased range of motion, trauma, or no improvement with initial conservative therapy. Assess for fractures or signs of arthritis.
  • For recalcitrant cases
    • Musculoskeletal ultrasound (US) reveals abnormal tendon appearance (e.g., tendon thickening, partial tear at tendon origin, calcifications). US can also guide injections of steroid and/or anesthetic.
    • MRI can show intermediate or high T2 signal intensity within the common flexor or extensor tendon or the presence of peritendinous soft tissue edema.

Diagnostic Procedures/Other
Infiltration of local anesthetic with subsequent resolution of symptoms supports the diagnosis if clinically in doubt.  

TREATMENT


GENERAL MEASURES


Initial treatment consists of activity modification, counterforce bracing, oral or topical NSAIDs, ice, and physical therapy:  
  • Observation: If left untreated, symptoms typically last between 6 months and 2 years. For patients with good function and minimal pain, consider conservative management using a "wait and see" approach based on patient preference.
  • Modify activity, encourage relative rest, and correct faulty biomechanics
  • Counterforce bracing with a forearm strap is easy and inexpensive. Systematic reviews are inconclusive about overall efficacy, but initial bracing may improve the ability to perform daily activities in the first 6 weeks.
  • Consider nighttime wrist splinting for repetitive daily activities if counterforce bracing fails.
  • Ice frequently after activities
  • Physical therapy
    • Begin once acute pain is resolved. Infiltration of local anesthetic can reduce pain and allow for physical therapy
    • Eccentric strength training and stretching program
    • US therapy
    • Corticosteroid iontophoresis
    • Dry needling

MEDICATION


First Line
  • Topical NSAIDs: Low-quality evidence suggests topical NSAIDS are significantly more effective than placebo with respect to pain and number needed to treat to benefit (NNT = 7) in the short term (up to 4 weeks) with minimal adverse effects (1)[A].
  • Oral NSAIDs: Unclear efficacy with respect to pain and function, but may offer short-term pain relief. Associated with adverse GI effects (1)[A].

Second Line
  • Corticosteroid injections: Short-term (ā‰¤8 weeks) reduction in pain. No benefits found for intermediate or long-term outcomes (2)[A].

ISSUES FOR REFERRAL


Failure of conservative therapy  

ADDITIONAL THERAPIES


  • Platelet-rich plasma (PRP) injections
    • Injection of concentrated autologous PRP leads to a local inflammatory response. Platelets degranulate, release growth factors, and stimulate the physiologic healing cascade
    • PRP treatment of chronic lateral epicondylitis significantly reduces pain and increases function. The benefit exceeds that of corticosteroid injection even after a follow-up of 2 years (3)[B].
  • Autologous blood injections
    • Stimulates the inflammatory cascade within the degenerated tendon by providing cellular and humoral mediators for regeneration.
    • More effective at 3 months then corticosteroid injection for improving pain, function and grip strength (4)[B]
  • US-guided percutaneous needle tenotomy
    • Injection of a local anesthetic followed by US-guided tendon fenestration, aspiration, and abrasion the underlying bone. Thought to break apart scar tissue and stimulate inflammation and healing.
  • Prolotherapy
    • Injection of a dextrose solution into and around the tendon attachment stimulates a localized inflammatory response, leading to increased blood flow to stimulate healing.
  • Glyceryl trinitrate (GTN) transdermal patch
    • Nitric oxide (NO) is a small free radical generated by nitric oxide synthases. NO is expressed by fibroblasts and is postulated to aid in collagen synthesis. Topical application of GTN theoretically improves healing by this mechanism. 1/4 of a 5-mg/24-hour GTN transdermal patch is applied once daily for up to 24 weeks.
    • Significant decreases in pain are seen at 3 weeks and 6 months compared to placebo patch (5)[B].
  • Botulinum toxin A for chronic lateral epicondylitis
    • Injections into the forearm extensor muscles (60 units) can be performed in the outpatient setting.

SURGERY/OTHER PROCEDURES


  • Elbow surgery may be indicated in refractory cases:
    • Fair evidence for treatment (6)[B]
    • Involves d ©bridement and tendon release
    • Can be performed open or arthroscopically
  • Denervation of the lateral humeral epicondyle
    • Transection of the posterior cutaneous nerve of the forearm with implantation into the triceps may help with chronic symptoms and pain.

COMPLEMENTARY & ALTERNATIVE MEDICINE


Acupuncture: effective for short-term pain relief for lateral epicondyle pain  

ONGOING CARE


PROGNOSIS


Good: Majority resolve with conservative care.  

REFERENCES


11 Pattanittum  P, Turner  T, Green  S, et al. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Cochrane Database Syst Rev.  2013;(5):CD003686.22 Krogh  TP, Bartels  EM, Ellingsen  T, et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med.  2013;41(6):1435-1446.33 Gosens  T, Peerbooms  JC, van Laar  W, et al. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med.  2011;39(6):1200-1208.44 Arik  HO, Kose  O, Guler  F, et al. Injection of autologous blood versus corticosteroid for lateral epicondylitis: a randomised controlled study. J Orthop Surg (Hong Kong).  2014;22(3):333-337.55 Ozden  R, Uru §  V, Doğmaci  Y, et al. Management of tennis elbow with topical glyceryl trinitrate. Acta Orthop Traumatol Turc.  2014;48(2):175-180.66 Yeoh  KM, King  GJ, Faber  KJ, et al. Evidence-based indications for elbow arthroscopy. Arthroscopy.  2012;28(2):272-282.

ADDITIONAL READING


  • Cullinane  FL, Boocock  MG, Trevelyan  FC. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil.  2014;28(1):3-19.
  • Dingemanse  R, Randsdorp  M, Koes  BW, et al. Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: a systematic review. Br J Sports Med.  2014;48(12):957-965.
  • Green  S, Buchbinder  R, Barnsley  L, et al. Acupuncture for lateral elbow pain. Cochrane Database Syst Rev.  2002;(1):CD003527.
  • Kalichman  L, Bannuru  RR, Severin  M, et al. Injection of botulinum toxin for treatment of chronic lateral epicondylitis: systematic review and meta-analysis. Semin Arthritis Rheum.  2011;40(6):532-538.
  • McShane  JM, Shah  VN, Nazarian  LN. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow: is a corticosteroid necessary? J Ultrasound Med.  2008;27(8):1137-1144.
  • Rose  NE, Forman  SK, Dellon  AL. Denervation of the lateral humeral epicondyle for treatment of chronic lateral epicondylitis. J Hand Surg Am.  2013;38(2):344-349.

SEE ALSO


Algorithm: Pain in Upper Extremity  

CODES


ICD10


  • M77.00 Medial epicondylitis, unspecified elbow
  • M77.10 Lateral epicondylitis, unspecified elbow
  • M77.01 Medial epicondylitis, right elbow
  • M77.02 Medial epicondylitis, left elbow
  • M77.12 Lateral epicondylitis, left elbow
  • M77.11 Lateral epicondylitis, right elbow

ICD9


  • 726.31 Medial epicondylitis
  • 726.32 Lateral epicondylitis

SNOMED


  • 73583000 Epicondylitis (disorder)
  • 202855006 Lateral epicondylitis (disorder)
  • 53286005 Medial epicondylitis
  • 15636041000119105 Bilateral medial epicondylitis of elbows (disorder)
  • 15636001000119108 Lateral epicondylitis of bilateral humerus (disorder)

CLINICAL PEARLS


  • Medial epicondylitis (golfer's elbow) is characterized by pain and tenderness at the tendinous origins of the wrist flexors at the medial epicondyle.
  • Lateral epicondylitis (tennis elbow) is characterized by pain and tenderness at the tendinous origins of the wrist extensors at the lateral epicondyle.
  • Left untreated, symptoms typically last between 6 months and 2 years.
  • Most patients improve using conservative treatment with bracing, activity modification, and physical therapy.
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