Tennis Elbow Impormasyon In-depth

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• The term 'Tennis Elbow' is considered inaccurate by some authors [1].
• The diagnosis of tennis elbow is often made too quickly [1].
• Rapid diagnosis may contribute to high rates of recalcitrant complaints due to insufficient consideration of differential diagnoses [1].
• Approximately 90% of people with untreated tennis elbow achieve symptom resolution at 1 year based on placebo or no-treatment control arms of randomized trials [3].
• Pooled data from randomized controlled trials indicate a lack of intermediate- to long-term clinical benefit after nonsurgical treatment of lateral epicondylitis compared with observation only or placebo [4].
• No single universally accepted protocol has emerged for the treatment of epicondylitis despite numerous available options [7].
• Most patients with lateral epicondylitis resolve spontaneously or with standard conservative management [12].
• Refractory cases of lateral epicondylitis may benefit from interventional therapies or surgical approaches [12].
• Current research evidence suggests that surgery for tennis elbow is no more effective than nonsurgical treatment, based on evidence with significant methodological limitations [31].
• There was insufficient evidence to support or refute the effectiveness of surgery for lateral elbow pain due to a small number of studies, large heterogeneity in interventions, small sample sizes, and poor reporting of outcomes [11].
• Denervation of the elbow for management of tennis elbow is a simple safe procedure [16].

Anatomy & Pathophysiology

Anatomy

• The pathology of lateral epicondylitis is primarily localized to the origin of the extensor carpi radialis brevis (ECRB) [51].
• The ECRB and extensor digitorum communis (EDC) have tendinous origins and lie deep to the extensor carpi radialis longus (ECRL), which has a muscular origin [51].
• The common extensors lie superficial to the lateral collateral ligament complex proximally and to the supinator distally [51].
• The ECRB tendon lies superficial to the joint capsule, making it accessible arthroscopically [51].
• The posterior interosseous nerve enters the supinator distal to the radial head [51].
• Compression of the posterior interosseous nerve at the radial tunnel can coexist with lateral epicondylitis [51].
• The pathologic process mainly involves the origin of the extensor carpi radialis brevis but can involve the tendons of the extensor carpi radialis longus and the extensor digitorum communis [52].
• The anatomic basis of the injury to the extensor carpi radialis brevis origin involves hypovascular zones, eccentric tendon stresses, and a microscopic degenerative response [25].

Pathophysiology

• Lateral epicondylitis is initiated as a microtear, most often within the origin of the extensor carpi radialis brevis [52].
• The current consensus is that lateral epicondylitis is a degenerative process rather than an inflammatory one [25].
• Histologic studies of lateral epicondylitis show angiofibroblastic hyperplasia [51, 52].
• Histologic findings include neovascularization, infiltration by mucopolysaccharide, a disordered collagen scaffold, bone formation, and angiofibroblastic proliferation [51].
• Inflammation is not usually seen in lateral epicondylitis but is likely present in the early stages [51].
• The lesion occurs in a vascular watershed area that is relatively avascular, limiting healing potential [51].
• Eccentric contractions of the extensor carpi radialis brevis muscle during backhand tennis swings are the likely cause of repetitive microtrauma that causes tears in the tendon and lateral epicondylitis [35].
• The presence of hypoechogenicity and bone changes on ultrasound indicates the presence of a stressed common extensor origin-lateral epicondyle complex in elbows with lateral epicondylalgia [5].
• Repetitive exposure to bending and straightening the elbow is a significant risk factor for lateral epicondylitis [84].
• There is a strong association between combined physical exertion and elbow movements and lateral epicondylitis [8].
• Biomechanical exposure involving the wrist and/or elbow at work is associated with the incidence of lateral epicondylitis [57].

Classification

• The term "Tennis Elbow" is considered inaccurate, and the diagnosis is often made too quickly, which may explain high rates of recalcitrant complaints due to insufficient consideration of differential diagnoses [1].
• A considerable terminological heterogeneity exists in the description of lateral elbow pain, associated with a lack of clear and recognized diagnostic criteria [30].
• Approximately 46.5% of patients presenting with lateral-sided elbow pain are diagnosed with a condition other than lateral epicondylitis [14].
• The findings of an epidemiologic study are consistent with the hypothesis that tennis elbow is a degenerative disease, the onset of which is hastened by overuse of the arm and elbow [13].
• Pathologic tissue studies have noted a failed reparative process rather than active inflammation in lateral epicondylitis [25].
• The presence of hypoechogenicity and bone changes on musculoskeletal ultrasound indicates the presence of a stressed common extensor origin-lateral epicondyle complex in elbows with lateral epicondylalgia [5].
• Accurate diagnosis of medial epicondylitis requires distinguishing it from other elbow conditions, and treatment is guided by the specific pathologic stage of the tendon [10].
• The arthroscopic identification of three types of Baker lesions helps the surgeon confirm the presence of pathology commonly seen intra-articularly in patients with lateral epicondylitis [68].
• Failed surgical treatment of lateral epicondylitis is multifactorial, and distinguishing the cause is critical for appropriate management [15].

Clinical Presentation

• The term 'Tennis Elbow' is considered inaccurate, and the diagnosis is often made too quickly, potentially explaining high rates of recalcitrant complaints due to insufficient consideration of differential diagnoses [1].
• Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years [26].
• The findings are consistent with the hypothesis that tennis elbow is a degenerative disease, the onset of which is hastened by overuse of the arm and elbow [13].
• Almost half of the patients (46.5%) presenting with lateral sided elbow pain were diagnosed with a condition other than lateral epicondylitis [14].
• A considerable terminological heterogeneity exists in the description of lateral elbow pain, associated with the lack of clear and recognised diagnostic criteria [30].
• The diagnosis of lateral epicondylitis based on Japanese Orthopaedic Association guidelines requires pain in the elbow joint within 2 weeks, pain in the lateral epicondyle region on resisted extension of the wrist with the elbow extended, and tenderness in the lateral epicondyle [46].
• Tenderness for the diagnosis of lateral epicondylitis is considered positive if observed in the lateral epicondyle or adjacent tissue up to 4 cm distal to the epicondyle and elicited by any degree of palpation [46].
• Physical examination of the elbow should focus on functional anatomy and includes inspection, palpation, range of motion, strength, stability, and special tests [54].
• The history is the most valuable tool to guide the clinical examination, with location, quality, context, duration, and severity of elbow pain being important for understanding pathology [54].
• Determining the symptom trajectory (whether pain is getting better, worse, or remaining constant) is helpful when considering intervention [54].
• Characteristic elements of the history for lateral elbow tendinopathy include pain lifting things from a bag with a pronated hand, turning doorknobs, taking milk from the fridge, shaking hands, taking a laptop out of a bag, and bumping the lateral elbow [54].
• Physical examination maneuvers to elicit lateral elbow tendinopathy include direct palpation of the ECRB origin, the tennis elbow shear test, pain with resisted wrist or long finger extension, and the laptop test [54].
• Imaging studies to evaluate lateral elbow tendinopathy include MRI if the lateral ulnar collateral ligament is suspected as part of the pathology and ultrasonography [54].

Investigations

Clinical Diagnosis and Differential Diagnosis

• The physical exam is directed by history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect of the elbow [49].

Imaging: Ultrasound

• Ultrasonographic imaging of the elbow includes imaging techniques and the normal appearance of anatomic structures [44].

Imaging: Magnetic Resonance Imaging (MRI)

• The routine use of MRI for the diagnosis of lateral epicondylitis is low, although its use is associated with downstream effects [69].
• Increased MRI signal in the extensor carpi radialis brevis (ECRB) origin is common in both symptomatic and asymptomatic elbows [70].
• MRI can be used to evaluate ligaments and tendons of the elbow, but it is rarely indicated [45].
• The reliability and validity of magnetic resonance imaging in the assessment of chronic lateral epicondylitis has been evaluated [47].
• Magnetic resonance evaluation of the elbow includes the review of ligament complexes [44].
• A review of the MR appearance of osseous and soft-tissue anatomy of the elbow, as well as commonly encountered pathology including overuse injury, has been performed [44].

Imaging: Radiographs and CT

• Plain radiographs remain the hallmark and the best screening test for the evaluation of the elbow [49].
• Standard AP, lateral, and oblique radiographs are obtained for elbow evaluation, with serial radiography used as follow-up when heterotopic ossification is present [45].
• CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [45].
• Three-dimensional CT is used to check for heterotopic ossification [45].
• CT is not necessary when elbow stiffness is entirely soft-tissue related [45].

Neurological Assessment

• Electromyography/nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists [45].
• An assessment for ulnar nerve subluxation should be performed, as subluxation of the nerve is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [45].

Treatment

Non-Operative Management

• Approximately 90% of people with untreated tennis elbow achieve symptom resolution at 1 year [3].
• Lateral epicondylitis is usually self-limited, resolving over a 12- to 18-month period without treatment [33].
• The probable best recommendation for treatment is oral analgesics for symptom relief, activity modification, and a plan of “waiting things out” for up to 18 months [42].
• Corticosteroid injection has little, if any, benefit over placebo and usually does not change the natural history of the disease [42].
• Recent data suggest that poorer results are seen in the intermediate and long term following corticosteroid injections relative to placebo [42].
• Patients who undergo corticosteroid injection may actually be worse at the end of a year [42].
• The significant short-term benefits of corticosteroid injection are paradoxically reversed after six weeks, with high recurrence rates [22].
• Peri-articular hyaluronic acid treatment for tennis elbow was significantly better than control in improving pain at rest and after maximal grip testing [61].
• Nonsurgical treatment is the mainstay of management for lateral epicondylitis, involving options such as rest, physical therapy, and injections [62].
• Nonoperative treatment for epicondylitis has a success rate of up to 90% [66].
• A high-repetition, low-resistance home exercise program may be useful for lateral epicondylitis [42].
• There is wide variability of treatments offered when physiotherapy fails patients with tennis elbow [28].
• Further investigations are needed on tendinopathies in other areas of the upper limb, including epicondylar tendinopathy [18].

Operative Management

• There was insufficient evidence to support or refute the effectiveness of surgery for lateral elbow pain due to small number of studies, heterogeneity, small sample sizes, and poor reporting [11].
• Greater than 90% of people with lateral epicondylitis are successfully treated nonoperatively [21].
• Most surgical patients for lateral epicondylitis are in their fifth decade of life, have had symptoms for an average of 19 months, and have had failure of nonoperative treatment including an average of 3.1 corticosteroid injections [21].
• The majority of patients undergoing surgery for lateral epicondylitis have surgery on their dominant elbow, with an average incidence of dominant arm involvement of 74% [21].
• Outcomes between open and arthroscopic surgical procedures for lateral epicondylitis are comparable [42].
• Arthroscopic treatment of lateral epicondylitis is accompanied by an increased risk of neurovascular injury and instability compared with open release of the elbow [42].
• Good to excellent results have been achieved in 83% to 96% of patients using variations in technique for medial epicondylitis [42].
• Poorer outcomes are reported in patients with ulnar nerve symptoms undergoing medial epicondylitis surgery [42].
• Surgical intervention for refractory medial epicondylitis often has a high success rate with patients generally demonstrating an improvement in patient-reported outcomes and an encouraging number returning to work with limited complications [17].
• The median time of minimum conservative management before surgery for lateral epicondylitis was six months [64].
• Surgical intervention is reserved for patients with continued symptoms after 6 months or more of treatment [43].
• There is no good algorithm for the type of surgical treatment that is most effective for lateral epicondylitis [21].
• No single universally accepted protocol has emerged for the treatment of epicondylitis [7].

Complications

• Corticosteroid injections have a short-term beneficial effect on lateral epicondylitis, but a negative effect in the intermediate term [32].
• The significant short-term benefits of corticosteroid injection are reversed after six weeks, with high recurrence rates [22].
• Heterotopic ossification has been reported as a complication following elbow arthroscopy for lateral epicondylitis [39].
• Three or more preoperative injections is the most significant risk factor for revision surgery after operative treatment of lateral epicondylitis [71].
• Short-term complication rates appear comparable between open and arthroscopic treatment of lateral epicondylitis [73].

Recovery

• Lateral epicondylitis often resolves spontaneously, warranting considerable circumspection before embarking on treatment [19].
• The prognosis for medial epicondylitis in occupational settings was good with a 3-year recovery rate at 81% [20].
• Poor prognosis at 1 year of follow-up for lateral epicondylitis was related to manual work and high baseline pain [77].
• No relation was found between the type of medical treatment given or chosen and prognosis for lateral epicondylitis at 1 year [77].
• The annual incidence of lateral epicondylitis per 10,000 patients and the proportion of cases treated surgically remained constant from 2007 to 2014 [38].

Key Evidence

• [Letter] The authors agree that the term 'Tennis Elbow' is inaccurate and that the diagnosis is often made too quickly, potentially explaining high rates of recalcitrant complaints due to insufficient consideration of differential diagnoses. [1] (10.1177/1758573218816086)
• [L1] Based on the placebo or no-treatment control arms of randomized trials, about 90% of people with untreated tennis elbow achieve symptom resolution at 1 year. [3] (10.1097/corr.0000000000002058)
• [L1] Pooled data from RCTs indicate a lack of intermediate- to long-term clinical benefit after nonsurgical treatment of lateral epicondylitis compared with observation only or placebo. [4] (10.1007/s11999-014-4022-y)
• [L4] The presence of hypoechogenicity and bone changes indicates presence of a stressed common extensor origin-lateral epicondyle complex in elbows with lateral epicondylalgia. [5] (10.1186/1471-2342-14-10)
• [L5] This article is a review of recently published information on elbow tendinopathy and tendon ruptures intended to assist clinicians in diagnosis and management, noting that while numerous treatment options exist for epicondylitis, no single universally accepted protocol has emerged. [7] (10.1016/j.jhsa.2009.01.022)
• [L4] This study emphasizes the strength of the associations between combined physical exertion and elbow movements and lateral epicondylitis. [8] (10.1002/ajim.22140)
• [L5] Accurate diagnosis requires distinguishing it from other elbow conditions, and treatment is guided by the specific pathologic stage of the tendon. [10] (10.1016/j.csm.2004.04.011)
• [L1] Due to a small number of studies, large heterogeneity in interventions across trials, small sample sizes and poor reporting of outcomes, there was insufficient evidence to support or refute the effectiveness of surgery for lateral elbow pain. [11] (10.1002/14651858.cd003525.pub2)
• [L4] Most patients with lateral epicondylitis resolve spontaneously or with standard conservative management, but refractory cases may benefit from interventional therapies or surgical approaches. [12] (10.5397/cise.2019.22.4.227)
• [L4] The findings are consistent with the hypothesis that tennis elbow is a degenerative disease, the onset of which is hastened by overuse of the arm and elbow. [13] (10.1177/036354657900700405)
• [L3] Almost half of the patients (46.5%) were diagnosed with a diagnosis other than lateral epicondylitis. [14] (10.1016/j.jseint.2024.08.047)
• [L5] Failed surgical treatment of lateral epicondylitis is multifactorial, and distinguishing the cause is critical for appropriate management. [15] (10.1016/j.xrrt.2023.07.006)
• [L2] Denervation of the elbow for management of tennis elbow is a simple safe procedure. [16] (10.5435/jaaosglobal-d-24-00352)
• [L4] Surgical intervention for refractory medial epicondylitis often has a high success rate with patients generally demonstrating an improvement in patient-reported outcomes and an encouraging number returning to work with limited complications. [17] (10.1177/03635465221095565)
• [L2] Further investigations are needed, not only focused on shoulder impingement or epicondylar tendinopathy, but on tendinopathies in other areas of the upper limb. [18] (10.1016/j.jsams.2015.06.007)
• [L4] Overall, the available data suggest that lateral epicondylitis often resolves spontaneously, warranting considerable circumspection before embarking on treatment. [19] (10.1016/j.otsr.2019.09.004)
• [L2] The prognosis for medial epicondylitis in this population was good with a 3-year recovery rate at 81%. [20] (10.1097/01.jom.0000085888.37273.d9)
• [L4] [21] (10.1097/blo.0b013e3181483dc4)
• [L1] The significant short term benefits of corticosteroid injection are paradoxically reversed after six weeks, with high recurrence rates, implying that this treatment should be used with caution in the management of tennis elbow. [22] (10.1136/bmj.38961.584653.ae)
• [L4] [25] (10.1016/j.jhsa.2007.07.019)
• [L5] Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years. [26] (10.1302/0301-620x.95b9.29285)
• [L4] There is wide variability of treatments offered when physiotherapy fails patients with tennis elbow. [28] (10.1177/1758573217738199)
• [L1] In this SR, a considerable terminological heterogeneity emerged in the description of LEP, associated with the lack of clear and recognised diagnostic criteria in evaluating and treating patients with lateral elbow pain. [30] (10.3390/healthcare10061095)
• [L1] Current research evidence suggests that surgery for tennis elbow is no more effective than nonsurgical treatment based on evidence with significant methodological limitations. [31] (10.1177/1758573217745041)
• [L1] Corticosteroid injections have a shortterm beneficial effect on lateral epicondylitis, but a negative effect in the intermediate term. [32] (10.1136/bmjopen-2013-003564)
• [L2] Lateral epicondylitis is a condition that is usually self-limited, resolving over a 12- to 18-month period without treatment. [33] (10.1007/s11552-014-9642-x)
• [L5] [35] (10.1016/j.csm.2004.06.004)
• [L4] The annual incidence of lateral epicondylitis per 10,000 patients and the proportion of cases treated surgically remained constant from 2007 to 2014. [38] (10.1007/s11420-017-9559-3)
• [L4] To our knowledge, we present the first case of HO development after elbow arthroscopy for lateral epicondylitis. [39] (10.1177/1558944716668844)
• [L3] [46] (10.1016/j.jseint.2024.01.008)
• [L2] The results of this meta-analysis strongly support the hypothesis of an association between biomechanical exposure involving wrist and/or elbow at work and incidence of lateral epicondylitis. [57] (10.1002/acr.22874)
• [L1] Peri-articular HA treatment for tennis elbow was significantly better than control in improving pain at rest and after maximal grip testing. [61] (10.1186/1758-2555-2-4)
• [L5] Nonsurgical treatment is the mainstay of management for lateral epicondylitis, involving options such as rest, physical therapy, and injections. [62] (10.5435/00124635-200801000-00004)
• [L4] [64] (10.1016/j.xrrt.2024.08.008)
• [Paper] The article reviews the pathology, clinical presentation, and treatment options for lateral and medial epicondylitis in athletes, noting that nonoperative treatment has a success rate of up to 90% and that surgical options are reserved for recalcitrant cases. [66] (10.1016/j.csm.2010.06.009)
• [L4] The arthroscopic identification of the 3 types of Baker lesions helps the surgeon to confirm the presence of pathology commonly seen intra-articularly in patients with lateral epicondylitis. [68] (10.1016/j.eats.2024.103142)
• [L3] Although there is variation in the use of MRI for lateral epicondylitis and its use is associated with downstream effects, the routine use of MRI for the diagnosis of lateral epicondylitis is low. [69] (10.1016/j.jhsa.2023.03.025)
• [L4] Increased MRI signal in the ECRB origin is common in symptomatic and in asymptomatic elbows. [70] (10.1016/j.jse.2016.01.033)
• [L4] [71] (10.1016/j.jse.2016.10.022)
• [L3] Surgical management of lateral epicondylitis varies depending on surgeons' fellowship training, and short-term complication rates appear comparable between open and arthroscopic treatment. [73] (10.1016/j.arthro.2017.04.078)
• [L2] Poor prognosis at 1yr of follow-up for lateral epicondylitis was related to manual work and high baseline pain, whilst no relation was found between the type of medical treatment given/chosen and prognosis. [77] (10.1093/rheumatology/keg360)
• [L4] Repetitive exposure to bending/straightening the elbow was a significant risk factor for medial and lateral epicondylitis. [84] (10.1093/rheumatology/ker228)

References

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