Cotovelo de tenista Folheto In-depth

O que você está sentindo

A epicondilite lateral é a dor na parte externa do cotovelo, no ponto ósseo onde os músculos do antebraço se fixam. Ela ocorre quando o tendão nessa região fica desgastado e irritado. É mais comum entre as idades de 35 e 65 anos, afetando cerca de 3% da população.

A dor piora ao segurar objetos, levantar peso ou girar o braço. Girar uma maçaneta, segurar uma xícara de café, despejar água de uma chaleira ou pegar uma sacola de compras podem desencadear a dor. A pressão na parte externa do cotovelo geralmente causa sensibilidade. Esticar o punho ou os dedos contra resistência — como ao levantar algo com a palma da mão virada para baixo — também costuma provocar dor.

A dor tende a piorar após atividades físicas e pode persistir à noite ou logo ao acordar. Com o passar das semanas, ela pode interferir na rotina diária. Algumas pessoas percebem restrições em seu trabalho e atividades sociais devido à dor. Cerca de 20% das pessoas com epicondilite lateral sentem dor intensa o suficiente para limitar suas atividades profissionais e cotidianas.

A boa notícia é que a epicondilite lateral geralmente melhora por si só. Os sintomas costumam diminuir gradualmente ao longo de três a quatro meses, e a maioria dos casos se resolve em até 6 meses, independentemente do tratamento adotado. Aproximadamente 90% das pessoas com epicondilite lateral não tratada têm seus sintomas resolvidos em até 1 ano. Mesmo que a dor persista há bastante tempo, as chances de recuperação no próximo ano permanecem praticamente as mesmas.

Como a condição costuma melhorar espontaneamente, a maioria das pessoas não precisa de cirurgia. A cirurgia é indicada apenas para a pequena porcentagem de pacientes cuja dor não responde a outros tratamentos.

O que está realmente acontecendo

O ponto dolorido corresponde a um tendão chamado extensor carpi radialis brevis. Ele conecta os músculos do punho e dos dedos ao osso localizado na parte externa do cotovelo. Pense nele como uma corda que prende uma vela ao mastro: toda ação de segurar, levantar ou torcer exerce força sobre essa “corda”.

Com o uso repetido, a corda começa a se desgastar. O processo natural de reparação do corpo não consegue acompanhar esse desgaste, fazendo com que as fibras do tendão se tornem desorganizadas, em vez de fortes e alinhadas. Não se trata de inchaço nem de um surto inflamatório, embora o termo “epicondilite” sugira isso. É um problema de desgaste, mais semelhante a uma corda desfia do que a uma corda queimada; por isso a dor reaparece sempre que você usa a mão.

O desgaste ocorre exatamente no ponto onde o tendão se conecta ao osso, e a carga nessa região aumenta quando o cotovelo está esticado e a palma da mão voltada para baixo. Isso coincide com os movimentos que lhe causam dor: segurar objetos, levantar coisas com a palma voltada para baixo e torcer alças. Além disso, a percepção do cotovelo sobre sua própria posição no espaço pode ficar menos precisa, e o pequeno músculo na parte posterior do cotovelo não se ativa como deveria ao segurar algo. Por isso o problema não envolve apenas o tendão em si; cuidar do pescoço, do ombro e de todo o braço também é importante, não apenas do cotovelo.

Se a dor persistir por muito tempo e o cotovelo sofrer outra lesão, um ligamento próximo que estabiliza a articulação também pode ficar sobrecarregado. Isso pode deixar o cotovelo instável e dolorido; é um dos motivos pelos quais alguns casos não respondem bem ao tratamento simples.

O que podemos fazer a respeito

O Dr. Kieran Hirpara, cirurgião de membros superiores no Mater Private Hospital Rockhampton, começa com as opções menos invasivas adequadas ao seu quadro clínico. Em geral, os pacientes são encaminhados à nossa clínica pelo médico de família; caso um fisioterapeuta tenha sugerido que você nos procure, ainda assim será necessário um encaminhamento do seu médico de família para que você tenha direito ao reembolso do Medicare. Na sua primeira consulta, colhemos o histórico clínico, examinamos o cotovelo e solicitamos exames de imagem, se necessário.

Na maioria dos casos, o cotovelo de tenista melhora sem cirurgia; por isso, geralmente iniciamos com tratamento não cirúrgico. Você pode diminuir a carga sobre o tendão alterando a forma como segura objetos, levanta pesos e gira os braços no trabalho e em casa. A fisioterapia visa aliviar a dor e recuperar a força do pulso e do antebraço. É importante persistir nesse tratamento por alguns meses. As chances de recuperação permanecem praticamente as mesmas durante o primeiro ano, mesmo que a dor já esteja presente há bastante tempo.

Os analgésicos e anti-inflamatórios podem atenuar um pouco a dor, porém o alívio é limitado e esses medicamentos podem causar efeitos colaterais. As injeções são uma opção que podemos discutir. A cortisona pode aliviar a dor a curto prazo. O ácido hialurônico é um fluido lubrificante injetado ao redor do tendão. O plasma rico em plaquetas utiliza uma amostra do seu próprio sangue, processada para concentrar as células de cicatrização, sendo então injetada no tendão. Conversaremos sobre o que cada um desses tratamentos envolve e por quanto tempo o efeito pode durar, antes de decidirmos juntos qual seria a melhor opção para você.

A cirurgia é considerada quando esses tratamentos não trouxerem melhoria suficiente e a dor continuar a limitar suas atividades profissionais ou cotidianas. A operação consiste em retirar a parte desgastada e danificada do tendão na região onde ele se fixa ao osso, na parte externa do cotovelo. Consideramos isso uma decisão compartilhada, tomada em conjunto após você compreender o que o procedimento envolve e quais são seus benefícios e limitações.

O que esperar

O prognóstico para o cotovelo de tenista é, na maioria dos casos, favorável; você já viu os números: a maioria dos casos melhora dentro de um ano, independentemente do tratamento adotado. A dor tende a diminuir gradualmente, em vez de desaparecer da noite para o dia. Ao longo de semanas e meses, você deve notar que as crises ficam mais curtas e menos intensas, e que atividades cotidianas como segurar uma chaleira ou girar uma maçaneta tornam-se mais fáceis. O fato de a dor persistir há muito tempo não reduz suas chances de recuperação.

Caso o cotovelo não melhore com os tratamentos mais simples, a cirurgia continua sendo uma opção viável. Alguns procedimentos para casos crônicos de cotovelo de tenista apresentam taxas de sucesso entre 75% e 80%.

Vale ressaltar que a cirurgia não garante a cura. Um pequeno número de pacientes, cerca de 1,5%, precisa de uma nova operação posteriormente. A realização de três ou mais injeções antes da cirurgia aumenta essa probabilidade. Como em qualquer operação, existem riscos gerais, como infecção ou rigidez; além disso, alguns procedimentos podem deixar o cotovelo um pouco mais rígido do que antes.

Portanto, a realidade é a seguinte: muito provavelmente seu cotovelo melhorará por conta própria ou com fisioterapia e ajustes no modo como você utiliza o braço. Caso isso não ocorra, a cirurgia ajuda a maioria das pessoas nessa situação, mas não a todas.

Quando procurar ajuda médica

Na maioria dos casos, o cotovelo de tenista melhora por conta própria; portanto, o tempo costuma ser o principal “tratamento”. Consulte seu médico de família se a dor na parte externa do cotovelo persistir por mais de 6 semanas ou se ela impedir que você trabalhe ou durma. Solicite uma avaliação especializada caso tratamentos simples e fisioterapia ao longo de vários meses não tenham surtido efeito, ou se o cotovelo estiver não apenas dolorido, mas também instável – pois, às vezes, um ligamento lesionado pode ser a causa do problema. Informe ao seu médico quantas injeções você já recebeu, pois três ou mais injeções de corticosteroidees antes de qualquer cirurgia aumentam a probabilidade de precisar de outra intervenção posterior. Caso perceba calor, vermelhidão ou febre associados à dor, procure imediatamente um médico em vez de esperar que a situação melhore.

Em maior profundidade

Advanced reading: the deeper science (optional)

Esta seção aborda temas que vão além do necessário para suas próprias decisões de tratamento. O cotovelo de tenista merece uma leitura mais aprofundada, pois é uma das condições em que o tratamento que parece mais eficaz no primeiro mês acaba sendo o pior resultado no final do ano.

A condição geralmente cura-se sozinha, ainda que lentamente

Se deixada sem intervenção, a epicondilite lateral tende a melhorar. No estudo abaixo mencionado, o grupo que foi orientado a simplesmente aguardar, sem injeções nem fisioterapia, foi reavaliado após 52 semanas; 56 de 62 (90%) relataram melhora significativa ou recuperação completa [1].

Esse percentual serve como referência para a avaliação de qualquer tratamento. Uma intervenção só se justifica se proporcionar resultados melhores do que a melhoria espontânea, que, na maioria dos casos, acaba ocorrendo por si só.

O paradoxo dos corticosteroides

Um estudo randomizado de referência comparou a injeção de corticosteroides, a fisioterapia e a simples espera, acompanhando os pacientes por um ano inteiro [1].

Após seis semanas, os resultados da injeção pareciam excelentes: 51 de 65 (78%) dos pacientes do grupo de injeção relataram sucesso, em comparação com 16 de 60 (27%) daqueles que apenas aguardaram. O número necessário para tratar foi de 2 [1].

Porém, a situação se reverteu. Dos pacientes que obtiveram sucesso inicial, 47 de 65 (72%) acabaram apresentando piora posteriormente. Aos 52 semanas, o grupo que recebeu injeção apresentou resultados significativamente piores que o grupo de fisioterapia em todos os desfechos; além disso, em duas das três medidas primárias, os resultados foram piores até mesmo que os daqueles que nada fizeram [1].

Vale repetir a explicação dada pelos próprios autores: a injeção alivia a dor tão rapidamente que os pacientes voltam a sobrecarregar um tendão que, na verdade, ainda não cicatrizou. A conclusão do estudo foi que os corticosteroides “devem ser usados com cautela” no tratamento da epicondilite lateral – uma afirmação surpreendente, considerando que esse é o tratamento que a maioria dos pacientes espera receber.

Por isso, a aplicação de injeções nesse caso deve ser uma decisão ponderada, visando apenas a função a curto prazo, e jamais deve substituir o programa de exercícios de fortalecimento.

O que vale a pena fazer, então?

A fisioterapia superou a simples espera aos seis semanas em todos os critérios avaliados; aos 52 semanas, os resultados dos dois grupos tornaram-se indistinguíveis, pois quase todos os pacientes de ambos os grupos haviam se recuperado [1]. Portanto, seu valor reside em ajudar o paciente a superar mais rapidamente os meses dolorosos, e não em alterar o desfecho final. Vale ressaltar que o grupo que fez fisioterapia também procurou menos tratamentos adicionais durante o processo [1]. Diante disso, o plano mais sensato é o controle da carga de esforço e um programa progressivo de exercícios para os tendões, reconhecendo que o tempo de recuperação se mede em meses.

A cirurgia é indicada apenas para a pequena minoria de pacientes que permanecem incapacitados após um tratamento não cirúrgico realmente prolongado e adequado. O motivo para estabelecer esse limiar tão alto é justamente a evolução natural da doença mencionada acima: operar precocemente significa competir contra uma condição que, em nove de cada dez casos, acabaria se resolvendo por si só.

Injeção de células tendinosas cultivadas

Pode ser que lhe seja oferecida, ou que você leia a respeito, da implantação de tenócitos autólogos (ATI; comercializada na Austrália como OrthoATI), que consiste na injeção de células tendinosas suas, cultivadas em laboratório. O procedimento é seguro e biologicamente sensato; os resultados observados em casos de cotovelo de tenista resistentes ao tratamento mantiveram-se por mais de quatro anos. Contudo, na literatura mundial, há apenas cinco estudos envolvendo 50 pacientes no total, nenhum dos quais contou com grupo de comparação. Considerando-se o prognóstico natural da doença descrito acima, torna-se evidente a necessidade de cautela. Uma descrição completa do que se sabe e do que ainda é desconhecido, acompanhada de referências, encontra-se na página sobre implantação de tenócitos autólogos.

Referências

[1] Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilização com movimento e exercícios, injeção de corticosteroide ou observação para o cotovelo de tenista: ensaio randomizado. BMJ. 2006;333(7575):939. https://doi.org/10.1136/bmj.38961.584653.ae

Evidence & references

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)

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