Bệnh khuỷu tay tennis Thông tin

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

• Tennis elbow diagnosis and treatment concepts impact work participation [1].
• About 90% of people with untreated tennis elbow achieve symptom resolution at 1 year [2].
• Elbow arthroscopy is a safe modality of treatment for a variety of pathologies in experienced hands [4].
• Numerous treatment options exist for epicondylitis, but no single universally accepted protocol has emerged [5].
• Most patients with lateral epicondylitis resolve spontaneously or with standard conservative management [7].
• Refractory cases of lateral epicondylitis may benefit from interventional therapies or surgical approaches [7].
• There is insufficient evidence to support or refute the effectiveness of surgery for lateral elbow pain due to small study numbers, large heterogeneity, small sample sizes, and poor outcome reporting [10].
• 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 [11].
• Failed surgical treatment of lateral epicondylitis is multifactorial, and distinguishing the cause is critical for appropriate management [12].
• There is wide variability of treatments offered when physiotherapy fails patients with tennis elbow [14].
• Most patients with lateral epicondylosis experience relief with non-operative management [16].
• Controversy remains regarding the optimal modality for quickest recovery and the role of surgical intervention for refractory cases of lateral epicondylosis [16].
• Surgical intervention for refractory medial epicondylitis often has a high success rate with patients generally demonstrating an improvement in patient-reported outcomes [24].
• Patients with refractory medial epicondylitis have an encouraging number returning to work with limited complications after surgical intervention [24].
• Current research evidence suggests that surgery for tennis elbow is no more effective than nonsurgical treatment, based on evidence with significant methodological limitations [26].

Anatomy & Pathophysiology

• Tennis elbow is a degenerative disease [8].
• The onset of tennis elbow is hastened by overuse of the arm and elbow [8].
• Lateral epicondylitis is associated with combined physical exertion and elbow movements [3].
• Biomechanical exposure involving wrist and/or elbow at work is associated with the incidence of lateral epicondylitis [34].
• Repetitive exposure to bending or straightening the elbow is a significant risk factor for medial and lateral epicondylitis [48].
• Self-reported physical exposures implicating repetitive and extensive/prolonged wrist bend/twisting and forearm movements are associated with incident cases of lateral and medial epicondylitis [50].
• Hypoechogenicity and bone changes indicate the presence of a stressed common extensor origin-lateral epicondyle complex in elbows with lateral epicondylalgia [13].
• Increased MRI signal in the extensor carpi radialis brevis (ECRB) origin is common in both symptomatic and asymptomatic elbows [31].
• The common extensor tendon (CET) is thicker in men and in the dominant elbow [49].
• There is no difference in CET thickness regarding age groups [49].
• Lateral epicondylalgia is characterized by considerable terminological heterogeneity and a lack of clear, recognized diagnostic criteria [17].
• Accurate diagnosis of medial epicondylitis requires distinguishing it from other elbow conditions [9].
• Treatment of medial epicondylitis is guided by the specific pathologic stage of the tendon [9].
• Persistent lateral elbow pain can result from overlooked posterolateral impingement of the elbow [22].
• Understanding the static and dynamic anatomy of the lateral part of the elbow is necessary for developing future treatment and preventive strategies [22].
• Arthroscopic tennis elbow release involves establishing a proximal medial or superomedial portal located approximately 2 cm proximal to the medial epicondyle and 1 cm anterior to the intermuscular septum [42].
• During arthroscopic tennis elbow release, the joint is distended with 20 to 30 mL of saline through an 18-gauge needle introduced through the direct lateral portal [42].
• A 2.7-mm, 30-degree arthroscope is introduced into the joint through the proximal medial or superomedial portal, maintaining contact with the anterior aspect of the humerus [42].
• A superolateral portal is established with an 18-gauge needle through the lesion to identify the undersurface of the extensor carpi radialis brevis tendon [42].
• Pathologic tendinous attachment of the extensor carpi radialis brevis is debrided using a curet and motorized shaver, and the lateral epicondyle is decorticated [42].
• Decortication of the lateral epicondyle and lateral epicondylar ridge can be performed with an arthroscopic burr, handheld instruments, or electrocautery [42].
• A 70-degree arthroscope may be required in rare instances during arthroscopic tennis elbow release [42].
• Heterotopic ossification (HO) can develop after elbow arthroscopy for lateral epicondylitis [15].

Classification

• Tennis elbow is considered a degenerative disease [8].
• There is considerable terminological heterogeneity in the description of lateral elbow pain (LEP) [17].
• There is a lack of clear and recognised diagnostic criteria for evaluating and treating patients with lateral elbow pain [17].
• Persistent tennis elbow symptoms have little prognostic value [2].
• No single universally accepted protocol has emerged for the treatment of epicondylitis [5].
• There is little clear consensus on which modality works best for both conservative and operative options for lateral epicondylitis [29].
• The understanding of the disease process of lateral epicondylitis is currently incomplete [29].
• Failed surgical treatment of lateral epicondylitis is multifactorial [12].
• Distinguishing the cause of failed surgical treatment of lateral epicondylitis is critical for appropriate management [12].

Clinical Presentation

• Tennis elbow is a degenerative disease whose onset is hastened by overuse of the arm and elbow [8].
• Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years [37].
• Lateral elbow tendinosis is relatively common, particularly among individuals aged 40 to 49 years [20].
• Lateral epicondylitis is a condition that is usually self-limited, resolving over a 12- to 18-month period without treatment [27].
• Nonoperative treatment for lateral and medial epicondylitis in athletes has a success rate of up to 90% [28].
• Lateral epicondylitis often resolves spontaneously, warranting considerable circumspection before embarking on treatment [18].
• Work-related risk factors for lateral epicondylitis include combined physical exertion and elbow movements [3].
• There is considerable terminological heterogeneity in the description of lateral elbow pain (LEP), associated with a lack of clear and recognised diagnostic criteria [17].
• The presence of hypoechogenicity and bone changes indicates a stressed common extensor origin-lateral epicondyle complex in elbows with lateral epicondylalgia [13].

Investigations

• Tennis elbow is a degenerative disease, the onset of which is hastened by overuse of the arm and elbow [8].
• Combined physical exertion and elbow movements are strongly associated with lateral epicondylitis [3].
• Accurate diagnosis requires distinguishing lateral epicondylitis from other elbow conditions [9].
• Treatment is guided by the specific pathologic stage of the tendon in epicondylitis [9].
• No single universally accepted protocol has emerged for the diagnosis and management of epicondylitis [5].
• The presence of hypoechogenicity and bone changes indicates presence of a stressed common extensor origin-lateral epicondyle complex in elbows with lateral epicondylalgia [13].
• There is evidence to support the use of ultrasound in the detection of lateral epicondylitis [52].
• Routine use of MRI for the diagnosis of lateral epicondylitis is low [41].
• Lateral epicondyle calcifications are much more common in lateral epicondylitis than previously reported, possibly owing to modern digital radiography and magnification [53].
• Lateral epicondyle calcifications do not appear to be related to clinical factors including patient-reported measures [53].

Treatment

Natural History and Prognosis

• 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 [2].
• Lateral epicondylitis is a self-limited condition that usually resolves over a 12- to 18-month period without treatment [27].
• Lateral epicondylitis has a self-limiting course of 12 to 18 months, with most patients well-managed with non-operative treatment and activity modification [35].
• The prognosis for medial epicondylitis in occupational settings is good, with a 3-year recovery rate of 81% [19].

Non-Operative Management

• Nonsurgical treatment is the mainstay of management for lateral epicondylitis, involving options such as rest, physical therapy, and injections [38].
• Most patients with tennis elbow experience relief with non-operative management [16].
• Corticosteroid injections provide significant short-term benefits for tennis elbow, but these benefits are reversed after six weeks with high recurrence rates, implying the treatment should be used with caution [21].
• Peri-articular hyaluronic acid (HA) treatment for tennis elbow was significantly better than control in improving pain at rest and after maximal grip testing [36].
• Normal saline (NS) injections yielded a statistically significant and clinically meaningful improvement in pain and functional outcomes in patients with lateral epicondylitis [39].
• Local platelet-rich plasma (PRP) injections were associated with superior outcomes for reducing pain and improving elbow joint function compared with local corticosteroid treatment for lateral epicondylitis at a follow-up of 6 months [40].
• Further investigations are needed regarding the effectiveness of eccentric exercise therapy for epicondylar tendinopathy [6].

Operative Management

• 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 [24].
• Surgical options for tennis elbow are reserved for recalcitrant cases [28].
• There is 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 [10].

Clinical Practice and Consensus

• While numerous treatment options exist for epicondylitis, no single universally accepted protocol has emerged [5].
• There is little clear consensus on which modality works best for both conservative and operative options for lateral epicondylitis, indicating that the understanding of the disease process is currently incomplete [29].
• There is wide variability of treatments offered when physiotherapy fails patients with tennis elbow in UK clinical practice [14].

Complications

• Corticosteroid injection for tennis elbow provides significant short-term benefits but reverses after six weeks with high recurrence rates [21].
• Corticosteroid injections have a short-term beneficial effect on lateral epicondylitis but a negative effect in the intermediate term [25].
• Heterotopic ossification (HO) has been reported as a complication following elbow arthroscopy for lateral epicondylitis [15].
• Short-term complication rates appear comparable between open and arthroscopic surgical treatment for lateral epicondylitis [43].
• Medial elbow pain during the return-to-throwing period after ulnar collateral ligament reconstruction in pitchers is associated with an increased risk for further surgical intervention [45].

Recovery

• Enthesopathy of the extensor carpi radialis brevis origin is a benign, self-limiting disorder with a natural history of spontaneous resolution [33].
• No treatments have been proven to alter the course of enthesopathy of the extensor carpi radialis brevis origin [33].
• The prognosis for medial epicondylitis in occupational settings was good with a 3-year recovery rate at 81% [19].
• Poor prognosis at 1 year of follow-up for lateral epicondylitis was related to manual work and high baseline pain [46].
• No relation was found between the type of medical treatment given or chosen and prognosis for lateral epicondylitis at 1 year [46].
• Corticosteroid injections have a short-term beneficial effect on lateral epicondylitis [25].
• Corticosteroid injections have a negative effect in the intermediate term for lateral epicondylitis [25].
• The significant short-term benefits of corticosteroid injection are paradoxically reversed after six weeks, with high recurrence rates [21].
• Radial extracorporeal shock wave therapy (ESWT) was related to better effects in lateral epicondylitis [30].
• Symptom duration of longer than 6 months was related to better effects with radial ESWT for lateral epicondylitis [30].
• Short follow-up duration (less than 24 weeks) was related to better effects with radial ESWT for lateral epicondylitis [30].
• Due to heterogeneity in studies regarding disorder duration, shock wave therapy type, frequency, dose, management type, control group, follow-up timing, and outcomes assessed, a pooled meta-analysis of shock wave therapy for lateral elbow tendinopathy was considered inappropriate [55].
• Controversy remains regarding the optimal modality for quickest recovery in lateral epicondylosis [16].
• Controversy remains regarding the role of surgical intervention for refractory cases of lateral epicondylosis [16].

Key Evidence

• [L4] This review gives an overview of the current concepts of diagnosis and treatment of tennis elbow and the impact on work participation. [1] (10.1177/1758573218797973)
• [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. [2] (10.1097/corr.0000000000002058)
• [L4] This study emphasizes the strength of the associations between combined physical exertion and elbow movements and lateral epicondylitis. [3] (10.1002/ajim.22140)
• [L4] In experienced hands, elbow arthroscopy is a safe modality of treatment for a variety of pathologies. [4] (10.1016/j.arthro.2007.03.080)
• [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. [5] (10.1016/j.jhsa.2009.01.022)
• [L2] Further investigations are needed, not only focused on shoulder impingement or epicondylar tendinopathy, but on tendinopathies in other areas of the upper limb. [6] (10.1016/j.jsams.2015.06.007)
• [L4] Most patients with lateral epicondylitis resolve spontaneously or with standard conservative management, but refractory cases may benefit from interventional therapies or surgical approaches. [7] (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. [8] (10.1177/036354657900700405)
• [L5] Accurate diagnosis requires distinguishing it from other elbow conditions, and treatment is guided by the specific pathologic stage of the tendon. [9] (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. [10] (10.1002/14651858.cd003525.pub2)
• [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. [11] (10.1007/s11999-014-4022-y)
• [L5] Failed surgical treatment of lateral epicondylitis is multifactorial, and distinguishing the cause is critical for appropriate management. [12] (10.1016/j.xrrt.2023.07.006)
• [L4] The presence of hypoechogenicity and bone changes indicates presence of a stressed common extensor origin-lateral epicondyle complex in elbows with lateral epicondylalgia. [13] (10.1186/1471-2342-14-10)
• [L4] There is wide variability of treatments offered when physiotherapy fails patients with tennis elbow. [14] (10.1177/1758573217738199)
• [L4] To our knowledge, we present the first case of HO development after elbow arthroscopy for lateral epicondylitis. [15] (10.1177/1558944716668844)
• [L5] This article serves to provide an updated review of the various treatment options and management for lateral epicondylosis, noting that while most patients experience relief with non-operative management, controversy remains regarding the optimal modality for quickest recovery and the role of surgical intervention for refractory cases. [16] (10.1016/j.jhsa.2024.07.003)
• [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. [17] (10.3390/healthcare10061095)
• [L4] Overall, the available data suggest that lateral epicondylitis often resolves spontaneously, warranting considerable circumspection before embarking on treatment. [18] (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%. [19] (10.1097/01.jom.0000085888.37273.d9)
• [L3] The study indicates that lateral elbow tendinosis is relatively common, particularly among individuals aged 40 to 49 years. [20] (10.1177/0363546514568087)
• [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. [21] (10.1136/bmj.38961.584653.ae)
• [L4] Further understanding of the static and dynamic anatomy of the lateral part of the elbow will help to develop future treatment and preventive strategies. [22] (10.5397/cise.2023.01081)
• [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. [24] (10.1177/03635465221095565)
• [L1] Corticosteroid injections have a shortterm beneficial effect on lateral epicondylitis, but a negative effect in the intermediate term. [25] (10.1136/bmjopen-2013-003564)
• [L1] Current research evidence suggests that surgery for tennis elbow is no more effective than nonsurgical treatment based on evidence with significant methodological limitations. [26] (10.1177/1758573217745041)
• [L2] Lateral epicondylitis is a condition that is usually self-limited, resolving over a 12- to 18-month period without treatment. [27] (10.1007/s11552-014-9642-x)
• [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. [28] (10.1016/j.csm.2010.06.009)
• [L4] Although many treatments have been advocated for lateral epicondylitis, there is little clear consensus on which modality works best for both conservative and operative options, indicating that the understanding of the disease process is currently incomplete. [29] (10.1016/j.jhsa.2007.07.019)
• [L1] Radial ESWT, symptom duration of longer than 6 months, and short follow-up duration (less than 24 weeks) were related to better effects. [30] (10.1097/corr.0000000000001246)
• [L4] Increased MRI signal in the ECRB origin is common in symptomatic and in asymptomatic elbows. [31] (10.1016/j.jse.2016.01.033)
• [L5] Enthesopathy of the extensor carpi radialis brevis origin is a benign, self-limiting disorder with a natural history of spontaneous resolution, for which no treatments have been proven to alter the course. [33] (10.5435/jaaos-d-15-00233)
• [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. [34] (10.1002/acr.22874)
• [L5] Lateral epicondylitis is a common condition with a self-limiting course of 12 to 18 months, and most patients are well-managed with non-operative treatment and activity modification, though many surgical techniques exist for refractory symptoms. [35] (10.1302/2058-5241.1.000049)
• [L1] Peri-articular HA treatment for tennis elbow was significantly better than control in improving pain at rest and after maximal grip testing. [36] (10.1186/1758-2555-2-4)
• [L5] Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years. [37] (10.1302/0301-620x.95b9.29285)
• [L5] Nonsurgical treatment is the mainstay of management for lateral epicondylitis, involving options such as rest, physical therapy, and injections. [38] (10.5435/00124635-200801000-00004)
• [L1] NS injections yielded a statistically significant and clinically meaningful improvement in pain and functional outcomes in patients with lateral epicondylitis. [39] (10.1177/0363546519899644)
• [L1] Local PRP injections was associated with superior outcomes for reducing pain and improving elbow joint function compared with local corticosteroids treatment for LE at a follow-up of 6 months. [40] (10.1016/j.ijsu.2019.05.003)
• [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. [41] (10.1016/j.jhsa.2023.03.025)
• [L3] Surgical management of lateral epicondylitis varies depending on surgeons' fellowship training, and short-term complication rates appear comparable between open and arthroscopic treatment. [43] (10.1016/j.arthro.2017.04.078)
• [L3] Those who experience medial elbow pain are at increased risk for further surgical intervention. [45] (10.1177/2325967118808782)
• [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. [46] (10.1093/rheumatology/keg360)
• [L4] Repetitive exposure to bending/straightening the elbow was a significant risk factor for medial and lateral epicondylitis. [48] (10.1093/rheumatology/ker228)
• [L3] This study presents the US characteristics and normal values of the CET, finding that the tendon was thicker in men and in the dominant elbow with no difference regarding age groups. [49] (10.1177/2325967117704186)
• [L2] Self-reported physical exposures that implicate repetitive and extensive/prolonged wrist bend/twisting and forearm movements were associated with incident cases of lateral and medial epicondylitis in a large longitudinal study. [50] (10.1136/oemed-2012-101341)
• [L2] There is evidence to support the use of ultrasound in the detection of lateral epicondylitis. [52] (10.1016/j.otsr.2014.01.006)
• [L4] Lateral epicondyle calcifications are much more common in lateral epicondylitis than previously reported, possibly owing to modern digital radiography and magnification, although they do not appear to be related to clinical factors including patient-reported measures. [53] (10.1016/j.jhsa.2017.03.016)
• [L1] With current studies heterogeneous in terms of the duration of the disorder; type, frequency and total dose of SWT; period of time between SWT; type of management and control group; timing of follow-up and outcomes assessed, a pooled meta-analysis of SWT for lateral elbow tendinopathy was considered inappropriate. [55] (10.1093/bmb/ldm019)

References

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[31] Incidental magnetic resonance imaging signal changes in the extensor carpi radialis brevis origin are more common with age. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.01.033

[33] Enthesopathy of the Extensor Carpi Radialis Brevis Origin. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-15-00233

[34] Lateral Epicondylitis and Physical Exposure at Work? A Review of Prospective Studies and Meta‐Analysis. Arthritis Care & Research. 2016. DOI: 10.1002/acr.22874

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[39] Effect of Normal Saline Injections on Lateral Epicondylitis Symptoms: A Systematic Review and Meta-analysis of Randomized Clinical Trials. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546519899644

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[42] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC REPAIR OF POSTERIOR HUMERAL AVULSION OF THE GLENOHUMERAL LIGAMENT > ARTHROSCOPIC TENNIS ELBOW RELEASE.

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[45] Medial Elbow Pain During the Return-to-Throwing Period After Ulnar Collateral Ligament Reconstruction in Pitchers. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118808782

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[48] Occupation and epicondylitis: a population-based study. Rheumatology. 2011. DOI: 10.1093/rheumatology/ker228

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