History

Fact Explanation
Pain over the lateral elbow Sharp and intermittent pain over the lateral elbow which aggravates with repeated extension of the wrist. Pain usually radiates along the extensor surface of the forearm towards the wrist. Pain is of insidious onset while the acute pain can recur following activities that involve repeated pronation of the forearm with the elbow extended. eg:- playing a backhand in tennis, using a screwdriver, playing the violin, carrying a heavy briefcase, shaking hands or typing. [1] Patient usually pinpoints pain at 1.5 cm distal to the origin of the Extensor carpi radialis brevis (ECRB). This is due to microtrauma and subsequent tendinosis at the origin of ECRB with or without involvement of the extensor digitorum communis (EDC)[2]. This is often called ‘‘angiofibroblastic tendinosis’’ which is a degenerative process characterized by an abundance of fibroblasts,vascular hyperplasia and unstructured collagen rather than an inflammatory reaction. [2],[3]
Weak grip The elbow pain is made worse by gripping activities and, in some cases, simple things like turning a door handle can cause intense pain.Gripping either too hard or for too long can cause exacerbations of pain. [1]
References
  1. GEOFFROY,P. et al. Diagnosing and treating lateral epicondylitis.Can Fam Physician. Jan 1994,40,73–78. [viewed 9 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379994/
  2. SMEDT,T.D. et al. Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment.Br J Sports Med, 2007,41,816–819. [viewed 9 March 2014]. Available from: doi: 10.1136/bjsm.2007.036723
  3. KRAUSHAAR,B.S, R.P.NIRSCHL. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am,1999,81,259–78. [viewed 9 March 2014]. Available from: http://jbjs.org/article.aspx?articleid=24244

Examination

Fact Explanation
Tenderness at the lateral epicondyle. Maximum tenderness is 1-2 cm distal to the origin of the ECRB (Extensor carpi radialis brevis) where the tendinosis occurs.[1]
Pain increases when the wrist is extended against resistance When the wrist is extended, with the wrist radially deviated and pronated more force is exerted on affected ECRB origin.[1,2]
Coffee cup test Patient feels pain at the lateral epicondyle when picking up a heavy cup of coffee.[2]
Mills' test The examiner palpates the patient’s lateral epicondyle with his/her thumb while passively pronating the forearm, flexing the wrist and extending the elbow. A positive test would be the reproduction of pain near the lateral epicondyle. [3]
Maudsley's test Extension against resistance of the middle finger when the elbow is fully extended and the forearm is pronated. This causes stress to the extensor digitorum muscle and tendon. A positive sign would be pain or discomfort in the region of the lateral epicondyle [4,5]
Swelling and Redness Occurs rarely; due to inflammation during the early stages of lateral epicondylitis.[2]
References
  1. SMEDT,T.D. et al. Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment.Br J Sports Med, 2007,41,816–819. [viewed 9 March 2014]. Available from: doi: 10.1136/bjsm.2007.036723
  2. COONRAD,R.W. Tennis elbow. Instr Course Lect, 1986,55,94-101. [viewed 9 March 2014]. Available from:http://www.ncbi.nlm.nih.gov/pubmed/3819433
  3. MILLS,G.P. Treatment of tennis elbow. Br Med J. 1937 Jul 31,2(3995),212-3. [viewed 9 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2087033/
  4. ROLES,N.C, R.H.MAUDSLEY. Radial tunnel syndrome: resistant tennis elbow as a nerve entrapment. ] BoneJoint Surg Br,1972,54-B,499-508. [viewed 9 March 2014]. Available from:http://www.bjj.boneandjoint.org.uk/content/54-B/3/499.long
  5. GEOFFROY,P. et al. Diagnosing and treating lateral epicondylitis.Can Fam Physician. Jan 1994,40,73–78. [viewed 9 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379994/

Differential Diagnoses

Fact Explanation
Radiculopathy Nerve compression from a herniated disk or arthritic bony spurs causes irritation of C6 and C7 nerve roots of the cervical spine. This manifests as radiating neck and arm pain or numbness.There may be an associated sensory deficit, or motor dysfunction in the neck and upper extremities. [1,2]
Entrapment of the Posterior interosseus nerve. (Posterior interosseus Syndrome) Causes dorsal upper forearm pain and weakness.Point tenderness is felt 3 - 4 cm distal to the lateral epicondyle (over the area of the radial neck), or at the edge of the supinator muscle. [3]
Osteoarthritis Commonly seen in the elderly.Pain occurs with reduced range of movement at elbow. Crepitation may be felt in examination. Secondary osteoarthritis has a predilection for previously diseased or injured joints.[4]
Osteochondritis dissecans Disease process is due to defects in the articular cartilage and the underlying subchondral bone.This manifests as gradual onset activity-related pain and swelling.There may be mechanical symptoms including catching, locking, popping and giving way.[5]
Osteonecrosis Avascular necrosis or ossteonecrosis is seen more often among children. Presents as an Insidious onset pain which worsens with activity and improves with rest.The elbow extension may be limited.[6]
Plica synovialis (Elbow synovial fold syndrome) Seen commonly among athletes. It is caused from repeated impingement of redundant synovial folds of the elbow joint.Pain and sensation of snapping or clicking of the elbow are the predominant complaints. [7]
References
  1. ELLENBERG,M.R. et al. Cervical radiculopathy. Arch Phys Med Rehabil, 1994 Mar,75(3),342-52. [viewed 12 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8129590
  2. MALANGA,G.A. The diagnosis and treatment of cervical radiculopathy. Med Sci Sports Exerc,1997 Jul, 29(7 suppl),S236-45. [viewed 12 March 2014]. Available from: http://journals.lww.com/techhandsurg/Abstract/2002/12000/Radial_Tunnel_Syndrome.10.aspx
  3. SARRIS,L.K. Radial Tunnel Syndrome. Techniques in Hand and Upper Extremity Surgery, 6 (4), 209–212. [viewed 12 March 2014]. Available from: doi: 10.1097/00130911-200212000-00010
  4. GREGORY,P.J.et al. Dietary supplements for osteoarthritis. Am Fam Physician. 2008,77,177-184. [viewed 12 March 2014]. Available from: http://www.aafp.org/afp/2008/0115/p177.html
  5. HIXON,A.L, L.M.GIBBS. Osteochondritis dissecans: a diagnosis not to miss. American Family Physician, 61 (1),151–6, 158. [viewed 12 March 2014]. Available from: http://www.aafp.org/afp/2000/0101/p151.html
  6. CROWTHER,M. Elbow pain in pediatrics.Curr Rev Musculoskelet Med. Jun 2009; 2(2): 83–87. [viewed 12 March 2014]. Available from: doi: 10.1007/s12178-009-9049-4.
  7. AWAYA. et al. Elbow Synovial Fold Syndrome: MR Imaging Findings. American Journal of Roentgenology, 2001, 177.1377-1381. [viewed 12 March 2014]. Available from: http://www.ajronline.org/doi/abs/10.2214/ajr.177.6.1771377

Investigations - for Diagnosis

Fact Explanation
X-Ray Elbow Diagnosis based primarily on clinical findings.Laboratory and Imaging studies are rarely useful but may be needed in chronic cases to exclude the other causes such as osteochondritis dissecans, osteophyte fomration and degenerative disease.[1] In treatment resistant patients; calcification of soft tissues around the lateral epicondyle has been reported in 22% of cases.[2]
MRI To evaluate and exclude osteochondritis dissecans or stress fractures. [3]
References
  1. POMERANCE, J. Radiographic analysis of lateral epicondylitis. J Shoulder Elbow Surg, 2002,11,156–7. [viewed 12 March 2014]. Available from:http://www.ncbi.nlm.nih.gov/pubmed/11988727
  2. COONRAD,R.W. Tennis elbow. Instr Course Lect, 1986,55,94-101. [viewed 9 March 2014]. Available from:http://www.ncbi.nlm.nih.gov/pubmed/3819433
  3. AOKI,M. et al. Magnetic resonance imaging findings of refractory tennis elbows and their relationship to surgical treatment. J Shoulder Elbow Surg,2005,14,172–7. [viewed 12 March 2014]. Available from:http://www.ncbi.nlm.nih.gov/pubmed/15789011

Management - General Measures

Fact Explanation
Cessation of any offending activities and practice watchful waiting. Appropriate as initial management; however complete inactivity or immobilization should be avoided to avoid the possibility of disuse atrophy, which will affect rehabilitation. [1]
Application of ice Provides local vasoconstrictive and analgesic effects. [1]
Counter-force bracing. Reduce the forces on the wrist extensor tendons. Significantly Improve rest pain. [2] This should be applied firmly 10 cm distal to the elbow joint. Counter-force bracing is found to increase grip strength at 3 weeks. [3]
References
  1. JOBE,F.W, M.G.CICCOTTI. Lateral and medial epicondylitis of the elbow. J Am Acad Orthop Surg,1994,2,1–8. [viewed 12 March 2014]. Available from:http://www.jaaos.org/content/2/1/1.full.pdf
  2. COONRAD,R.W. Tennis elbow. Instr Course Lect, 1986,55,94-101. [viewed 9 March 2014]. Available from:http://www.ncbi.nlm.nih.gov/pubmed/3819433
  3. BORKHOLDER,C.D, et al. The efficacy of splinting for lateral epicondylitis: a systematic review. J Hand Ther,Apr-Jun 2004,17(2),181-99. [viewed 12 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0020869/

Management - Specific Treatments

Fact Explanation
Non-steroidal anti-inflammatory drugs. (NSAID) The anti inflammatory is useful initially to provide pain relief. Topical application can be supplemented by oral NSAID's. In the long term, oral NSAIDs with physiotherapy is more effective than corticosteroid injections in providing analgesia. [1]
Corticosteroid injections. Improves pain and functional limitation due to tennis elbow in the short term. But has a higher recurrence rate at 6 weeks, when compared to NSAID's or othoses. Repeated corticosteroid injections are ineffective in reducing pain and It increases the need for surgical intervention. [1,2] Post-injection pain and local skin atrophy are possible complications. [3]
Extracorporeal shock wave therapy. (ECSWT) Not commonly used, it is less effective in reducing the pain when compared to other therapeutic options.[1]
Physiotherapy Involves several components: ultrasound, phonophoresis (use of ultrasound to enhance the delivery of topically applied drugs), electrical stimulation, physical manipulation, soft tissue mobilization, neural tension, friction massage and augmented soft tissue mobilization (ASTM). Success rate at one year is greater than other therapeutic options (91%).[4]
Acupuncture A homeopathic technique, only a few studies show evidence of improvement in pain at 2 to 8 weeks. [5]
Laser therapy Definitive data on possible short or long term benefits is inconclusive. [6]
Autologous whole blood injections and platelet rich plasma. High concentrations of platelet derived growth factors that enhance wound, bone and also tendon healing. [7]
Arthroscopuc Surgery A surgical option is indicated if 6 months of conservative management has failed. Prior to surgery it is mandatory to exclude other possible causes. Arthroscopic removal of pathological tendinosis tissue is a successful treatment strategy in such cases.[8] Abnormal tissue within the Extensor carpi radialis brevis (ECRB) tendon origin at the lateral epicondyle is either excised or the tendon is released altogether.[9,10,11]
Open Surgery An open approach with release of the tendons of the extensor muscles at the lateral epicondyle is most widely used. Currently this extra-articular technique is popular, with excision of the pathologic portion of the extensor tendon origin, repair of the defect and reattachment of the origin to the lateral epicondyle. Satisfactory results are described in 85% to 90% of the patients. [11,12]
Sonographically guided percutanous needle tenotomy Performed under local anesthesia, a sonographically guided a needle is advanced into the common extensor tendon. The tip of the needle is used to repeatedly fenestrate the tendinotic tissue. Calcifications, if present, are mechanically fragmented, and the adjacent bony surface of the apex and face of the epicondyle are abraded. Finally the fenestrated tendon is infiltrated with a mixture of a steroid and a local anesthetic.This method is found to have better short term outcomes than open surgery. [11]
References
  1. BISSET,L. et al.Tennis elbow.Clin Evid (Online).2011,1117. [viewed 12 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217754/
  2. DAY,B.H. et al. Corticosteroid injections in the treatment of tennis elbow. Practitioner,1978,220,459–462. [viewed 12 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/347424
  3. SMIDT,N.et al. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain,2002,96,23–40. [viewed 12 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11932058
  4. SMIDT,N. et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002,359,657–62. [viewed 12 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11879861
  5. FINK,M. et al. Acupuncture in chronic epicondylitis: a randomized controlled trial.Rheumatology (Oxford). 2002 Feb,41(2),205-9. [viewed 12 March 2014]. Available from: http://rheumatology.oxfordjournals.org/content/41/2/205.long
  6. SMIDT,N. et al. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Ann Med, 2003,35(1),51-62. [viewed 12 March 2014]. Available from:http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0020433/
  7. EDWARDS,S.G, J.H.CALANDRUCCIO. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg [Am], Mar 2003,28(2),272-8. [viewed 12 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12671860
  8. BAKER,C.L. et al. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med. Feb 2008,36(2),254-60. [viewed 12 March 2014]. Available from:http://www.ncbi.nlm.nih.gov/pubmed/18202296
  9. MULLET,H. et al. Arthroscopic treatment of lateral epicondylitis: clinical and cadaveric studies. Clin Orthop Relat Res,2005,439,123–8.[viewed 12 March 2014]. Available from: http://journals.lww.com/corr/Abstract/2005/10000/Arthroscopic_Treatment_of_Lateral_Epicondylitis_.25.aspx
  10. PEART,R.E. et al. Lateral epicondylitis: a comparative study of open and arthroscopic lateral release. Am J Orthop,2004,33,565–7.[viewed 12 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15603517
  11. SZABO,S.J et al. Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment. J Shoulder Elbow Surg, 2006,15,721–7. [viewed 12 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16963287
  12. COONRAD,R.W. Tennis elbow. Instr Course Lect, 1986,55,94-101. [viewed 9 March 2014]. Available from:http://www.ncbi.nlm.nih.gov/pubmed/3819433Jobe FW, Ciccotti MG. Lateral and medial epicondylitis of the elbow. J Am Acad Orthop Surg 1994;2:1–8.