LATERAL EPICONDYLITIS - Human & Disease

LATERAL EPICONDYLITIS


 LATERAL EPICONDYLITIS ( Tennis Elbow Pain )


LATERAL EPICONDYLITIS ( Tennis Elbow Pain ) Definition: tendinitis of the common extensor tendon origin, also known as tennis elbow Lateral-sided elbow pain. Possible reported history of injury or repetitive trauma Pain worse with lifting and gripping. Pain is also possible at night when the elbow is moved from a resting position.
Lateral epicondylitis








Definition: tendinitis of the common extensor tendon origin, also known as tennis elbow Lateral-sided elbow pain.

Possible reported history of injury or repetitive trauma Pain worse with lifting and gripping.

Pain is also possible at night when the elbow is moved from a resting position.

LATERAL EPICONDYLITIS ( Tennis Elbow Pain ) Definition: tendinitis of the common extensor tendon origin, also known as tennis elbow Lateral-sided elbow pain. Possible reported history of injury or repetitive trauma Pain worse with lifting and gripping. Pain is also possible at night when the elbow is moved from a resting position.

Physical Examination:

- Possible mild edema over the lateral epicondyle.

- Point tenderness to palpation over the lateral epicondyle.

- Pain with resisted wrist extension.

- Pain at the lateral epicondyle caused by grip strength testing with a dynamometer; pain is worse when the test is performed with the elbow extended rather than flexed.

LATERAL EPICONDYLITIS ( Tennis Elbow Pain ) Definition: tendinitis of the common extensor tendon origin, also known as tennis elbow Lateral-sided elbow pain. Possible reported history of injury or repetitive trauma Pain worse with lifting and gripping. Pain also possible at night when the elbow is moved from a resting position. LATERAL EPICONDYLITIS Physical Examination: - Possible mild edema over lateral epicondyle. - Point tenderness to palpation over lateral epicondyle. - Pain with resisted wrist extension. - Pain at the lateral epicondyle caused by grip strength testing with a dynamometer; pain worse when test performed with the elbow extended rather than flexed. Differential Diagnosis: - Lateral collateral ligament (LCL) sprain. - Radial tunnel syndrome (compression of the posterior interosseous nerve[PIN] in the supinator). - Distal humerus fracture. ¤ Initial Treatment: Patient Education: Lateral epicondylitis is also known as tennis elbow and is a form of tendinitis. It is an inflammatory condition. Treatment revolves around decreasing the inflammation, using proper lifting











Differential Diagnosis:

- Lateral collateral ligament (LCL) sprain.

- Radial tunnel syndrome (compression of the posterior interosseous nerve[PIN] in the supinator).

- Distal humerus fracture.


¤ Initial Treatment:

Patient Education:

Lateral epicondylitis is also known as tennis elbow and is a form of tendonitis. It is an inflammatory condition. Treatment revolves around decreasing inflammation, using proper lifting techniques, and strengthening the musculature. Because the tendons that are inflamed are responsible for wrist extension, the pain is worse with grip and lifting.

LATERAL EPICONDYLITIS ( Tennis Elbow Pain ) Definition: tendinitis of the common extensor tendon origin, also known as tennis elbow Lateral-sided elbow pain. Possible reported history of injury or repetitive trauma Pain worse with lifting and gripping. Pain also possible at night when the elbow is moved from a resting position. LATERAL EPICONDYLITIS Physical Examination: - Possible mild edema over lateral epicondyle. - Point tenderness to palpation over lateral epicondyle. - Pain with resisted wrist extension. - Pain at the lateral epicondyle caused by grip strength testing with a dynamometer; pain worse when test performed with the elbow extended rather than flexed. Differential Diagnosis: - Lateral collateral ligament (LCL) sprain. - Radial tunnel syndrome (compression of the posterior interosseous nerve[PIN] in the supinator). - Distal humerus fracture. ¤ Initial Treatment: Patient Education: Lateral epicondylitis is also known as tennis elbow and is a form of tendinitis. It is an inflammatory condition. Treatment revolves around decreasing the inflammation, using proper lifting







First Treatment Steps:

- Patient education and activity modification are paramount to successful treatment.

- Good results are reported in the literature after 12 months of conservative management.

- Measures include avoidance of aggravating activities and repetitive lifting and gripping, correction of improper lifting or gripping techniques, a nonsteroidal anti-inflammatory drug (NSAID) regimen if tolerated, possible use of transdermal anesthetic patches, heat and ice modalities with stretching, and occupational therapy referral.

- Some advocate the use of a wrist brace to limit wrist extension during activities.

LATERAL EPICONDYLITIS ( Tennis Elbow Pain ) Definition: tendinitis of the common extensor tendon origin, also known as tennis elbow Lateral-sided elbow pain. Possible reported history of injury or repetitive trauma Pain worse with lifting and gripping. Pain is also possible at night when the elbow is moved from a resting position.




Treatment Options:

A- Nonoperative Management:
- Conservative management is reserved for patients with no previous treatment or whose previous treatment was successful but the problem recurred after several months or years.

- In addition to the initial treatments listed earlier, a cortisone injection may be performed.

- Avoid multiple repeat injections over a short time because they can result in local tissue destruction and possible tendon or ligament rupture.

- Advise the patient on a period of rest and activity modification after injection.

- If referring the patient to occupational therapy, the referral should include instructions to provide elbow stretching, gradual protected strengthening, counseling on lifting techniques, and use of local modalities for inflammation.

- If the patient notes no improvement or diminishing improvement in symptoms with injections, consider an MRI scan to evaluate for any other causes of lateral elbow pain such as an LCL injury. Lateral epicondylitis may be described on an MRI as

“high-grade partial tearing of the common extensor tendon origin.”

- Interest in the use of platelet-rich plasma (PRP) injections is increasing, but no definitive data on its efficacy are available, and this treatment is still considered experimental.

B- Operative Indications:

- Conservative management for at least 1 year has failed.

- Indications and techniques vary, and more studies are necessary for an evidence-based approach.

- Informed Consent and Counseling

- Surgical débridement has shown good results in the literature, but the risk of partial or no relief of symptoms is approximately 15%.


LATERAL EPICONDYLITIS ( Tennis Elbow Pain ) Definition: tendinitis of the common extensor tendon origin, also known as tennis elbow Lateral-sided elbow pain. Possible reported history of injury or repetitive trauma Pain worse with lifting and gripping. Pain also possible at night when the elbow is moved from a resting position. LATERAL EPICONDYLITIS Physical Examination: - Possible mild edema over lateral epicondyle. - Point tenderness to palpation over lateral epicondyle. - Pain with resisted wrist extension. - Pain at the lateral epicondyle caused by grip strength testing with a dynamometer; pain worse when test performed with the elbow extended rather than flexed. Differential Diagnosis: - Lateral collateral ligament (LCL) sprain. - Radial tunnel syndrome (compression of the posterior interosseous nerve[PIN] in the supinator). - Distal humerus fracture. ¤ Initial Treatment: Patient Education: Lateral epicondylitis is also known as tennis elbow and is a form of tendinitis. It is an inflammatory condition. Treatment revolves around decreasing the inflammation, using proper lifting










-The surgical procedure is not likely to be successful if the patient fails to modify activities or cease repetitive trauma postoperatively.

-The patient will require a 2- to 3-month recovery period with monitored progressive occupational therapy.

Anesthesia

Regional block with sedation, or general anesthesia.

Patient Positioning

- Supine with the arm on an arm board, with the shoulder, internally rotated and the elbow flexed.

- Nonsterile tourniquet high on the brachium.

Surgical Procedures:

- Lateral approach for tendon débridement.

- Arthroscopy with débridement.

Lateral Epicondyle Débridement:

An oblique incision is made just anterior to the lateral epicondyle and common extensor tendon origin. Care is taken to avoid injury to the lateral antebrachial cutaneous nerve.

- The lateral epicondyle is identified, and a split is made in the common extensor tendon origin parallel to the fibers. The tissue is divided into layers until the underlying joint capsule is identified.

- A rongeur or curette is used to débride the dysvascular tissue and to stimulate bleeding. Avoid injury to the underlying LCL. Sometimes, a Kirschner wire (K-wire) is used to puncture the lateral epicondyle several times and stimulate bleeding at the origin of the tendon.

LATERAL EPICONDYLITIS ( Tennis Elbow Pain ) Definition: tendinitis of the common extensor tendon origin, also known as tennis elbow Lateral-sided elbow pain. Possible reported history of injury or repetitive trauma Pain worse with lifting and gripping. Pain also possible at night when the elbow is moved from a resting position. LATERAL EPICONDYLITIS Physical Examination: - Possible mild edema over lateral epicondyle. - Point tenderness to palpation over lateral epicondyle. - Pain with resisted wrist extension. - Pain at the lateral epicondyle caused by grip strength testing with a dynamometer; pain worse when test performed with the elbow extended rather than flexed. Differential Diagnosis: - Lateral collateral ligament (LCL) sprain. - Radial tunnel syndrome (compression of the posterior interosseous nerve[PIN] in the supinator). - Distal humerus fracture. ¤ Initial Treatment: Patient Education: Lateral epicondylitis is also known as tennis elbow and is a form of tendinitis. It is an inflammatory condition. Treatment revolves around decreasing the inflammation, using proper lifting









- Once débridement has concluded, the common extensor tendon is repaired in layers using a suture. The fascia is also closely followed by the subcutaneous tissues and the skin. Most surgeons immobilize the patient in a long-arm posterior splint for 10 to 14 days.

Estimated Postoperative Course:

1- Postoperative days 10 to 14

• Perform a wound check and suture removal.

• Therapy:
 
Start therapy for gentle elbow ROM. The patient should avoid lifting with the operative extremity.

LATERAL EPICONDYLITIS ( Tennis Elbow Pain ) Definition: tendinitis of the common extensor tendon origin, also known as tennis elbow Lateral-sided elbow pain. Possible reported history of injury or repetitive trauma Pain worse with lifting and gripping. Pain also possible at night when the elbow is moved from a resting position. LATERAL EPICONDYLITIS Physical Examination: - Possible mild edema over lateral epicondyle. - Point tenderness to palpation over lateral epicondyle. - Pain with resisted wrist extension. - Pain at the lateral epicondyle caused by grip strength testing with a dynamometer; pain worse when test performed with the elbow extended rather than flexed. Differential Diagnosis: - Lateral collateral ligament (LCL) sprain. - Radial tunnel syndrome (compression of the posterior interosseous nerve[PIN] in the supinator). - Distal humerus fracture. ¤ Initial Treatment: Patient Education: Lateral epicondylitis is also known as tennis elbow and is a form of tendinitis. It is an inflammatory condition. Treatment revolves around decreasing the inflammation, using proper lifting









2- Postoperative 6 weeks
• Perform a motion check. Evaluate and document whether the patient has tenderness to palpation at the lateral epicondyle.

Therapy: Start a graduated strengthening program.

3- Postoperative 3 months

• Perform a motion and strength check. Evaluate and document whether the patient has tenderness at the lateral epicondyle, and test for pain with resisted wrist extension.

• If the patient is asymptomatic, release him or her to regular activities.


Suggested Readings:

1- Buchbinder R, Johnston RV, Barnsley L, et al: Surgery for lateral elbow pain, Cochrane Data-Base Syst Rev 16(3):CD003525, 2011.

2- Dorf ER, Chhabra AB, Golish SR, et al: Effect of elbow position on grip strength in the evaluation of lateral epicondylitis, J Hand Surg Am 32: 882–886, 2007.

3- Faro F, Wolf JM: Lateral epicondylitis: review and current concepts, J Hand Surg Am 32: 1271–1279, 2007.

4- Hall MP, Band PA, Meislin RJ, et al: Platelet-rich plasma: current concepts and application in sports medicine, J Am Acad Orthop Surg 17: 602–608, 2009
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