Lateralepicondylitis, also known as tennis elbow, is an overuse injury that results ininflammation, tendinosis, and lateral elbow pain. It is the most common causeof pain in the lateral elbow, affecting between 1 and 3% of the generalpopulation (1). The primary structure impacted in tennis elbow is the extensor carpiradialis brevis, which originates at the lateral epicondyle (2). This condition is primarily seen in middle-aged individuals,especially those between the ages of 40 and 50 (3). Tennis players (up to 50% of regular players) and workers who engagein heavy lifting or repetitive gripping are more likely to develop tennis elbow(2). Other conditions, such as rotator cuff pathology or De Quervain’sdiseases, and lifestyle factors, such as smoking, are associated risk factorsfor lateral epicondylitis (4). Rotator cuff pathology could be a risk factor because lateralepicondylitis can also be caused by biomechanical stress, but it is unclearexactly why it and other conditions are associated with each other (4). In terms of histology, disorganized collagen, dense fibroblasts, andvascular hyperplasia are primarily seen (2). Immature fibroblastic and vascular infiltration of the origin of theextensor carpi radialis brevis has consistently been identified during surgery (5). A physical exam and history are typically used to diagnose thiscondition. Clinical tests to assist in diagnosis include grip strength,Cozen’s, Maudsley’s, and Mill’s tests (3). Lateral epicondylitis is indicated if the previous tests arepositive along with reduced grip strength or reproduced pain (3). If necessary, diagnostic scans can be obtained. Majority of patientsshow altered signal around the lateral epicondyle on MRI scans and hot focus on infrared thermography (6, 7). Radialtunnel syndrome is a differential diagnosis of tennis elbow. This syndrome is seen in 5% of patients who have compression of the posterior interosseous nerve. The pain associated with radial tunnel syndrome is approximately 3-4 cm distal and anterior to the lateral epicondyle, which differentiates it from tennis elbow.
Non-surgical treatments are the primary mode of treatment and there is a 95% success ratewith treatments to relieve pain. The most frequently used treatment iscorticosteroid injection (2). Oral or topical non-steroidal anti-inflammatory drugs (NSAIDs) canalso be prescribed, but their effectiveness is variable (8). Patients can also undergo physical therapy to relieve theirsymptoms. Eccentric exercises have been shown to be especially effective inpain management (9). Using an inelastic, nonarticular proximal forearm brace could alsobe recommended (10). Two relatively newer treatments for tennis elbow are ultrasonic (US)and extracorporeal shock wave therapy (ESWT). There are minimal side effects toUS and ESWT, thus making them preferable for patients and clinicians (11). Even though there is no difference between US and ESWT in elbowfunction evaluation scores, ESWT has been shown to have greater efficacy in pain relief (12). Surgical procedures are a last resort for treatment of tennis elbowand only indicated if patients are unresponsive to conservative treatments after an extended period of time. Debridement is the most common surgicalintervention, but it can result in injury of the lateral collateral ligamentand subsequent posterolateral rotary instability of the elbow.
References
1. Shiri R, Viikari-JunturaE, Varonen H, Heliovaara M. Prevalence and Determinants of Lateral and MedialEpicondylitis: A Population Study. American Journal of Epidemiology. 2006;164(11):1065-74. doi: 10.1093/aje/kwj325.
2. Cutts S, Gangoo S, Modi N, Pasapula C.Tennis elbow: A clinical review article. Journal of Orthopaedics.2020;17:203-7. doi: 10.1016/j.jor.2019.08.005.
3. Speers CJ, Bhogal GS, Collins R.Lateral elbow tendinosis: a review of diagnosis and management in generalpractice. British Journal of General Practice. 2018;68(676):548-9. doi: 10.3399/bjgp18x699725.
4. Titchener AG, Fakis A, Tambe AA, SmithC, Hubbard RB, Clark DI. Risk factors in lateral epicondylitis (tennis elbow):a case-control study. Journal of Hand Surgery (European Volume). 2013;38(2):159-64. doi: 10.1177/1753193412442464.
5. Nirschl RP, Pettrone FA. Tennis elbow.The surgical treatment of lateral epicondylitis. The Journal of bone and jointsurgery American volume. 1979;61(6A):832-9. PubMed PMID: 479229.
6. Steinborn M, Heuck A, Jessel C, BonelH, Reiser M. Magnetic resonance imaging of lateral epicondylitis of the elbowwith a 0.2-T dedicated system. European Radiology. 1999;9(7):1376-80. doi: 10.1007/s003300050851.
7. Thomas D, Siahamis G, Marion M, BoyleC. Computerised infrared thermography and isotopic bone scanning in tenniselbow. Annals of the Rheumatic Diseases. 1992;51(1):103. doi: 10.1136/ard.51.1.103.
8. Pattanittum P, Turner T, Green S,Buchbinder R. Non‐steroidal anti‐inflammatory drugs (NSAIDs) for treatinglateral elbow pain in adults. Cochrane Database of Systematic Reviews. 2013(5). doi: 10.1002/14651858.CD003686.pub2. PubMed PMID: CD003686.
9. Croisier J-L, Foidart-Dessalle M,Tinant F, Crielaard J-M, Forthomme B. An isokinetic eccentric programme for themanagement of chronic lateral epicondylar tendinopathy. British Journal of Sports Medicine. 2007;41(4):269. doi: 10.1136/bjsm.2006.033324.
10. Johnson GW, Cadwallader K, Scheffel SB,Epperly TD. Treatment of lateral epicondylitis. Am Fam Physician.2007;76(6):843-8. Epub 2007/10/04. PubMed PMID: 17910298.
11. Coombes BK, Connelly L, Bisset L,Vicenzino B. Economic evaluation favours physiotherapy but not corticosteroidinjection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial. British Journal of Sports Medicine. 2016;50(22):1400-5. doi: 10.1136/bjsports-2015-094729.
12. Yan C, Xiong Y, Chen L, Endo Y, Hu L, LiuM, et al. A comparative study of the efficacy of ultrasonics and extracorporealshock wave in the treatment of tennis elbow: a meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research. 2019;14(1). doi: 10.1186/s13018-019-1290-y.
