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Lateral epicondylitis (tennis elbow)

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Lateral Epicondylitis Overview

Lateral epicondylitis (commonly known as tennis elbow) is a widespread condition characterized by pain originating near the lateral epicondyle of the humerus at the elbow [1, 2]. It is primarily considered a tendinopathy (degeneration) of the common extensor tendon origin, particularly involving the Extensor Carpi Radialis Brevis (ECRB) tendon, rather than an acute inflammatory process [1, 2].

Epicondylitis is often found in people whose profession or activities involve repetitive wrist extension or forearm supination movements, forceful gripping, or prolonged static exertion of the hand and wrist muscles [1, 2]. It is common in athletes, especially tennis players (hence the name), but also occurs frequently due to occupational or other recreational activities [1]. Medial epicondylitis ("golfer's elbow") affects the medial epicondyle and common flexor tendon origin [1].

In the treatment of epicondylitis, wearing a counterforce brace over the forearm muscles near the elbow helps to reduce tension on the tendon origin and alleviate pain [1, 2].

Epicondylitis Diagnosis

The diagnosis of lateral epicondylitis is primarily clinical, based on history and physical examination findings [1, 2]. While neurological examination, radiography, and electromyographic (EMG) studies are generally normal in isolated lateral epicondylitis, they may be performed to rule out other conditions, particularly cervical radiculopathy or nerve entrapment syndromes, which can sometimes cause referred pain to the elbow [1]. Some studies suggest an association between neck pain/cervical spine issues and lateral elbow pain, but a direct causal link via osteochondrosis is not the primary pathophysiology of epicondylitis itself [1]. Imaging like ultrasound or MRI can confirm tendinopathic changes but is often not required for diagnosis unless atypical features are present or conservative treatment fails [2, 3].

Differential Diagnosis of Lateral Elbow Pain [1, 2, 3]

Condition Key Features / Distinguishing Points Typical Provocative Tests / Findings
Lateral Epicondylitis (Tennis Elbow) Pain localized directly over lateral epicondyle & common extensor origin. Worse with gripping, wrist extension. Usually insidious onset. Tenderness over lateral epicondyle. Pain with resisted wrist extension (Cozen's), resisted middle finger extension (Maudsley's).
Radial Tunnel Syndrome Aching pain ~4-5 cm distal to lateral epicondyle, over radial nerve course in supinator muscle. May have associated forearm muscle fatigue/weakness. Tenderness over radial tunnel. Pain often worse at night. Pain with resisted supination, resisted middle finger extension (may be positive but pain more distal than epicondyle). Tenderness over radial tunnel. +/- Weakness (less common than PIN). Normal EMG usually.
Posterior Interosseous Nerve (PIN) Syndrome Primarily motor weakness (finger drop, wrist extension weakness with radial deviation) due to nerve compression. Pain is less prominent feature than weakness. Weakness of finger/thumb extensors and ECU. No sensory loss. EMG often abnormal.
Cervical Radiculopathy (C6/C7) Pain often radiates from neck/shoulder down arm. May have associated numbness/tingling in C6/C7 dermatome (thumb, index, middle finger). Neck pain/stiffness often present. Neck examination findings (limited ROM, + Spurling's test). Neurological exam may show sensory changes, reflex changes (triceps - C7), or weakness in specific myotomes.
Radiocapitellar Joint Pathology (e.g., OA, OCD) Pain more localized to the joint line (anterior/lateral). May have crepitus, clicking, or locking. Pain often worse with pronation/supination. Restricted ROM may be present. Tenderness over radiocapitellar joint. Pain with passive pronation/supination. X-ray/MRI may show joint changes (narrowing, osteophytes, OCD lesion).
Lateral Collateral Ligament (LCL) Injury Usually follows trauma (fall, dislocation). Symptoms of instability, clicking, or catching. Tenderness over LCL origin/insertion. Pain or laxity with Varus stress test. Posterolateral rotatory instability tests may be positive.

 

Clinical Presentation

In the clinical course of epicondylitis, acute (reactive tendinopathy/exacerbation) and chronic (degenerative tendinosis) stages are distinguished, though overlap exists [1, 2].

Lateral epicondylitis (commonly known as tennis elbow) typically resolves without treatment in 6 to 12 months.
Lateral epicondylitis (commonly known as tennis elbow) often resolves with conservative management over 6 to 12 months, although symptoms can persist or recur [1, 2].

With acute onset or exacerbation of epicondylitis, pain occurs primarily at the lateral epicondyle, often described as sharp or burning [1, 2]. Pain radiates down the forearm along the extensor muscles [1]. Function is often impaired, particularly with activities requiring wrist extension or gripping (e.g., shaking hands, lifting objects, turning a doorknob) [1, 2]. Patients may report weakness when gripping or holding objects, often dropping them due to pain [1].

In chronic epicondylitis (tendinosis), pain is often dull and aching, provoked by specific activities [1, 2]. Morning stiffness may be present [1]. Tenderness remains localized over the lateral epicondyle [1]. Palpation may reveal thickening of the common extensor tendon [2].

 

Epicondylitis Treatment

Treatment of lateral epicondylitis is primarily conservative and depends on symptom severity and duration [1, 2].

Initial management focuses on pain relief and reducing stress on the tendon [1, 2]:

  • Activity Modification: Identifying and avoiding or modifying aggravating activities.
  • Pain Relief: Ice application, topical or oral NSAIDs (medications).
  • Counterforce Bracing: A strap worn around the forearm just distal to the elbow can reduce tension on the epicondylar origin.
  • Wrist Splinting: Occasionally used temporarily to rest the wrist extensors.

Once acute pain subsides, rehabilitation is key [1, 2, 4]:

  • Stretching: Gentle stretching of wrist extensors and flexors.
  • Strengthening: Progressive eccentric and concentric exercises for wrist extensors and forearm muscles.
  • Physical Therapy: Modalities like ultrasound, phonophoresis (ultrasound with medication), iontophoresis, or manual therapy (cross-friction massage) may be used.
In the treatment of epicondylitis, reduction of pain and inflammation, and restoration of function can be aided by physiotherapy modalities [1, 4].

Other treatment options for persistent symptoms include [1, 2]:

  • Corticosteroid Injections: Can provide significant short-term pain relief but evidence for long-term benefit is limited, and repeated injections may potentially weaken the tendon.
  • Autologous Blood or Platelet-Rich Plasma (PRP) Injections: Investigational treatments aiming to stimulate healing.
  • Extracorporeal Shockwave Therapy (ESWT): May be beneficial for chronic cases.
  • Acupuncture: Some evidence supports its use for pain relief.

Surgical treatment (operative debridement of the diseased ECRB tendon origin) is reserved for refractory cases that fail extensive conservative management (typically >6-12 months) [1, 2].

References

  1. Buchbinder R, Johnston RV, Barnsley L, et al. Surgery for lateral elbow pain. Cochrane Database Syst Rev. 2011 Mar 16;(3):CD003525. (Or similar comprehensive review on epicondylitis).
  2. Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006 Dec 1;164(11):1065-74.
  3. Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: pathogenesis, imaging, and treatment. Radiographics. 2010 Jan;30(1):167-84.
  4. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010 Nov 20;376(9754):1751-67.