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Lateral Epicondylitis M77.10 726.32

 

elbow lateral image

elbow cross section image

synonyms: Tennis Elbow, lateral epicondylitis, common extensor tear, common extensor tenosynovitis, extensor carpi radialis brevis tear

Lateral Epicondylitis ICD-10

Lateral Epicondylitis ICD-9

  • 726.32 (lateral epicondylitis)

Lateral Epicondylitis Etiology / Epidemiology / Natural History

  • Pain at the lateral epicondyle which often radiates into the forearm and is typically insidious in onset.  Usually hx of repetitive activity.
  • Associated with tennis, squash, fencing, meat cutting, plumbing, painting, raking, weaving
  • Believed to be initiated by a microtear, most often within the origin of the extensor carpi radialis brevis.  May originate in any muscle originating from the epicondyle
  • Angiofibroblastic hyperplasia of involved tissue demonstrating fibroblast proliferation, neovascularization and hyaline degeneration without acute inflammatory cells. (Regan W, AJSM 1992;20:746)
  • Male = female
  • Incidence is 2-3.5 times greater in tennis players with over 2hrs of racket time per week than those with less than 2 hrs per wk (Gruchow HW, AJSM 1979;7:234).
  • Affects 10-50% of tennis players (Jobe FW, JAAOS 1994;2:1).
  • Typically 4th to 5thdecade
  • Affects 1-3% of adults/year.
  • More common in dominant arm.

Lateral Epicondylitis Anatomy

Lateral Epicondylitis Clinical Evaluation

  • Tenderness over the extensor tendon origin, usually localized to the ECRB portion.
  • Maximal tenderness usually 2-5mm distal and anterior to the midpoint of the lateral epicondyle
  • Resisted wrist and finger extension with the elbow in full extension exacerbates pain
  • Normal wrist/elbow ROM
  • If pt has pain on resisted suppination consider PIN irritation as cause.

Lateral Epicondylitis Xray / Diagnositc Tests

Lateral Epicondylitis Classification / Treatment

  • Initial Treatment
    -Cessation of offending activity is required initially.
    -Avoid immobilization/inactivity which leads to disuse atrophy
    -Ice 20minutes 3-4x/day
    -NSAIDs for 10-14 days
    -Counterforce brace placed over the forearm musculature; questionable benefit (Struijs PA, AJSM 2004;32:462).
    -Dynamic extensor bracing has shown statistically significant benefits (Faes M, CORR 2006;442:149).
  • Secondary Treatment
    -corticosteriod injection deep to ECRB, anterior and distal to the lateral epicondyle into fatty subaponeurotic recess.  SQ injection-SQ atrophy
    -Corticosteriod injection=55-89% pain relief: 18-54% recurrence. (Beller E, BMJ 2006;333:939). Provides short term benefit, but may be detrimental in the long term (Bisset L, BMJ 2006;333:939).
    -Platelet-Rich Plasma injection. 81% improvement in VAS score at 6 months (Mishra A, AJSM 2006;34:1774).
    -Ultrasound, high-voltage galvanic stimulation no prospective randomized trials
    -Botulinum Toxin A: shown to have short-term benefit (Placzek R, JBJS 2007;89A:255).
  • Final Treatment
    -If fails 6-12 months of non-operative treatment consider Lateral Epicondyle Debridement., Percutaneous technique (Dunkow PD, JBJS 2004;86Br:701), arthrocsopic debridement.
  • Botulinum toxin injection has not been shown to be of benefit (Hayton MJ, JBJS A 2005;87:503-507).
  • Shock wave therapy / ESWT has little or no benefit (Buchbinder R, Cochrane Database Syst Rev 2005;4:CD003524).

Lateral Epicondylitis Associated Injuries / Differential Diagnosis

Lateral Epicondylitis Complications

  • Persistent pain of varying degree
  • Infection
  • Residual strength deficit
  • Functional limitations
  • Joint instability

Lateral Epicondylitis Follow-up Care

  • Lateral Epicondylitis Rehab Protocol: wrist extensor stretching and progressive isometric exercises. Later begin eccentric and concentric exercises
  • 26% of patients will have recurrence of symptoms and over 40% have prolonged minor discomfort.  Other more optomisitic reports show 85-90% successful nonoperative treatment
  • Surgery=posterior mold for 7-10days.  Then progressive mobilization/gentle passive and active elbow, wrist, hand motion.  Counterforce bracing for 3-6 months.  Resisted isometrics at 4wks, progressive strengthening at 6 wks.  Return to lifting/athletics usually by 3-4 month.

Lateral Epicondylitis Review References

 

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