1.0000EOR0010.1302/2058-5241.1.

000049
review-article2016

EOR  |  volume 1  |  November 2016

  Shoulder & Elbow    DOI: 10.1302/2058-5241.1.000049
www.efort.org/openreviews

Lateral epicondylitis of the elbow

Alfonso Vaquero-Picado
Raul Barco
Samuel A. Antuña

„„ Lateral epicondylitis, also known as ‘tennis elbow’, is a a common condition, affecting between 1% and 3% of
very common condition affecting mainly middle-aged the population,3 generally affecting the middle-aged
patients. without gender predisposition.
„„ The pathogenesis remains unknown but there appears to Despite its relatively high prevalence, there is no single
be a combination of local tendon pathology, alteration in effective and consistent algorithm of management. Fortu-
pain perception and motor impairment. nately, most cases are self-limiting and well-managed
with simple pain medication, with 90% of patients recov-
„„ The diagnosis is usually clinical but some patients may
ering within one year. Patients with severe or persistent
benefit from additional imaging for a specific differential
symptoms are suitable for treatment with further conserv-
diagnosis.
ative or operative options.4
„„ The disease has a self-limiting course of between 12 and
18 months, but in some patients, symptoms can be persis-
tent and refractory to treatment. Aetiology and pathogenesis
„„ Most patients are well-managed with non-operative treat- In the majority of cases, non-obvious underlying causes
ment and activity modification. Many surgical techniques can be identified.5 Extensor carpi radialis brevis (ECRB) is
have been proposed for patients with refractory symp- the most commonly affected muscle, but supinator and
toms. other wrist extensors such as extensor carpi radialis lon-
„„ New non-operative treatment alternatives with promising gus, extensor digitorum, extensor digiti minimi and exten-
results have been developed in recent years. sor carpi ulnaris can be involved. Any activity involving
excessive and repetitive use of these muscles (for example
Keywords: lateral epicondylitis; tennis elbow; lateral elbow tennis, playing an instrument, typing, manual work) may
pain; conservative management; operative management cause the tendinosis.6,7 Smoking and obesity have been
identified as significant risk factors.5
Cite this article: Vaquero-Picado A, Barco R, Antuña SA. Lat- Though LE was classically identified as an inflamma-
eral epicondylitis of the elbow. EFORT Open Rev 2016;1:391- tory process, the histology does not show many inflam-
397. DOI: 10.1302/2058-5241.1.000049. matory cells; most authors therefore consider LE as a
tendinosis, a symptomatic degenerative process of the
tendon.8
The application of tension to a tendon usually increases
Introduction cross-linkage and collagen deposition.9 Tendons can
Lateral elbow pain is one of the most common sources of stretch easily in response to gradually increasing forces. If
medical consultation for non-traumatic elbow disorders. The this stress exceeds the tendon’s tolerance to stretch, a
most frequent diagnosis is the tendinous disorder known as microtear may occur. Multiple microtears lead to degen-
lateral epicondylitis (LE) or ‘tennis elbow’. However there are erative changes within the tendon which are known as
many pathological conditions that may mimic LE such as tendinosis. Histological changes such as angiofibroblastic
intra-articular plica, osteochondritis dissecans (OCD), radio- hyperplasia (a manifestation of granulation tissue that dis-
capitellar arthritis or posterolateral rotatory instability.1 turbs correct collagen synthesis) can also be seen. Histo-
Lateral epicondylitis was first described by Runge in pathological studies of ECRB in patients with long-standing
1873.2 It was described as a chronic symptomatic degen- LE have shown necrosis as well as signs of fibre regenera-
eration of the wrist extensor tendons involving their tion. Nevertheless, additional pathophysiological mecha-
attachment to the lateral epicondyle of the humerus. It is nisms have been suggested.
Fig. 1  a) Patient with pain (small blue circle) on the lateral epicondyle with resisted wrist extension and with the arm in full
extension, alleviated by flexing the elbow. b) The mechanism by which pain is reduced might be the decreased tension of the
extensor muscles against the superolateral aspect of the capitellum.

Painful symptomatic LE can result in underuse of the motion exists, other concomitant pathology needs to be
tendon. Underuse changes the tendon structure, leading excluded.12
to progressive weakening and increasing the risk of injury. There are many tests employed in LE physical examina-
In conjunction with underuse, shearing forces lead to tion. Maudley’s test,13 Thomson’s manoeuvre, diminished
fibrocartilaginous formation at the ECRB enthesis, which grip strength14 and the ‘chair’ test (Fig 1a, b) are some of
contributes to weakening at the tendon-bone junction.4,10 the tests employed to reproduce the pain of LE.
In addition, the tendon vascularisation is deficient and
sustained muscle contractions can lead to tendon ischae-
mia. Repetitive activities increase temperature which can
Imaging studies
lead to hyperthermic injuries of the enthesis. Most LE cases can be clinically diagnosed. However when
Despite all of these considerations, there is a lack of clinical symptoms are not well-defined, some diagnostic
knowledge to explain the great variability of symptoms studies can be helpful.
among patients. Peripheral nerve irritation and local Plain anteroposterior (AP) and lateral radiographs are
altered pain response have been proposed.11 Shoulder useful for the assessment of bone diseases such as OCD,
and neck pain are frequent symptoms in this population, arthropathy and loose bodies. In cases of long-standing
but they can be associated with alterations in upper limb LE, calcifications of ECRB insertion can be seen.
biomechanics.10 Ultrasound is one of the most useful tools to diagnose
or rule out LE. Structural changes affecting tendons (thick-
ening, thinning, intra-substance degenerative areas and
Clinical presentation tendon tears for example), bone irregularities or calcific
The majority of the patients complain of pain located just deposits can be detected. Neo-vascularisation can also be
anterior to, or in, the bony surface of the upper half of the assessed by colour Doppler exploration. Absence of this
lateral epicondyle, usually radiating in line with the com- finding, or no changes in a greyscale ultrasound sonogra-
mon extensor mass. The pain can vary from intermittent phy (USG), can be useful to rule out LE.15
and low-grade pain to continuous and severe pain which Magnetic resonance imaging (MRI) is more reproduci-
may cause sleep disturbance. It is typically produced by ble, reduces inter-operator variability and gives more
wrist and finger extensor and supinator muscle contrac- information about intra-articular pathology (Fig. 2).
tion against resistance. The pain lessens slightly if the Unfortunately, findings on MRI are not well correlated
extensors are stressed with the elbow held in flexion. with the severity of clinical symptoms, and is an expensive
On inspection, there is no remarkable alteration in the modality to be used routinely for such a common condi-
early stages. As the disease evolves, a bony prominence tion.16 CT arthrography has been demonstrated to be
over the lateral epicondyle can be detected. Muscle and more accurate than MRI to diagnose capsular tears.17
skin atrophy as well as detachment of common extensor Electromyography of the posterior interosseous nerve
origin can be seen as a result of corticosteroid injections or (PIN) and local anaesthetic injection just distal to the
long-standing disease.4 radial head can be useful to diagnose a PIN compression.
Range of motion is not usually affected. Motion may be Blood tests should be used when infection or inflamma-
painful in more advanced stages where it can be elicited in tory diseases are suspected as the cause of lateral elbow
full elbow extension with the forearm pronated. If limited pain.

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 Lateral epicondylitis of the elbow

Fig. 3  Location of the site of greatest tenderness may be helpful

in defining the diagnosis for further clinical testing and/or
imaging techniques.

and nerve conduction studies have all been

Fig. 2  Coronal T-2 weighted MRI image of a right elbow
showing an injury of the insertion of the extensor muscles at described to assist in the diagnosis of radial tunnel
the lateral epicondyle. syndrome.20
4. Degenerative changes and OCD of the capitellum.
It has been observed that 59% of cases of lateral
Overall, radiological findings are not always well cor- elbow pain refractory to conservative treatment
related with clinical symptoms. Therefore, clinical exami- have some chondral changes in the radiocapitellar
nation cannot be substituted with these complementary joint.21 OCD typically affects young individuals
studies. involved in sports and physical activities who have
mild grinding and pain when performing a moving
valgus test.
Diferential diagnosis 5. Inflammation and oedema of the anconeus muscle.
In a middle-aged patient with pain on the lateral side of the Some studies have reported a relatively high inci-
elbow and typical symptoms and signs (Fig. 3), lateral epi- dence of anconeus oedema, shown in MRI of
condylitis should undoubtedly be the main diagnosis, but patients complaining of lateral elbow pain.22 Fasci-
one must rule out other potential conditions which can otomy of the muscle can solve that problem.23
cause lateral pain. The following should be considered 6. Posterolateral elbow instability should definitely be
(Table 1): ruled out in every patient suffering from lateral elbow
pain. The association between instability and epicon-
1. Cervical radiculopathy with pain in the elbow and dylitis has been established, following excessive use
forearm.18 of steroids or the local pathogenic insult. The presen-
2. Elbow overuse to compensate for a disease in an tation is low-grade and may require examination of
adjacent joint (frozen shoulder for example). the patient under anesthesia to test it properly. The
3. Posterior interosseous nerve (PIN) entrapment (also presence of cubitus varus, previous surgery or dislo-
known as ‘radial tunnel syndrome’). Nerve com- cations of the elbow should be assessed.
pression produces neuropathic pain in the lateral 7. Other causes of pain include low-grade infection
forearm. However, pain is not reproduced by wrist (Propionibacterium acnes)24 or other inflammatory
extension. Resisted supination can produce pain as diseases such as rheumatoid arthritis.25
the supinator is one of the possible areas of PIN
compression. An anaesthetic block of PIN can be
diagnostic, but injection should be performed
Treatment
selectively to avoid diffusion of the local anaesthetic To date, no universally accepted regime of treatment exists;
to the lateral epicondyle area.19 The middle finger however some general principles of treatment should be
extension test, resisted supination of the forearm taken into consideration. The treatment of LE should be

393
orientated to the management of pain, preservation of unless a short-term good result is advisable (such as
movement, improvement in grip strength and endurance, a professional tennis player in mid-season), as most
return to normal function and control of further clinical patients improve without corticosteroids and better
deterioration.4 long-term results can be achieved without them.31
Patients should be advised of potential side-effects
Non-operative treatment including changes in colouration of the skin, fat atro-
Non-operative treatment includes a wide array of possi- phy and muscle wasting.
bilities with a rate of improvement in 90% of cases. Several 6. Autologous blood injections are thought to work by
new techniques have been developed in last decade stimulating an inflammatory response which will
including percutaneous radiofrequency treatment and bring in the necessary nutrients to promote heal-
injections with different preparations of growth factors. It ing. Short-term good results have been reported
is wise to involve the patient and gain their commitment recently;32,33 however, no benefit in the long-term
to the management programme as it may be months follow-up has been found and its use is only recom-
before improvement is observed: mended for those recalcitrant cases when other
modalities of treatment have failed.
1. Rest, modification or avoidance of painful activities 7. Platelet-rich plasma injections (PRP). These prepara-
usually leads to symptomatic relief. tions are thought to contain high concentrations of
2. Physiotherapy is another alternative. Some studies growth factors, which could theoretically enhance
have reported good outcomes with physiotherapy tendon healing. General technique involves patient-
regimes of stretching and strengthening, with more blood extraction, centrifugation and re-injection of
favourable results than rest and reduced activity at the plasma into the lateral epicondyle. Good out-
short-term follow-up.26 No standard regime has comes have been reported.34,35 However, no differ-
been established as superior to any other method. ences were seen between PRP and whole blood
The fundamental principle is to load the tendon as injections.36 Moreover, significant differences
close as possible to its limit but without surpassing among available commercial systems and variations
it. Eccentric exercises and partial load-favouring in the technique make it difficult to draw clear con-
tendon healing are the mainstay of physiotherapy clusions about the use of PRP in this pathology. New
regimes. legal regulations could slow down the adoption of
A stable shoulder and scapula are necessary for cor- these last techniques.
rect elbow function; strengthening exercises of the 8. Percutaneous radiofrequency thermal treatment. A
scapular stabilisers including the lower trapezius, ser- radiofrequency electrode is introduced percutane-
ratus anterior and rotator cuff muscles is mandatory. ously under ultrasound guidance which produces a
3. Epicondylar counterforce braces work by reducing thermal injury when activated, inducing a microte-
tension in the wrist extensors. Elbow straps, clasps notomy and removing all pathological tissue. Good
or sleeve orthoses have been demonstrated as outcomes have been reported, and no reduction of
superior for pain relief and grip strength when tendon size has been observed.37
compared with placebo orthoses.27 However, no 9. Extracorporeal shock-wave therapy (ECSW) has been
differences between braces were shown in a sys- proposed as an alternative to non-operative man-
tematic review28 and we do not use them in our agement. The mechanism of action is not fully
practice. We have seen patients with secondary known. A generator of specific frequency sound
nerve problems due to prolonged use of a counter- waves is applied directly onto the overlying skin of
force brace. the ECRB tendon. It has not been demonstrated to
4. Non-steroidal anti-inflammatory drugs (NSAIDs) can be more beneficial than other treatment
be useful for the short-term relief of symptoms. modalities.38
Even if their use is superior to a placebo, no differ- 10. The use of low-level laser therapy has been proposed
ences between oral and topical NSAIDs have been due to the stimulating effect of laser on collagen
established.29 production in tendons. Although laser was not ini-
5. Corticosteroid injections are commonly used to treat tially viewed as particularly useful among LE thera-
LE. The way in which they work is currently unknown; pies, a recent study has demonstrated some
they probably help to control local inflammatory short-term benefits when using an adequate dose
response and pain mediation.30 Corticosteroid injec- and wavelength.39
tions seem to be superior to NSAIDs at four weeks, 11. Acupuncture has demonstrated good outcomes on
but no differences are observed at a later stage. Cor- short-term follow-up.40 However, long-term results
tisone injections should be avoided in all cases, remain unclear.

394
 Lateral epicondylitis of the elbow

tendon can be repaired (or not), lengthened (or not), and

drilling or decortication of the epicondyle to stimulate
blood flow may be performed.
There is no consensus on the best surgical technique to
manage LE, and evidence is lacking to support or refute a
specific technique.44 As a potential disadvantage, exces-
sive release may lead to lateral instability of the elbow.
Long-term good outcomes have been reported with dif-
ferent open techniques.45 A percutaneous approach is
advocated by some authors with good mid-term out-
comes.46-48 Percutaneous release may be performed in the
office setting with the patient conscious. However, it gen-
erally precludes reconstruction after debridement.
Arthroscopic treatment of LE has become more popu-
lar in recent years. It was first described in 1995 by
Baker49 and has the advantage of a quick return to work
and the ability to address and treat intra-articular pathol-
ogy. It is performed through posterolateral and antero-
Fig. 4  Patient with lateral epicondylitis of the right elbow medial viewing portals and an anterolateral working
undergoing an open technique. Debridement of the ECRB portal (Fig. 5a, b).
has been performed and the joint is visible through the
Debridement and reconstruction is possible and safe
capsular defect present in this case. Perforation of the lateral
epicondyle and reconstruction of the extensor muscles are but it takes slightly longer than open surgery, and there is
optional additional techniques after debridement of the typical a risk of potential damage of the radial nerve and to the
injury. lateral collateral ligament if the debridement extends pos-
teriorly past the centre of the epicondyle. Good to excel-
lent long-term results have been reported with this
12. Botulinum toxin A injections act by diminishing mus- technique.50,51 Post-operatively it is usually recommended
cle tone. Reducing the tension on the ECRB inser- to refrain from aggravating activities for at least three
tion could be beneficial for pain relief. Good months. Desk-workers can return to work immediately
short-term results have been published,41 but as yet and manual workers are encouraged to restart work after
there is no consensus on its use and the effects may four weeks. Bad compliance, infections, haematoma or
be conditioned by the technique, the operator and nerve injuries can complicate the process, but generally
the dose. nine out of ten patients improve with surgical treatment.
It is important to recognise that there is a group of
Operative treatment patients who do not improve after adequate non-­
Patients with persistent pain and disability after a course operative treatment and well-performed surgical tech-
of well-performed conservative treatment are candidates niques. Reasons for persistent symptoms after any
for clinical re-evaluation and, possibly, operative treat- treatment modality include working compensation
ment. Open, percutaneous and arthroscopic approaches issues, misdiagnosis of an associated problem or an incor-
have been used. rect initial diagnosis.
The basic principle of open surgery involves debriding
the angio-fibrotic tissue of the ECRB with or without pos-
Conclusions
terior tendon repair. Multiple variations of open surgery
have been proposed in the literature including extensor Lateral elbow epicondylitis is frequently a self-limiting
release with intra-articular modifications, extensor fasci- entity, with a normal course of between 12 and 18
otomy, V-Y slide of the common extensor tendon, dener- months. In the vast majority of patients, symptoms resolve
vation of the lateral epicondyle, epicondylar resection with non-operative treatment, physiotherapy and activity
with anconeus muscle transfer and lengthening of the modification.
ECRB.42,43 Basically, the ECRB insertion is approached Multiple non-operative treatments have been pro-
through a standard longitudinal incision over the lateral posed, but none of them has demonstrated superiority
aspect of the elbow. The insertion then can be detached, over others, therefore no specific recommendations can
dividing its fibres longitudinally, or tendinotic tissue can be made. Operative treatment is reserved for those
be debrided (Fig. 4). After debridement, the rest of the patients with persistent symptoms who have failed a

395
Fig. 5  Clinical photograph of a patient with lateral epicondylitis of the right elbow undergoing an arthroscopic technique. a) A
capsular injury is observed in the superolateral aspect of the joint. b) After debridement and reconstruction of the extensor muscles
with the help of an anchor the capsular defect has been repaired.

well-performed non-operative programme. However, there 2. Runge F. Zur Genese und Behandlung des schreibe Kranfes. Bed Klin Worchenschr
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1Hospital Universitario La Paz, Madrid, Spain
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Conflict of Interest
None declared. 9.  Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features
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No benefits in any form have been received or will be received from a commercial
10.  Coombes BK, Bisset L, Vicenzino B. A new integrative model of lateral
party related directly or indirectly to the subject of this article.
epicondylalgia. Br J Sports Med 2009;43:252-258.
Licence 11. Rath AM, Perez M, Mainguené C, Masquelet AC, Chevrel JP. Anatomic basis
© 2016 The author(s) of the physiopathology of the epicondylalgias: a study of the deep branch of the radial nerve.
This article is distributed under the terms of the Creative Commons Attribution- Surg Radiol Anat 1993;15:15-19.
NonCommercial 4.0 International (CC BY-NC 4.0) licence (https://creativecommons. 12. Orchard J, Kountouris A. The management of tennis elbow. BMJ 2011;342:d2687–
org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and d2687. PMID: 21558359.
distribution of the work without further permission provided the original work is
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attributed.
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