DEFINITION

Lateral epicondylitis involves tendinosis at the origin of the common wrist extensors.

It is commonly referred to as tennis elbow and is likely more correctly termed lateral elbow tendinopathy.15

 

 

ANATOMY

 

The common extensor origin is located on the lateral epicondyle.

 

The common extensor origin includes the extensor carpi radialis brevis (ECRB), extensor digitorum communis (EDC), extensor digiti minimi, and extensor carpi ulnaris.

 

The ECRB is the primary muscle-tendon unit affected, followed by the EDC with the tendons becoming confluent at their origin.13

PATHOGENESIS

 

Epicondylitis results from repetitive microtrauma, followed by an incomplete reparative response, resulting in chronic tendinosis.13

 

Functionally, this condition can more correctly be described as “gripper's elbow,” as synergistic wrist extension increases finger flexion strength. Patients afflicted with lateral epicondylar tendinopathy commonly engage in repetitive forceful gripping activities as they lift, pull, twist, and push objects.

 

Recently, concurrent radiocapitellar cartilage lesions have been noted in a high prevalence on arthroscopic examination.14

NATURAL HISTORY

 

Lateral epicondylitis is a self-limiting condition that resolves in over 80% of patients over the course of 1 year.4

 

Most patients receiving active treatment (ie, anti-inflammatory medication, orthotics, ultrasound, physical or occupational therapy, injections) improve with nonoperative treatment.

 

Typically, fewer than 10% of patients require surgical intervention.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Acute phase: Lateral elbow pain or ache occurs with activities that typically resolves with rest, ice, or anti-inflammatory medication.

 

Intermediate phase: Lateral elbow pain or ache occurs with activity and at rest and may not resolve without prolonged activity restriction.

 

Chronic phase: Pain or ache occurs with sleep and is unresponsive to rest, medication, and injections.13

 

Examination methods include the following:

 

 

Palpation of the lateral epicondyle for tenderness, a universal finding in lateral epicondylitis

 

Pain either at the epicondyle or radiating distally along the ECRB is a positive finding in any of these circumstances:

 

Passive stretch test: With the elbow in full extension, the wrist is flexed, and the forearm is pronated.

 

Mill test: With the elbow flexed, the forearm slightly pronated, and the wrist slightly dorsiflexed, the patient actively supinates against the examiner, who resists this rotation.

 

Thompson test: With the elbow extended, the wrist in slight dorsiflexion, and making a fist, the patient dorsiflexes against the examiner, who resists this motion.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

 

Plain radiographs may show calcifications at the extensor origin. Magnetic resonance imaging (MRI)

 

Increased intratendon signal is reliably demonstrated on T2-weighted sequences.

 

Most also show increased intratendon signal or tendon thickening on T1-weighted sequences.

 

 

 

A small percentage of patients may show increased T2 signal in the lateral epicondyle or anconeus edema.9 Periosteal reaction is not commonly seen on MRI.9

 

Lateral collateral ligament tears often are over interpreted on MRI reports, but this possibility must be ruled

out by an accurate history and pre- and intraoperative examinations.

 

 

DIFFERENTIAL DIAGNOSIS

Synovial plica

Lateral collateral ligament tear Radial tunnel syndrome Loose bodies

Degenerative joint disease (typically early radiocapitellar joint) Avascular necrosis of the capitellum

 

 

NONOPERATIVE MANAGEMENT

 

Appropriate initial treatment includes avoidance of painful activities and symptomatic relief with ice and nonsteroidal anti-inflammatory drugs (NSAIDs).

 

Daytime strapping is biomechanically and clinically effective.

 

Nighttime wrist bracing to prevent palmar wrist flexion and prolonged tension on the extensor tendons

 

Physical or occupational therapy to supervise and instruct on stretching and strengthening protocol for patients not otherwise inclined to perform these exercises

 

 

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Corticosteroid injection have repeatedly not outperformed placebo injections in the literature and have even

shown inferior results. They may be used sparingly once other nonoperative measures are exhausted.2,3,5

 

Platelet-rich plasma injections showed some promising early results1,11 but have not held up to more critical scrutiny.8

SURGICAL MANAGEMENT

 

A minority of patients fail nonoperative management.

 

Careful patient selection is critical to ensure an excellent outcome following surgical management.

 

No prospective randomized studies have yet been done to examine the advantages of open versus arthroscopic techniques for the treatment of lateral epicondylitis. However, the authors choose arthroscopic treatment if there are any signs of a plica or synovial irritation (end point pain) as it allows for direct examination and treatment of these additional pathologies.

 

Two relatively new methods of percutaneous tenotomy are available and undergoing evaluation: Tenex Microtenotomy (Tenex Health Inc., Lake Forest, CA) and Topaz MicroDebrider (ArthroCare, Austin, TX). Both are percutaneous methods that allow for a minimally invasive approach to replicate outcomes of open and arthroscopic methods.

 

The Topaz MicroDebrider provides a preset amount of energy to débride and stimulate neovascularization as its mechanism of action, whereas the Tenex Microtenotomy has a proposed advantage of removal of pathologic tissue as well via a phacoemulsification mechanism of action.

 

Studies examining results from percutaneous tenotomy have been optimistic in the short term,7,10 but comparative studies of percutaneous methods have yet to be published.

 

Preoperative Planning

 

 

Be prepared to address concurrent extensor tendon rupture. Be prepared to address lateral collateral ligament rupture.

Positioning

 

The patient is placed in the supine position.

 

The arm is internally rotated at the shoulder, and padding is placed under the elbow, and the ulnar nerve is protected.

 

The arm should rest in a position that allows ready access to the lateral aspect of the elbow without requiring constant holding by an assistant.

 

The elbow should be examined after the administration of anesthesia to ensure stability, and the result is documented in the operative note.

 

The goal of surgery is to débride the degenerative tissue at the extensor origin and create an environment

conducive to proper healing of the tendon.

TECHNIQUES

• Open Lateral Epicondylar Fasciectomy and Partial Ostectomy

A 3- to 5-cm incision through skin only is made beginning at the proximal edge of the center of the lateral epicondyle and extending distally through the mid-radiocapitellar joint plane along the axis of the forearm (TECH FIG 1A).

 

 

Blunt dissection with scissors is carried out through the subcutaneous tissues to expose the EDC aponeurosis and the ECRL.

 

The more anterior and reddish ECRL and the more tendinous EDC originating on the epicondyle are identified (TECH FIG 1B).

 

The interval between the ECRL and the EDC aponeurosis is then split in line with the mid-radiocapitellar joint plane. Distally, a fat stripe along the aponeurosis typically is seen along this dissection plane.

 

 

 

TECH FIG 1 • A. Surgical approach uses a 3-cm incision over the lateral epicondyle and can be extended in line with the forearm axis to avoid injury to the lateral collateral ligament. B. The interval between the tendinous EDC aponeurosis and the darker muscle of the ECRL is entered, and the ECRL is elevated off the underlying ECRB. (The patient's hand is to the right.) (continued)

 

 

A small posterior EDC flap is created for later closure, and the ECRL is elevated anteriorly revealing the underlying ECRB origin. The origin may be obliterated by degenerative tissue.

 

The abnormal tendon tissue to be excised can be identified by its grayish, unorganized mucoid appearance and should be sharply excised. Care is taken to dissect the ECRB off the underlying capsule.

 

Abnormal tissue typically will scrape away with a no. 15 blade but normal tendon will not (Nirschl scratch test). Sometimes, the ECRB tissue cannot be dissected free from the underlying capsule or it has already ruptured from its origin, and the underlying joint becomes exposed (TECH FIG 1C). This will not affect outcome.

 

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TECH FIG 1 • (continued) C. The degenerative ECRB is sharply excised. At times, as in this example, it is not possible to separate the ECRB and capsule, and a portion of the capsule also is excised.

Neighboring tendon of the EDC is scraped with a no. 15 blade to remove loose degenerative tissue. D. In this example, it was possible to excise the degenerative portion of the ECRB without the underlying capsule. E. The anterior portion of the lateral epicondyle is scratched clean of degenerative tissue with a no. 15 blade or rongeur but not decorticated. F. Some intact, normal ECRB fibers are left if they are present. G. Closure is done with an inverted stitch, size 0 Vicryl suture on a tapered needle in a running fashion.

 

 

If exposed, the joint should be inspected for degenerative change, which, if present, typically is found beneath a plica. The plica should be removed (TECH FIG 1D).

 

The pathologic tissue is débrided to margins showing an organized, tendinous appearance. Complete resection of the ECRB origin is not necessary if healthy viable portions remain (TECH FIG 1E).

 

The proximal stump of the ECRB should not be repaired because it has ample attachments and will not retract significantly.

 

The area of excision usually is 1 to 2 cm long and 5 to 10 mm wide.

 

The undersurface of the EDC often is affected, and degenerative tissue should be similarly removed.

 

A rongeur or knife blade is used to roughen the anterior portion of the lateral epicondyle to a bleeding surface without removing cortical bone.

 

Drilling of the epicondyle is not done, as it has been shown to confer no benefit and results in increased discomfort and stiffness for the patient.6

 

In some cases, patients have a significantly prominent epicondylar tip. This can be removed, especially if patients are focused on this finding and they are very thin, but the early recovery period will be more painful (TECH FIG 1F).

 

The defect in the tendon is closed with a single running or multiple inverted, simple absorbable suture,

using 0 or 1-0 suture material with a tapered needle. If a capsular rent occurs, there is no need to make a separate capsular closure, but the proximal tendon repair should be watertight to avoid a postoperative ganglion (TECH FIG 1G).

 

The subdermal layer is closed with buried, interrupted absorbable sutures, followed by a subcuticular skin closure and Steri-Strips.

• Arthroscopic Lateral Epicondylar Fasciectomy and Partial Ostectomy

   

  The patient is positioned according to surgeon's preference for elbow arthroscopy.

   

  We prefer the lateral decubitus position with the aid of the Tenet Spider Arm Holder (Smith & Nephew, Andover, MA).

   

  If prone or lateral, it is advantageous to keep the elbow well above the plane of the chest wall to optimize anterior superomedial portal camera positioning.

   

  The elbow is filled with 30 to 50 mL of irrigating solution until distended. An anterior superomedial portal is established.

   

  A small longitudinal portal incision is made about 2 cm proximal to the medial epicondyle and just anterior to the

   

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  medial intermuscular septum. A curved hemostat is used to spread underlying tissues and feel the medial intermuscular septum and then is slid along its anterior surface to the lateral, then anterior humerus.

   

   

   

  TECH FIG 2 • A. Arthroscopic view showing a capsular invagination lining a ruptured ECRB tendon. B. A radiocapitellar plica that is pathologic, causing degenerative changes on the radial head outer rim. C. A lateral portal is established at the anterior rim of the radial head at or just proximal to the radiocapitellar joint, often directly through the primary pathology. D. A shaver is used to excise abnormal capsule and ECRB tendon, leaving intact, shiny ECRL tendon. E. The shaver or burr (in reverse) can be used to clear degenerative ECRB tendon of the anterior portion of the lateral epicondyle from the capitellum back to the portal.

   

  This is repeated with the scope trocar, which is then passed distally along the anterior humerus toward the radiocapitellar joint, piercing the capsule and entering the joint.

   

  Documentation of intra-articular (eg, loose bodies, plica [TECH FIG 2A], osteochondritis dissecans, arthritis) and lateral capsular or tendon pathology (TECH FIG 2B) is made, and they are treated appropriately.

   

  A 25-gauge needle is placed from outside-in to choose an optimal radiocapitellar portal at the upper rim of the radial head at or just proximal to the radial head (TECH FIG 2C).

   

  A shaver is used to débride the abnormal capsule lining the EDC origin. Abnormal ECRB is débrided until normal superficial tendon fibers are identified and protected. If ruptured, all degenerative portions of the ECRB are excised. Normal, shining ECRL fibers can be seen superficially as well as the dark muscular appearance (TECH FIG 2D).

   

  Débridement should not proceed posteriorly to the mid-radiocapitellar plane to avoid injury to the lateral collateral ligament.

   

  A bone-cutting shaver or a less aggressive burr used in reverse will roughen, but not decorticate, the anterior aspect of the lateral epicondyle from the capitellum back to the portal entry site (TECH FIG 2E).

   

  A hooked electrocautery probe is useful to divide a plica to facilitate its resection.

   

  Lateral and posterior portals are closed with 3-0 Prolene sutures, and the medial portal is left open for rapid resolution of fluid distention and pain relief.

• Percutaneous Tenotomy: Tenex

   

   

   

  The console is used to set the desired amount of cutting power and intensity of aspiration. Ultrasound is used to identify the area of pathologic tissue, which appears as a hypoechoic focus. A stab incision is made distal to the ultrasound probe and the extensor tendon origin.

   

   

  The microdebrider tip is introduced retrograde into the pathologic tissue under ultrasound guidance. The device is activated until all ultrasound evidence of previously hypoechoic tissue is removed.

   

   

  Once satisfied with the treatment, the wound is irrigated with normal saline. The incision is closed with a single stitch or adhesive dressing.

   

  P.3909

• Radiofrequency Microtenotomy: Topaz

 

 

A 1-inch incision is made overlying the extensor tendon origin at the lateral epicondyle. Blunt dissection is carried out to visualize the extensor tendon origin

 

The Topaz MicroDebrider device is then assembled.

 

The saline rate of flow is adjusted till it reaches 2 to 3 drops per second.

 

The device is placed perpendicular to the tendon surface with gentle pressure and activated for 0.5 seconds.

 

Multiple applications are spaced 0.5 mm apart with altering depth to create a three-dimensional pattern within the pathologic extensor origin (TECH FIG 3).

 

 

Once we are satisfied with the treatment, the wound is irrigated with normal saline. The incision is closed identical to closure for the open technique.

 

 

 

 

TECH FIG 3 • Demonstration of multiple perforations in the common extensor origin created with Topaz MicroDebrider.

 

 

PEARLS AND PITFALLS
	Indications ▪ A minimum of 3-6 months of symptoms and failed nonoperative management     Coexisting ▪ Extensor tendon origin rupture may require débridement and repair. conditions ▪ Medial epicondylitis occurs in 30% of cases.     Failure to ▪ This will result in a poor result or recurrence; the rehabilitation protocol can be fully excise delayed in cases that require more significant débridement. devitalized tendon     Injury to the ▪ The ligament is posterior to the mid-radiocapitellar joint, and dissection in this area lateral should be avoided. collateral

 

	ligament     Extensor ▪ Rupture of the ECRB is of no consequence and should not be repaired. tendon ▪ Rupture of the EDC mandates repair and can be achieved by advancing the ECRL rupture posteriorly and the extensor carpi ulnaris anteriorly to close the gap. If this cannot be repaired, the anconeus muscle can be rotated to cover the defect.

 

 

POSTOPERATIVE CARE

 

 

Postoperatively, the patient is placed in a soft dressing and a removable cock-up wrist brace. The elbow is not immobilized, and gentle range of motion is allowed immediately.

 

The dressing is removed in 2 to 5 days. The patient may perform activities of daily living as tolerated with the wrist brace, removing the wrist brace several times daily for range of motion exercises.

 

Exertion is avoided.

 

A strengthening program is initiated at 6 weeks.

 

All restrictions are removed at 3 months, but impact activities are not allowed until 4 to 6 months postoperatively. Pain-free full activity may require 6 to 12 months.

 

OUTCOMES

Over 85% to 90% of all patients will have return to full activities with no pain. The remaining 10% to 15% have significant pain relief and strength improvement but do not return to normal preinjury levels. These outcomes hold true for both short follow-up and more than 10 years of follow-up.12,13,16 Future prospective

randomized trials will elucidate whether the reported more rapid recovery of the arthroscopic treatment is

realized.

Good short-term outcomes have been described for percutaneous procedures mentioned earlier.

It is uncommon (<5% of cases) for a patient to have absolutely no improvement in pain after surgery, even if the subjective outcome is unsatisfactory. Such a result should prompt consideration of incorrect diagnosis or the possibility of secondary gain issues.

 

 

COMPLICATIONS

Hematoma Infection

Lateral collateral ligament injury Weakness in grip strength

 

 

REFERENCES

1. Ahmad Z, Brooks R, Kang S-N, et al. The effect of platelet-rich plasma on clinical outcomes in lateral epicondylitis. Arthroscopy 2013;29(11):1851-1862.

    

    

2. Altay TT, Günal II, Oztürk HH. Local injection treatment for lateral epicondylitis. Clin Orthop Relat Res 2002; (398):127-130.

    

    

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3. Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA 2013;309(5):461-469

    

    

4. Greenbaum B, Itamura J, Vangsness CT, et al. Extensor carpi radialis brevis: an anatomical analysis of its origin. J Bone Joint Surg Br 1999;81(5):926-929.

    

    

5. Hay EM, Paterson SM, Lewis M, et al. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ 1999;319: 964-968.

    

    

6. Khashaba A. Nirschl tennis elbow release with or without drilling. Br J Sports Med 2001;35(3):200-201.

    

    

7. Koh JSB, Mohan PC, Howe TS, et al. Fasciotomy and surgical tenotomy for recalcitrant lateral elbow tendinopathy: early clinical experience with a novel device for minimally invasive percutaneous microresection. Am J Sports Med 2013;41(3):636-644.

    

    

8. Krogh TP, Fredberg U, Stengaard-Pedersen K, et al. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med 2013;41(3):625-635.

    

    

9. Martin CE, Schweitzer ME. MR imaging of epicondylitis. Skeletal Radiol 1998;27:133-138.

    

    

10. Meknas K, Odden-Miland A, Mercer JB, et al. Radiofrequency microtenotomy: a promising method for treatment of recalcitrant lateral epicondylitis. Am J Sports Med 2008;36(10):1960-1965.

     

     

11. Mishra AK, Skrepnik NV, Edwards SG, et al. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med 2014;42(2):463-471.

     

     

12. Nirschl RP, Davis LD. Mini-open surgery for lateral epicondylitis. In: Yamaguchi K, King GJW, McKee M, et al, eds. Advanced Reconstruction —Elbow. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2007:129-135.

     

     

13. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am 1979;61A:832-841.

     

     

14. Sasaki K, Onda K, Ohki G, et al. Radiocapitellar cartilage injuries associated with tennis elbow syndrome. J Hand Surg Am 2012;37(4): 748-754

     

     

15. Stasinopoulos D, Johnson MI. “Lateral elbow tendinopathy” is the most appropriate diagnostic term for the condition commonly referred-to as lateral epicondylitis. Med Hypotheses 2006;67: 1400-1402.

     

     

16. Verhaar J, Walenkamp G, Kester A, et al. Lateral extensor release for tennis elbow: a prospective longterm follow-up study. J Bone Joint Surg Am 1993;75(7):1034-1043.