Epicondylosis (lateral) with and without nerve entrapment

Author(s): Jennifer Yang, MD, Nicholas Elkins, DO

Originally published:09/19/2012

Last updated:09/14/2016

1. DISEASE/DISORDER:

Definition

Lateral epicondylosis (LE) is a common, painful condition affecting the lateral/extensor region of the elbow. This condition was previously known by many different names including lawn-tennis arm, tennis elbow, and lateral epicondylitis. Recent evidence indicates that the condition affects the common extensor tendon at the elbow, and the pathophysiologic process is a tendinosis instead of a tendinitis.1,2

Etiology

LE is a degenerative process involving the origin of the common extensor tendon. Injury occurs from accumulation of microtrauma from repetitive stress resulting in tendinosis. Untreated, tendinosis may lead to partial tears, progress to full-thickness tears, particularly in the setting of an acute overload injury.1

Epidemiology including risk factors and primary prevention

LE is the most common cause of elbow pain, occurring predominantly in the fourth and fifth decades with no predilection to gender. Its annual incidence is estimated at 1% to 3 % of the general population.1,3,4

Despite the common term “tennis elbow,” only 5% of cases of LE are secondary to racket sports. Risk factors typically include faulty biomechanics, overexertion, and repetition with repeated wrist extension and forearm supination and pronation.5,6

Patho-anatomy/physiology

The anterior aspect of the lateral epicondyle and lateral supracondylar ridge forms the origin of the conjoined tendon, incorporating the extensor carpi radialis brevis (ECRB), extensor digitorum communis (EDC), and extensor carpi ulnaris (ECU). Repetitive contraction of the forearm musculature yields microtearing with subsequent degeneration, immature repair, and tendinosis. Poor vascularity of the ERCB tendon contributes to degeneration and tendinosis.1,2

Nerve entrapment may occur as the deep branch of the radial nerve passes through the Arcade of Frohse/radial tunnel in the supinator muscles. Pathology occurs due to fibrous thickening of the periosteum and the interstitial connective tissue. Repetitive action of the extensor and supinator muscle groups may cause repeated microtrauma to the radial nerve.1,2

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Traditionally, it was thought that patients with LE would improve over time without intervention. While it is true that approximately 80% of patients with LE report improvement at one year, not all patients will improve without intervention. Fortunately, less than 11% of patients ever require surgical intervention. Poor prognostic factors for conservative treatment include manual labor, dominant arm, high pain perception, and poor coping mechanisms.7,8

Histopathologically, angiofibrosis leads to tendinosis and angiofibrotic degeneration of the tendon. Subsequently, tendinosis may develop, causing disruption of collagen fibers and tears within the tendon. Tendon rupture may follow and may be associated with fibrosis, soft tissue calcification, and osseous calcification.1,2

Specific secondary or associated conditions and complications

LE can be associated with a partial-thickness tear or a full-thickness tendon rupture, as well as entrapment neuropathy of the deep branch of the radial nerve. Posterior Interosseous Nerve (PIN) entrapment is another possible complication associated with LE causing weakness in the wrist and finger extensors, although most cases will present only with vague pain in the proximal forearm region with worsening of the pain with extension of the 3rddigit.  The inflammation from LE has been known to cause compression of the PIN.  Tendon rupture can be a complication of rapid or forceful eccentric strain in the setting of advanced tendinopathy.1,2

2. ESSENTIALS OF ASSESSMENT

History

The history often includes a description of pain over the lateral aspect of the elbow. This pain is typically sharp; it may radiate distally, exacerbated by activities involving gripping, wrist extension or wrist flexion.2,5,9 Aggravating and relieving factors should be identified, as well as motor weakness that may signify radial nerve involvement.

One must also ask about pertinent past history such as previous episodes of joint swelling, other joint involvement or skin lesion.  An occupational history must also be obtained.

Physical examination

Inspection of the involved wrist, elbow, shoulder, and cervical spine should be performed. Patients may present with localized swelling and erythema. Palpation reveals tenderness slightly anterior and distal to the lateral epicondyle over the origin of the ECRB and EDC muscles. Range of motion (ROM) may be decreased or elicit end range pain. A thorough neurologic exam may reveal weakness in the supinator, ECRB, EDC, ECU, abductor pollicis longus, and extensor indicis propius, indicating involvement of the deep branch of the radial nerve. Special tests may reproduce pain, including passive stretching of the wrist extensor muscles, grip testing, or resisted extension of the wrist or middle digit.2,5,9

Functional assessment

Activities of daily living or work tasks may be impaired due to pain. A thorough assessment of the patient’s ROM, grip strength and function may be necessary. Patients with biomechanical abnormalities may require an ergonomic evaluation to prevent further damage and worsening of symptoms.

Athletes presenting with LE require a thorough evaluation of equipment, warm-up regimen and technique.

Laboratory studies

Laboratory studies are rarely necessary. If multiple joints or tendons are involved, a rheumatologic work-up may be required.

Imaging

Plain radiographs may be utilized to rule out bony pathology and assess anatomical alignment. Rarely, plain films may reveal ectopic calcifications within the extensor muscle mass origin or intra-articular pathology.2,9

Magnetic resonance imaging (MRI) may demonstrate changes consistent with tendinosis. MRI can rule out any intra-articular processes, as well as assess the competency of the radiocollateral ligament complex. A dynamic musculoskeletal (MSK) ultrasound (US) examination can help visualize the entire common extensor tendon. The common extensor origin may be thickened and demonstrate a heterogeneous echotexture. Doppler US may show hyperemia of the involved area. Research suggests that a negative Doppler and grey scale US examination is sufficient to rule out LE. However, limitations may be present secondary to availability, ultrasonography skill and equipment.2,9,10,11

Supplemental assessment tools

Electrodiagnostic studies will be normal in isolated cases of LE. However, if there is involvement of the PIN, motor nerve conduction studies may demonstrate slowed conduction velocity across the elbow, prolonged distal latency, and reduced amplitude.

Supplemental assessment tools include the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and Patient-rated Tennis Elbow Evaluation (PRTEE) questionnaire. PRTEE is a useful tool that allows the patient to rate their pain and disability, and DASH can be utilized to evaluate the outcome of conservative treatments, as well as surgical treatment of LE.8,12

Environmental

One should consider modifying work or sport-specific tasks such as repetitive hammer use, machinery use, and employing proper technique in tennis racket swings to minimize repetitive strain on the extensor elbow tendons. Reducing tennis racket string tension and increasing racket grip diameter may help.

Social role and social support system

If the pain is severe and the afflicted person cannot work, this will impair a patient’s status within the family and society. Disability benefits for patients with LE may be difficult to obtain. .

Professional Issues

Patients with chronic LE may seek treatments such as cortisone or platelet-enriched plasma (PRP) injections. Although corticosteroid injections can provide short-term relief of pain, these injections can be detrimental to recovery and are known to pose a risk of tendon rupture. Furthermore, PRP injections have not proven effective in well-controlled clinical trials.13,14

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

Different rehabilitation techniques and treatments are currently under investigation. There is evidence to support eccentric wrist extension exercises for the treatment and rehabilitation of LE15. Autologous blood, PRP, prolotherapy, dry needle tendon fenestration and corticosteroid injections are treatments currently being utilized by practitioners for treatment of LE. However, there are no established treatment guidelines specifically for LE, with or without nerve entrapment.9,16,20

At different disease stages

Initial treatment should be tailored to the patient’s needs and desired activity, focusing primarily on symptomatic relief. Acute exacerbations can be managed with relative rest of the involved extremity. A wrist cock-up splint or a forearm counter-force brace may be necessary. However, the literature is divided on this issue.19,20

Non-steroidal anti-inflammatory drugs and cryotherapy are useful in the acute phase. Topical treatments such as menthol and diclofenac cream may be helpful as this medication preparation has minimal systemic absorption. Transcutaneous nerve stimulation (TENS), ultrasound, phonophoresis, ionotophoresis and acupuncture may be beneficial, as well.20 Glyceryl trinitrate patch therapy may decrease pain and enhance healing.17 Corticosteroid injections may give temporary partial pain relief, though their use is controversial. Prolotherapy and biologics such as PRP may offer sustained relief but their efficacy has not yet been established.13,14,16

Exercise therapy with progressive loading of the wrist extensors is initially performed with passive stretching, advancing to progressive resistance training. Strengthening is initially done with isometric exercise, advancing to concentric and eventually eccentric exercises.13,15

Returning to sport or occupation requires that abusive forces be modified and activity specific exercises be initiated. Patients may need counter-force bracing, workstation modifications, education, and postural retraining.

Surgery is indicated for chronic LE unresponsive to conservative management.

Coordination of care

Patients with chronic LE causing sustained disability may require coordinated interdisciplinary treatment incorporating physical and occupational therapy for strengthening and secondary prevention of LE. Vocational and rehabilitation psychologists can educate patients with LE on career modification and integration into the community with this impairment. In cases of tendon tear or rupture, recalcitrant LE or radial nerve involvement, a surgical consultation may be necessary.

Patient & family education

Family and societal roles may change secondary to functional impairments. In chronic cases, helping patients reestablish their role with family through active rehabilitation exercises is important for optimal outcomes.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Physicians may learn and integrate into their practice newer techniques described to treat LE with or without nerve entrapment. These techniques include the use of eccentric exercises and glyceryl trinitrate patches.15,17

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

Interventions directed at restoring normal tendon anatomy including PRP, autologous growth factors, and other biologics are emergent treatments for severe elbow tendinosis. More studies are needed to establish the efficacy of these treatments.14,19

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

One controversy results around the role of work in causing LE. Obtaining disability for repetitive strain disorders is nearly impossible. Controlled studies are required to establish the efficacy of injecting cortisone and biologics such as stem cells and platelet-rich plasma for treatment of LE.14,16,19

REFERENCES

  1. Bishai SK, Plancher KD. The basic science of lateral epicondylosis: Update for the future. Techniques in Orthopaedics. 2006;21(4):250-255.
  2. Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: Pathogenesis, imaging, and treatment. RadioGraphics. 2010;(30):167-183.
  3. Bigorre N, Raimbeau G, Fouque P-A, Saint Cast Y, Rabarin F, Cesari B. Lateral epicondylitis treatment by extensor carpi radialis fasciotomy and radial nerve decompression: Is outcome influenced by the occupational disease compensation aspect? Orthopaedics & Traumatology: Surgery & Research. 2011; 97(2): 159-163.
  4. Allander E. Prevalence, incidence and remission rates of some common rheumatic diseases and syndromes. Scand J Rheumatol. 1974;(3):145-153.
  5. Nirschl R. Tennis injuries. In: Hutton KS and McClellan JW.The upper extremity in sports medicine. St Louis, MO: Mosby Publishing; 1990:827-842.
  6. Haahr JP, Andersen JH. Physical and psychosocial risk factors for lateral epicondylitis: a population based case-referent study. Occup Environ Med. 2003;60(5):322-329.
  7. Haahr JP, Andersen JH. Prognostic factors in lateral epicondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice. Rheumatol. 2003;42(10):1216-1225.
  8. Janssen S, De Smet L. Responsiveness of the DASH questionnaire for surgically treated tennis elbow. Acta Chir Belg. 2008;108(5): 583-585.
  9. Calfee RP, Patel A, DaSilva MF, Akelman E. Management of lateral epicondylitis: Current concepts. J Am Acad Ortho Surg .2008;(16):19-29.
  10. Kotnis N, Chiavaras M, Srinivasan H.  Lateral epicondylitis and beyond: imaging of lateral elbow pain with clinical radiologic correlation.  Skeletal Radio. 2012 41:369-386.
  11. du Toit C, Stieler M, Saunders R, Bisset L, Vicenzino B. Diagnostic accuracy of power Doppler ultrasound in patients with chronic tennis elbow. Br J Sports Med. 2008;42:872–6.
  12. Rompe JD, Overend TJ, MacDermid JC. Validation of the patient-rated tennis elbow questionnaire. J Hand Ther. 2007;20(1):3-10.
  13. Behrens SB, Deren ME, Matson AP, Bruce B, Green A. A review of modern management of lateral epicondylitis. Phys Sportsmed. 2012;40(2): 34-40.
  14. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. American Journal of Sports Medicine. 34;(11):1774-1778.
  15. Kenas Andrew, Masi Michael, Kuntz Chad. Eccentric interventions for lateral epicondylalgia. Strength and Conditioning J.  2015 37(5):47-52.
  16. Lin YC, Tu YK, Chen SC, Chen SS, Lin IL, Guo HR. Comparison between botulinum toxin and corticosteroid injection in the Treatment of acute and subacute tennis elbow. Am J Phys Med Rehabil. 2010;(89):653-659.
  17. Paolini JA, Murrell GAC, Burch RM, Ang RY. Randomised, double-blind, placebo-controlled clinical trial of a new topical glyceral trinitrate patch for chronic lateral epicondylosis. Br J Sports Med. 2009;(43):299-302.
  18. Borkholder CD, Hill VA, Fess EE. The efficacy of splinting for lateral epicondylitis: a systematic review. J Hand Therapy. 2004;17(2):181-99.
  19. Ahmad Z, Siddiqui N, Malik SS, Abdus-samee M, Tytherleigh-strong G, Rushton N. Lateral epicondylitis: a review of pathology and management. Bone Joint J. 2013;95-B(9):1158-64.
  20. Smidt N, Lewis M, van der Windt DA, Hay EM, Bouter LM, Croft P. Lateral epicondylitis in general practice: course and prognostic indicators of outcome. Rheumatol, 2006;33(10):2053.

Original Version of the Topic:

Matthew Dounel, MD MPH, Kevin Pak, MD. Epicondylosis (lateral) with and without nerve entrapment. Publication Date: 2012/09/19.

Author Disclosure

Jennifer Yang, MD
Nothing to Disclose

Nicholas Elkins, DO
Nothing to Disclose

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