Lateral epicondylosis (LE) is a common, painful condition affecting the lateral region of the elbow. This condition was previously known by many different names, including tennis elbow and lateral epicondylitis. Evidence indicates that the condition affects the common extensor tendon at the elbow and that the pathophysiologic process is more often tendinosis instead of tendinitis (since tendinitis is usually seen in the acute phases).1,2
LE is most often a chronic degenerative process involving the origin of the common extensor tendon. Injury occurs from accumulation of microtrauma due to repetitive stress, resulting in tendinosis. If left untreated, tendinosis may lead to partial tears and 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 lateral elbow pain. It frequently occurs in the dominant upper extremity of middle-aged adults. Its annual incidence is estimated at 1% to 3% of the general population.3,4
Despite the common term “tennis elbow,” only 10% of cases of LE are secondary to racket sports.5 Intrinsic risk factors include female gender, type 2 diabetes mellitus, obesity, and biomechanical malalignments.6,7,8 Chronic hyperglycemia, advanced glycation end products, and insulin resistance have been shown to contribute to the development of diabetic tendinopathy.9 Extrinsic risk factors include current and former smoking, heavy manual labor occupation, and repetitive tasks involving wrist extension and forearm supination.6,7,10,11 More specifically, work tasks requiring handling of 1-kg tools or 20-kg loads, lifting for ≥3% of time, or repetitive stressful movements >2 hours a day have been associated with LE.10,11
The anterior aspect of the lateral epicondyle and supracondylar ridge forms the origin of the conjoined extensor tendon, incorporating the extensor carpi radialis brevis (ECRB), extensor digitorum communis (EDC), extensor digiti minimi (EDM), and extensor carpi ulnaris (ECU). Repetitive contraction of the forearm musculature yields microtearing with subsequent tendinosis. Poor vascularity of the ERCB tendon contributes to tendinosis, which is typically the initial site of injury.5
Histopathologically, tendinosis is characterized by a degenerative process marked by disorganized tendon fibers, with occasional local necrosis, calcification, or neovascular ingrowth. Tendon tearing can follow due to the degradation of the tendon fibers.1,2
Another important concept to consider when discussing tendinopathy is the amount and type of load placed on the tendon. Tendinopathy arises due to an excessive imbalance of tendon load. Though some tensile mechanical loading as opposed to immobilization, is essential for tendon integrity and strength as this results in upregulation of collagen expression and increased synthesis of collagen protein. This is important to recognize in the plan of treatment as there is a narrow range of ideal strain that stimulates an anabolic effect in tendon tissue.12,13,14
Recent studies also suggest LE may be a manifestation of elbow instability. There is close proximity of the ECRB and the nearby static stabilizers of the lateral elbow, the radial collateral ligament (RCL) and lateral ulnar collateral ligament (LUCL). Failure of these static stabilizers is thought to result in ECRB overloading during dynamic movement. RCL & LUCL abnormality is the most common accompanying finding with LE on ultrasound and MRI. Furthermore, the degree of RCL & LUCL injury positively correlates with severity of disease and outcomes.15,16
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 80-90% of patients with LE report improvement at one year with conservative treatment, not all patients will improve without intervention.17 Fortunately, less than 11% of patients ever require surgical intervention.18 Poor prognostic factors for conservative treatment include manual labor, dominant arm, high pain perception, poor coping mechanisms, and the presence of an associated lateral elbow ligament injury.15,16,19,20
Specific secondary or associated conditions and complications
LE can be associated with a partial-thickness tear or a full-thickness tendon rupture, which can be complications of rapid or forceful eccentric strain in the setting of advanced tendinopathy.1,2 Posterior interosseous nerve (PIN, also known as the deep branch of the radial nerve) compression or entrapment most commonly occurs as it passes through the Arcade of Frohse between the supinator muscle and is another possible complication. This can occur due to fibrous thickening of the periosteum and the interstitial connective tissue at this region. Repetitive action of the extensor and supinator muscle groups may also cause repeated microtrauma to the nerve.1,2 This results in weakness of the wrist and finger extensors, but no sensory disturbances. Despite a similar clinical presentation, radial tunnel syndrome (RTS) should be considered a different clinical entity. With RTS, compression of the PIN is milder and can occur more proximal near the point of bifurcation from the superficial sensory branch. Distinction can be made clinically with RTS which primarily presents with pain in the proximal dorsolateral forearm, possible sensory disturbance along the distal lateral forearm and the dorsal hand, but without remarkable weakness in finger extension.21,22
Essentials of Assessment
A typical patient history often includes a description of pain over the lateral aspect of the elbow, anterior to the lateral epicondyle. This pain is typically sharp; it may radiate distally, exacerbated by activities involving gripping and wrist extension.6,23 Aggravating and relieving factors should be identified, as well as motor weakness that may signify nerve involvement. One must also ask about pertinent past social and medical history, such as manual labor occupation, smoking use, and diabetes.
Inspection of the involved wrist, elbow, shoulder, and cervical spine should be performed. Tenderness to palpation occurs 2-5 mm distal to the lateral epicondyle. RTS can also cause tenderness to palpation but usually 4-5cm distal to the lateral epicondyle. Elbow range of motion (ROM) is often unaffected. With LE, pain can occur with supination, wrist extension, and finger extension strength testing but true weakness is not observed. In comparison, PIN compression, can result in weakness in wrist and finger extension as well as radial deviation with attempted wrist extension.21 Special tests for LE may reproduce pain, including resisted extension of the wrist (Cozen’s Test), resisted extension of the third digit of the hand (Maudsley’s test), passive stretching of the wrist extensor muscles (Mill’s Test), or lifting a chair with fully extended elbows (Chair Test).6,23 A positive tinel’s near the supinator muscle mass raises concern for RTS.22 If considering cervical radiculopathy, examination with focused attention on upper extremity strength, reflexes, evaluation for upper motor neuron signs, sensation, and special tests should be performed. Special tests for cervical radiculopathy include the Spurling’s Test.
Activities of daily living or work tasks may be impaired due to pain. A thorough appraisal 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 careful assessment of equipment, warm-up regimen, and technique.
Laboratory studies are rarely necessary. If multiple joints are involved or an infectious process is suspected, a further work-up may be indicated.
Plain radiographs may be utilized to rule out bony pathology and to assess anatomical alignment. Calcifications within the extensor muscle mass origin can also be seen.2,23
Magnetic resonance imaging (MRI) may demonstrate changes consistent with tendinosis and/or tears. An MRI can be useful in ruling out intra-articular and surrounding soft tissue processes, although MRI is not routinely recommended given the cost and poor correlation with clinical severity.
Musculoskeletal ultrasound is now considered ideal for initial clinical diagnostic investigation as it can evaluate for structural tendon changes, bone irregularities, calcific deposits, and neo-vascularization. However, limitations may exist due to availability of equipment and inter-operator variability.23-25
Both ultrasound and MRI can also assess for the presence of an associated lateral elbow ligament tear which can predict a poorer outcome with non-operative treatment.15,16
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. Superficial radial nerve SNAP is usually normal. EMG can show findings of acute denervation in PIN innervated muscles (ECRB, supinator, EDC, and ECU) and also evaluate for a cervical radiculopathy if that is a clinical concern.
Supplemental assessment tools include the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire. PRTEE is a useful tool that allows patients to rate their levels of pain and disability, and DASH can be utilized to evaluate the outcomes of conservative treatments, as well as surgical treatments for LE.20,26
One should consider modifying work or sport specific tasks such as repetitive hammer use, machinery use, and 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 so severe that the afflicted patient cannot work, this may become financially burdensome. Collaboration with occupational health and social support systems should be encouraged early in such circumstances.
Returning to one’s sport or occupation requires that the repetitive strenuous forces to the affected area be modified and that activity specific exercises be initiated. Patients may need ergonomic modifications, including workstation adjustments and postural retraining.
Rehabilitation Management and Treatments
Available or current treatment guidelines
Different rehabilitation techniques and treatments for LE are currently under investigation. To date, there are no standardized treatment guidelines for LE, although some general principles should be considered.10,11,18,27,28
At different disease stages
Treatment should be tailored to a patient’s needs and desired activities. Modifiable risks factors should be addressed including obesity, smoking cessation, and diabetes control. The initial focus is primarily on symptomatic relief. Acute exacerbations can be managed by activity modification to the involved extremity. A forearm counter-force brace or a wrist extension splint can sometimes be utilized, though studies have shown no differences between these and placebo braces.11, 28,29
Non-steroidal anti-inflammatory drugs and cryotherapy may also be considered for treatment of pain. Topical treatments such as menthol and diclofenac can serve as alternatives, as these medications have minimal systemic absorption. Transcutaneous nerve stimulation (TENS), ultrasound, phonophoresis, ionotophoresis, acupuncture, and dry needling may be beneficial as well.28,30,31 Glyceryl trinitrate patch therapy has been shown to decrease activity-related pain and to enhance healing, but have potential side effects such as headaches or flushing.28,32, 33 Corticosteroid injections may give temporary partial pain relief, but their use is controversial due to their long-term tenotoxic effects and increased risk of injury recurrence.34
After successful pain control, physical therapy should be initiated. This often begins with passive stretching of the wrist extensors, followed by progressive resistance training. Strengthening is initially done with isometric exercise, later advancing to concentric and eccentric exercises.35,36 There is reliable evidence to support that eccentric wrist extension exercises are effective.36
Patients with refractory symptoms of LE, despite conservative measures, can be considered for ultrasound-guided interventions and orthobiologic treatments. Current options include ultrasound-guided tenotomy, percutaneous ultrasonic tenotomy, prolotherapy, platelet rich plasma (PRP), and mesenchymal stem cells (MSCs). Of these, limited literature suggests that PRP and percutaneous ultrasonic tenotomy can provide significant long-term benefits when compared to conservative therapy.37,38
Surgery can be considered for patients with persistent pain and disability that have not responded to appropriate nonoperative management after 6 to 12 months. The available surgical options include open, arthroscopic, and percutaneous approaches; there have not been significant differences in recovery shown between these options.18
Coordination of care
Patients with chronic LE causing sustained disability may require interdisciplinary treatments which incorporate physical and occupational therapies for strengthening and secondary prevention of LE. Vocational and rehabilitation psychologists should educate patients with LE regarding career modifications and integration into the community. In cases of tendon tear or rupture, recalcitrant LE, or radial nerve involvement, a surgical consultation may be necessary.
Patient & family education
Patients’ family and societal roles may change due to functional impairments. In chronic cases, helping patients reestablish their roles within the family using 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
For treatment of LE, physicians should learn to integrate both traditional and modern techniques into their practices. Modern techniques include the use of musculoskeletal ultrasound for diagnostic and therapeutic purposes. Knowledge of how to differentiate LE vs. PIN compression vs. RTS based on clinical history and physical exam is important. Assessment for a concurrent RCL or LUCL injury with ultrasound or MRI can be helpful to predict those that may have a worse outcome with non-operative treatment. Understanding the underlying pathophysiology of LE and optimal conditions for healing including tendon load, can assist in determining non-operative treatments to meet patient goals.
Cutting Edge/ Emerging and Unique Concepts and Practice
Ultrasound-guided interventions and orthobiologics are emergent treatments directed at restoring normal tendon anatomy and function.29,39 Additional studies are still needed to establish the safety and efficacy of these treatments. Ultrasound elastography (UE) is now being used to assess tendon stiffness and improve tendon health characterization. UE has shown early promise in improved diagnostic accuracy, prediction of at-risk tendons and prognostication capability beyond conventional grey-scale US for tendinopathies.40
Gaps in the Evidence- Based Knowledge
Growing evidence suggests that PRP injections have long-term benefits, but there is still variability among practioners regarding optimal formulation.39 Additionally, post-PRP injection and ultrasound-guided intervention rehabilitation regimens are needed. Further studies should be performed in a homogeneous and larger patient population to establish which newly developed treatments are most effective. The eventual goal is to have a non-operative treatment algorithm based on the stage of the underlying pathology and mechanism of action of these treatments to provide individualized and targeted management.
- Bishai SK, Plancher KD. The basic science of lateral epicondylosis: Update for the future. Techniques in Orthopaedics. 2006;21(4):250-255.
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- 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.
- Allander E. Prevalence, incidence and remission rates of some common rheumatic diseases and syndromes. Scand J Rheumatol. 1974;(3):145-153.
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- 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.
- Sayampanathan AA, Basha M, Mitra AK. Risk factors of lateral epicondylitis: A meta-analysis. Surgeon. 2020 Apr;18(2):122-128
- Cannata F, Vadalà G, Ambrosio L, Napoli N, Papalia R, Denaro V, Pozzilli P. The impact of type 2 diabetes on the development of tendinopathy. Diabetes Metab Res Rev. 2020 Oct 27. doi: 10.1002/dmrr.3417. Epub ahead of print. PMID: 33156563.
- Thompson C, Visco C. Lateral epicondylosis: emerging management options. Curr Sports Med Rep. 2015 May-Jun;14(3):215-20. doi: 10.1249/JSR.0000000000000162. PMID: 25968855.
- Lenoir H, Mares O, Carlier Y. Management of lateral epicondylitis. Orthop Traumatol Surg Res. 2019 Dec;105(8S):S241-S246. doi: 10.1016/j.otsr.2019.09.004. Epub 2019 Sep 19. PMID: 31543413.
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- Cha YK, Kim SJ, Park NH, Kim JY, Kim JH, Park JY. Magnetic resonance imaging of patients with lateral epicondylitis: Relationship between pain and severity of imaging features in elbow joints. Acta Orthop Traumatol Turc. 2019 Sep;53(5):366-371. doi: 10.1016/j.aott.2019.04.006. Epub 2019 Apr 28. PMID: 31040053; PMCID: PMC6819801.
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- Gregory BP, Wysocki RW, Cohen MS. Controversies in Surgical Management of Recalcitrant Enthesopathy of the Extensor Carpi Radialis Brevis. The Journal of hand surgery. 2016;41(8):856-9.
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- Bo Tang J. Radial tunnel syndrome: definition, distinction and treatments. J Hand Surg Eur Vol. 2020 Oct;45(8):882-889. doi: 10.1177/1753193420953990. PMID: 32998611.
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- Paoloni JA, Appleyard RC, Nelson J, Murrell GA. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med. 2003 Nov-Dec;31(6):915-20.
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- Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. The American journal of sports medicine. 2006;34(11):1774-8.
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Original Version of the Topic:
Matthew Dounel, MD MPH, Kevin Pak, MD. Epicondylosis (lateral) with and without nerve entrapment. Published 9/19/2012.
Previous Revision(s) of the Topic:
Jennifer Yang, MD, Nicholas Elkins, DO. Epicondylosis (lateral) with and without nerve entrapment. Published 9/14/2016.
Christian Roehmer, MD
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Stephen Schaaf, MD
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