- Discussion:
- overuse syndrome or tendinosis involving the region of the
lateral humeral epicondyle;
- most often the origin of the
ECRB displays an abnormal vascular proliferation and focal hyaline
degeneration;
- ref:
Anatomic Factors
Related to the Cause of Tennis Elbow
-
EDC
may also be involved in some cases;
- ref: The role of the
extensor digitorum communis muscle in lateral epicondylitis.
- may or may not be associated w/ athletics;
- most common in 4th decade;
- microscopic Findings:
- include hyaline degeneration
and vascular proliferation in region of origin of
ECRB tendon, w/o any
evidence of chronic or acute inflammatory changes;
- ref: Microscopic
histopathology of chronic refractory lateral epicondylitis.
- diff dx:
-
C6
or C7
cervical nerve root compression
-
PIN
syndrome: entrapment at arcade of Frohse is recognized in approx 5% of pts;
- radial head arthritis;
- posterolateral plica:
- may accompany lateral epicondylitis;
- remnant plicae may become inflamed because of repeated trauma and
inflammation;
- resultant plicae may become entrapped in the radiocapitellar joint;
-
posterolateral instability;
- references:
-
Clinical presentation and radiographic findings of distal biceps tendon
degeneration: a potentially
forgotten cause of proximal radial forearm pain.
- Posterolateral
Rotatory Instability of the Elbow in Association with Lateral Epicondylitis.
- Exam:
- ROM of Wrist and Elbow;
- motor strength of ECRL/ECRB, EDC;
- note any tenderness over radial head;
- Maudsley's test: pain in the region of the lateral epicondyle
during resisted extension of the middle finger;
- elicit tenderness:
- greatest tension is elicited
w/ the elbow in extension, forearm in pronation, and wrist in flexion;
- note any tendnerness as the
pronated forearm actively extends the fingers and wrist against resistance;
- pinching w/ the wrist in
extension may elicit tenderness;
- chair test:
- patient is asked to lift a
chair with the shoulder adducted, the elbow extended, and the wrist pronated;
- lidocaine injection test:
- lidocaine injection 4 finger
breadths distal to the lateral epicondyle will result in temporary
PIN
palsy and,
in the case of PIN syndrome,
will result in temporary relief of pain;
- w/ lateral epicondylitis,
the patient should note pain relief following injection at the origin of the
ECRB tendon;
- Radiographs / MRI:
- rule out arthritis of the radial head;
- ref: MRI findings of refractory tennis elbows and their
relationship to surgical treatment.
- Non Operative Rx:
- reduce stenuous activities for at least 6 weeks;
- attempt to grasp objects in supination as opposed to pronation;
- wrist splint: consider use of a wrist splint, especially if elbow
tenderness is eccentuated by resisted wrist
extension;
- counter force strap:
- applied over the forearm flexor mass;
- prevents full muscular contraction, and therefore, reduces stress at
the insertion of the tendon to the
lateral epicondyle;
-
steroid
injection is also an option;
- steroid is injected adjacent to ECRB tendon (not in the tendon);
- references:
- Cortisone injection with anesthetic additives for radial
epicondylalgia (tennis elbow).
- Local injection treatment of tennis elbow - hydrocortisone,
triamcinolone and lidocaine compared.
British J. Rheumatology. Vol 30. p
39-44. 1991.
-
A
prospective randomized study comparing a forearm strap brace versus a wrist
splint for the treatment of
lateral epicondylitis
- Surgical Treatment:
- approach involves elevation of the
ECRB at the midportion of lateral epicondyle;
- additional pathology:
- anterior portion of the
EDC
may be involved;
- exostosis of the lateral epicondyle may be present;
- incision: 3-4 cm longitudinal incision is made just anterior to lateral
epicondyle;
- fascia overlying the posterior edge of the
ECRL is incised and elevated to expose the ECRB which lies
underneath the
ECRL;
- just posterior the the ECRL lies the extensor aponeurosis, the
anterior edge of which may be abnormal;
- ECRL is then sharply dissected off the anterior ridge and displaced
anteromedially to expose the ECRB;
- ECRB is inferior to the origin of the ECRL and deep to the EDC (border
between the ECRB and EDC is
often poorly defined);
- degenerated tissue is excised;
- if possible attempt to limit the debridement to the disease tissue
anterior to the EDC tendon at the mid-axis
of the epicondyle;
- Organ et al (AJSM Vol 25 No 6 Nov - Dec 1997) that inorder to avoid
recurrent symptoms, resect
the pathologic tissue present in ECRB;
- in about 1/3 cases, the anterior aspect of the EDC tendon origin is
involved as well;
- care is taken not to release normal appearing tendon;
- release operations, which weaken the extensor aponeurosis should be
avoided;
- defect between the ECRL and the extensor aponeurosis is firmly repaired;
- if PIN compression coexists with this condition, the two can be treated
through one incision that is slightly
more anterior and distal;
-
surgical complications:
- surgical debridement of lateral epicondylitis may result in
posterolateral instability, if there is
excessive debridement of collateral
ligament origins as well as the origins of the extensor
muslces from the lateral epicondyle;
-
controversies:
- should drilling accompany ECRB release?
- Khashaba et al (2001), the authors questioned whether
drilling was advantageous in ECRB;
- in prospective trial, authors shows that drilling confered
no benefit and actually caused more pain, stiffness, and wound bleeding than not
drilling;
- ref: Nirschl tennis elbow release with or without drilling.
Khashaba A. Br J Sports
Med 2001 Jun;35(3):200-1
- should
PIN
decompression be included in this procedure?
- J. Leppilahti et al: authors compared decompression of PIN and
lengthening of distal tendon of ECRB
in a randomised trial of 28 patients;
- 14 underwent decompression of PIN and 14, lengthening of
ERCB;
- average duration of preoperative symptoms was 23 months;
- PIN is exposed in groove between BR and brachialis muscles
and decompressed at arcade of Frohse
by means of a 1-2 cm incision through
supinator;
- ECRB tendon was lengthened by Z-plasty at the dorsilateral
aspect of the forearm;
- outcome after the primary operation was successful in 50% of
the PIN group and in 43% of the
ECRB group;
- 4 of the 5 patients with a poor outcome were reoperated in
the former group and 3 in the latter;
- overall outcome after a mean follow-up of 31 months after
the primary operation was successful
in 60% of the cases;
- references:
- The surgical treatment of chronic lateral humeral
epicondylitis by common extensor release.
- Surgical treatment of persistent elbow epicondylitis.
- Tennis elbow. The surgical treatment of lateral
epicondylitis.
- Lateral extensor release for tennis elbow. A prospective
long-term follow-up study.
- The results of operative treatment of medial epicondylitis.
- Salvage Surgery for Lateral Tennis Elbow. American J. of
Sports Med Vol 25 No 6 Nov -
Dec 1997 Scott W. Organ MD et al.
- Surgical treatment of resistant tennis elbow. A PR study
comparing decompression of the PIN
and lengthening of the tendon of the ECRB
muscle.
J. Leppilahti et al. Archives of Orthopaedic and
Trauma Surgery.
Abstract Volume 121 Issue 6 (2001) pp 329-332