Lateral Epicondylitis M77.10 726.32

synonyms: Tennis Elbow, lateral epicondylitis, common extensor tear, common extensor tenosynovitis, extensor carpi radialis brevis tear

Lateral Epicondylitis ICD-10

• M77.10 - Lateral epicondylitis, unspecified elbow
• M77.11 - Lateral epicondylitis, right elbow
• M77.12 - Lateral epicondylitis, left elbow

Lateral Epicondylitis ICD-9

• 726.32 (lateral epicondylitis)

Lateral Epicondylitis Etiology / Epidemiology / Natural History

• Pain at the lateral epicondyle which often radiates into the forearm and is typically insidious in onset.  Usually hx of repetitive activity.
• Associated with tennis, squash, fencing, meat cutting, plumbing, painting, raking, weaving
• Believed to be initiated by a microtear, most often within the origin of the extensor carpi radialis brevis.  May originate in any muscle originating from the epicondyle
• Angiofibroblastic hyperplasia of involved tissue demonstrating fibroblast proliferation, neovascularization and hyaline degeneration without acute inflammatory cells. (Regan W, AJSM 1992;20:746)
• Male = female
• Incidence is 2-3.5 times greater in tennis players with over 2hrs of racket time per week than those with less than 2 hrs per wk (Gruchow HW, AJSM 1979;7:234)(link is external).
• Affects 10-50% of tennis players (Jobe FW, JAAOS 1994;2:1)(link is external).(link is external)
• Typically 4^th to 5^thdecade
• Affects 1-3% of adults/year.
• More common in dominant arm.

Lateral Epicondylitis Anatomy

• Common extensor origin=ECRL, ECRB, EDC, ECU.
• ECRB is most commly involved, lies beneath ECRL.  ECRB origin includes the common extensor tendon, lateral collateral and annular ligaments, the investing fascia and the intermuscluar septum
• See also Elbow anatomy

Lateral Epicondylitis Clinical Evaluation

• Tenderness over the extensor tendon origin, usually localized to the ECRB portion.
• Maximal tenderness usually 2-5mm distal and anterior to the midpoint of the lateral epicondyle
• Resisted wrist and finger extension with the elbow in full extension exacerbates pain
• Normal wrist/elbow ROM
• If pt has pain on resisted suppination consider PIN irritation as cause.

Lateral Epicondylitis Xray / Diagnositc Tests

• A/P, lateral and oblique elbow films indicated, generally normal.
• 22-25% have calcification within the soft tissues about the lateral epicondyle

Lateral Epicondylitis Classification / Treatment

• Initial Treatment
  -Cessation of offending activity is required initially.
  -Avoid immobilization/inactivity which leads to disuse atrophy
  -Ice 20minutes 3-4x/day
  -NSAIDs for 10-14 days
  -Counterforce brace placed over the forearm musculature; questionable benefit (Struijs PA, AJSM 2004;32:462)(link is external).
  -Dynamic extensor bracing has shown statistically significant benefits (Faes M, CORR 2006;442:149)(link is external).
• Secondary Treatment
  -corticosteriod injection deep to ECRB, anterior and distal to the lateral epicondyle into fatty subaponeurotic recess.  SQ injection-SQ atrophy
  -Corticosteriod injection=55-89% pain relief: 18-54% recurrence. (Beller E, BMJ 2006;333:939). Provides short term benefit, but may be detrimental in the long term (Bisset L, BMJ 2006;333:939).
  -Platelet-Rich Plasma injection. 81% improvement in VAS score at 6 months (Mishra A, AJSM 2006;34:1774)(link is external).
  -Ultrasound, high-voltage galvanic stimulation no prospective randomized trials
  -Botulinum Toxin A: shown to have short-term benefit (Placzek R, JBJS 2007;89A:255).
• Final Treatment
  -If fails 6-12 months of non-operative treatment consider Lateral Epicondyle Debridement., Percutaneous technique (Dunkow PD, JBJS 2004;86Br:701)(link is external), arthrocsopic debridement.
• Botulinum toxin injection has not been shown to be of benefit (Hayton MJ, JBJS A 2005;87:503-507)(link is external).
• Shock wave therapy / ESWT has little or no benefit (Buchbinder R, Cochrane Database Syst Rev 2005;4:CD003524)(link is external).

Lateral Epicondylitis Associated Injuries / Differential Diagnosis

• Elbow Synovial Plica
• Cervical Radiculopathy
• Intraarticular elbow loose body
• Elbow Arthritis
• Posterolateral Rotatory Instability
• Olecranon Bursitis
• Posteromedial Elbow Impingement
• Posterior Interosseous Nerve Compression
• Radial Tunnel syndrome
• Radiocapitellar osteochondral lesions

Lateral Epicondylitis Complications

• Persistent pain of varying degree
• Infection
• Residual strength deficit
• Functional limitations
• Joint instability

Lateral Epicondylitis Follow-up Care

• Lateral Epicondylitis Rehab Protocol: wrist extensor stretching and progressive isometric exercises. Later begin eccentric and concentric exercises
• 26% of patients will have recurrence of symptoms and over 40% have prolonged minor discomfort.  Other more optomisitic reports show 85-90% successful nonoperative treatment
• Surgery=posterior mold for 7-10days.  Then progressive mobilization/gentle passive and active elbow, wrist, hand motion.  Counterforce bracing for 3-6 months.  Resisted isometrics at 4wks, progressive strengthening at 6 wks.  Return to lifting/athletics usually by 3-4 month.

Lateral Epicondylitis Review References

• Morrey BF, in Delee and Drez Orthopedic Sports Medicine, 2nd ed, 2003 (link is external)
• Operative Elbow Surgery: Expert Consult: 2012(link is external)
• AAOS/ASES Advanced Reconstruction Elbow, 2007(link is external)
• Orthopaedic Knowledge Update: Shoulder and Elbow, No. 3(link is external)
• Jobe FW, JAAOS 1994;2:1(link is external)
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