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Epicondylitis

BASICS

DESCRIPTION

  • Tendinopathy at the medial or lateral epicondyle of the humerus, involving wrist flexor/pronator or extensor/supinator tendons.
  • More accurate terms: medial epicondyle tendinopathy (MET) and lateral epicondyle tendinopathy (LET).
  • MET = "golfer's elbow" (wrist flexors/pronators, medial epicondyle).
  • LET = "tennis elbow" (wrist extensors/supinators, lateral epicondyle).
  • Most commonly involves extensor carpi radialis brevis (ERCB) tendon.
  • Common in athletes and manual laborers (carpenters, plumbers, gardeners).
  • 75% involve dominant arm.

EPIDEMIOLOGY

  • Age >40 years.
  • Male = female prevalence.
  • Incidence 1-3%, lateral > medial.
  • Prevalence: MET 0.4%, LET 1.3%.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Acute tendonitis rare; inflammatory response to injury or sudden contraction.
  • Chronic tendinosis/tendinopathy due to repetitive strain on flexor (MET) or extensor (LET) enthesis.
  • Tendon degeneration: calcium deposition, fibroblast and microvascular proliferation, hyaline cartilage destruction, diminished inflammation.
  • Aggravated by tool/racquet gripping, shaking hands, occupational activities (painters, mechanics, cooks), sports (golf, tennis, archery, pitching).

RISK FACTORS

  • Repetitive wrist motions (flexion/pronation → MET; extension/supination → LET).
  • Smoking, obesity.
  • Forceful upper extremity activities.

GENERAL PREVENTION

  • Limit overuse of wrist flexors/extensors/pronators/supinators.
  • Proper technique with hand tools and racquet sports.
  • Use lighter tools, smaller grips.

DIAGNOSIS

HISTORY

  • Insidious onset lateral or medial elbow pain/tenderness near epicondyle.
  • Aching pain radiating to forearm/wrist.
  • Pain with gripping; mild forearm weakness sensation.

PHYSICAL EXAM

  • Tenderness at medial or lateral epicondyle or tendon origin.
  • MET: pain with resisted wrist flexion and pronation.
  • LET: pain with resisted wrist extension and supination.
  • Normal elbow ROM.
  • Increased pain with gripping.

DIFFERENTIAL DIAGNOSIS

  • Arthritis (posterior osteophytes).
  • Epicondylar fractures.
  • Posterior interosseous nerve entrapment (lateral pain).
  • Radial tunnel syndrome (lateral pain).
  • Ulnar neuropathy (medial pain).
  • Pronator syndrome (anteromedial pain).
  • Synovitis, thoracic outlet syndrome.
  • Medial collateral ligament injury.
  • Referred shoulder or neck pain.

DIAGNOSTIC TESTS

  • No imaging needed initially.
  • X-rays (AP/lateral) if trauma, reduced ROM, or failed conservative treatment (to assess fractures or arthritis).
  • Musculoskeletal ultrasound (MSK US): tendon thickening, hypoechoic areas, partial tears, calcifications, hyperemia; guides injections.
  • MRI: T2 hyperintensity in tendon or peritendinous edema.
  • Local anesthetic infiltration to confirm diagnosis if uncertain.

TREATMENT

GENERAL MEASURES

  • Activity modification, counterforce bracing, oral/topical NSAIDs, ice, physical therapy.
  • Splinting discouraged except severe cases; associated with prolonged treatment.
  • Counterforce bracing (forearm strap) inexpensive; may improve daily function initially.
  • Frequent icing after activity.
  • Physical therapy: eccentric strengthening, stretching, therapeutic ultrasound, corticosteroid iontophoresis, dry needling.

MEDICATION

First Line

  • Topical NSAIDs: more effective than placebo short-term (up to 4 weeks) with minimal side effects.
  • Oral NSAIDs: unclear efficacy but may provide short-term relief; watch for GI effects.

Second Line

  • Corticosteroid injections: short-term pain reduction (≤8 weeks), no long-term benefit.
  • Corticosteroids superior to PRP in short-term; PRP better long-term (24 weeks).

ISSUES FOR REFERRAL

  • Failure of conservative therapy.

ADDITIONAL THERAPIES

  • Glyceryl trinitrate (GTN) patch (NO donor, collagen synthesis).
  • Extracorporeal shock wave therapy (ESWT), 89% effective in some studies.
  • Prolotherapy: dextrose injection to stimulate inflammation/healing.
  • Platelet-rich plasma (PRP): autologous growth factors stimulate healing; superior to steroids long-term.
  • Ultrasound-guided percutaneous needle tenotomy: fenestration, abrasion; requires specialist.
  • Autologous tenocyte injection: cultured tenocytes injected to regenerate tendon.
  • Botulinum toxin A injections for chronic LET pain.

SURGERY

  • Rare (~2.8% cases).
  • Debridement and tendon release (open or arthroscopic).
  • Denervation of lateral humeral epicondyle (transect posterior cutaneous nerve).
  • Improves pain, function, and grip strength.

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Acupuncture effective short-term for lateral epicondyle pain.

ONGOING CARE

PROGNOSIS

  • Good; most resolve with conservative care.

REFERENCES

  1. Pattanittum P, Turner T, Green S, et al. NSAIDs for lateral elbow pain: Cochrane review. 2013;CD003686.
  2. Krogh TP, Bartels EM, Ellingsen T, et al. Injection therapies in lateral epicondylitis: systematic review. 2013;41(6):1435-1446.
  3. Li A, Wang H, Yu Z, et al. PRP vs corticosteroids for elbow epicondylitis: meta-analysis. 2019;98(51):e18358.
  4. Aydın A, Atiç R. ESWT vs wrist-extensor splint for LET: RCT. 2018;11:1459-1467.
  5. Han SH, Lee JK, Kim HJ, et al. Surgical treatment results in medial epicondylitis: 5-year follow-up. 2016;25(10):1704-1709.

ADDITIONAL READING

  • Cullinane FL, Boocock MG, Trevelyan FC. Eccentric exercise for lateral epicondylitis: systematic review. 2014;28(1):3-19.
  • Dingemanse R, Randsdorp M, Koes BW, et al. Electrophysical modalities for epicondylitis: systematic review. 2014;48(12):957-965.
  • Green S, Buchbinder R, Barnsley L, et al. Acupuncture for lateral elbow pain: Cochrane review. 2002;(1):CD003527.
  • Lin YC, Wu WT, Hsu YC, et al. Botulinum toxin vs non-surgical treatments for LET: meta-analysis. 2018;32(2):131-145.
  • Mattie R, Wong J, McCormick Z, et al. Percutaneous needle tenotomy for lateral epicondylitis: systematic review. 2017;9(6):603-611.
  • Ozden R, Uruç V, Doğramaci Y, et al. GTN patch for tennis elbow management. 2014;48(2):175-180.

CODES

  • ICD10 M77.00 Medial epicondylitis, unspecified elbow
  • ICD10 M77.10 Lateral epicondylitis, unspecified elbow
  • ICD10 M77.01 Medial epicondylitis, right elbow

CLINICAL PEARLS

  • MET ("golfer’s elbow"): pain/tenderness at wrist flexor origin on medial epicondyle.
  • LET ("tennis elbow"): pain/tenderness at wrist extensor origin on lateral epicondyle.
  • Untreated symptoms last 6 months to 2 years.
  • Most improve with conservative therapy (NSAIDs, activity modification, PT).
  • New therapies (ATI, PRP, prolotherapy, tenotomy) focus on tendon regeneration.