Lateral and Medial

Epicondylitis
Ian S Rice MD
Sports Medicine Orthopedic Surgeon
 Outline
• Epidemiology
• Anatomy
• Biomechanics
• Pathophysiology
• Diagnosis
• Treatment
• Research
Lateral Epicondylitis

Tennis Elbow
 History

• First described in 1873 by Runge

• Tendinosis not inflammatory condition
• Affects common attachment of extensor muscles
of forearm to lateral epicondyle of humerus

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

Van Hofwegen, C., et al. (2010) Clin Sports Med 29: 577-97
 Epidemiology

• Incidence 1%-3% adults per year in UK

• 10-50% of people who play tennis regularly, Male > Female

• Lateral 4-7 times more common than Medial

• 35 – 55 years of age
• Male = Female in general population
• Dominant arm > Non-dominant

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

Van Hofwegen, C., et al. (2010) Clin Sports Med 29: 577-97
 Anatomy

• Common Extensors:
• Extensor Carpi Radialis
Brevis*
• Extensor Carpi Radialis
Longus
• Extensor Digitorum
• Extensor Carpi Ulnaris
• Radial  superficial
sensory + deep  PIN

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

Van Hofwegen, C., et al. (2010) Clin Sports Med 29: 577-97
 Anatomy

• Radial Collateral
Ligament
• Lateral Ulnar
Collateral Ligament
• Annular Ligament
Biomechanics: Extensor Group
• Eccentric contraction of ECRB
• Excessive/repetitive use extensors or supinator
• Tennis, typing, piano, manual work

• Risk factors in racquet sports:

• Incorrect technique
• Extended duration of play
• Frequency of play
• Size of handle
• Racquet weight

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

 Pathophysiology

• Paucity of inflammatory cells

• Gross: Grayish, homogenous, edematous and friable
tissue
• Tendinosis  degenerative process
• Rate of stretching exceeds tolerance  microtears  tendinosis

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

Van Hofwegen, C., et al. (2010) Clin Sports Med 29: 577-97
Histologic Stages of Microtrauma

• 1: Acute inflammatory response

• Sometimes resolves
• 2: Angiofibroblastic hyperplasia (increased concentration
of fibroblasts, vascular hyperplasia, disorganized collagen)
• Hypercellularity in both organized and unorganized fasion
• Most common stage of presentation for treatment
• 3: Structural failure of tendon with partial of complete
rupture
• 4: Features of stage 2 or 3 plus fibrosis, soft calcification
within collagen and hard osseous calcification

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

Pathophysiology: Microscopy

Normal Tendon

Kraushaar, BS, et al. (1999) J Bone Joint Surg. 81A(2): 1158-64

Pathophysiology: Microscopy

Tendinosis of ECRB with some normal tendon and some

disorganized tendon

Kraushaar, BS, et al. (1999) J Bone Joint Surg. 81A(2): 1158-64

Pathophysiology: Microscopy

Angiofibroblastic hyperplasia meets normal tendon

Kraushaar, BS, et al. (1999) J Bone Joint Surg. 81A(2): 1158-64

Pathophysiology: Other Theories

• Stress shielding certain sections of tendon leading to

structural weakening
• Shear forces leading to fibrocartilaginous composition of
ECRB attachment  weak attachment  tendinosis
• Long muscle contraction rendering tendon avascular 
free radicals
• Hyperthermic injury
• Protein kinase  apoptosis
• Altered gene expression and imbalance of matrix
metalloproteinases and growth factors

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

Pathophysiology: Neurologic Changes

• High variability of patient’s symptoms

• Increased concentration neurotransmitters
(glutamate), which sensitize pain response and direct
irritation by lactate
• Cascade of changes in PNS neurons, which leads to
sensitization of CNS
• May explain associated neck pain in 56% of patients
• Could be other overuse or altered biomechanics

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

 Diagnosis: History

• Pain at lateral epicondyle

• Radiates down extensor mass, occasionally proximally
• Exacerbated by contraction of extensor mass

• Insidious onset
• History of repetitive activity or overuse
• Inability to hold items

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

 Diagnosis: Physical Examination

• Tenderness ECRB origin or more diffuse centered about

lateral epicondyle
• Resisted extension
• Full elbow/wrist ROM
• Sensation normal
• Wrist Extensor weakness 2º pain
• Decreased grip strength
Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64
 Differential Diagnosis

• Cervical radiculopathy
• Elbow overuse compensating for frozen shoulder
• PIN entrapment
• Radiocapitellar degenerative changes or OCD
• Inflammation of anconeus
• Infection

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

 Diagnosis: Imaging

• Plain film: 22%-25%

calcification within soft
tissue
• Otherwise normal

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

 Diagnosis: Imaging

• MRI: Presence of degenerative tissue, tears in tendon

• More reproducible than US
• Intra-articular pathology
• Poor correlation with symptoms
• Generally not necessary
• Clinical diagnosis

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

 Treatment: Nonsurgical

• 80% + Improve within 1 year

• Relative rest
• Ice
• NSAIDs
• Steroid Injection: Short-term relief
• Counterforce Bracing (decrease tension on extensors)
and wrist splint
• PT/Rehab: range of motion, eccentric strengthening
Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64
 Treatment: Alternative

• Ultrasound/Extracorporeal shock waves (ECSW’s)

• Acupuncture/dry needling
• Platelet-rich plasma: growth factors

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

 Treatment: Surgical

• 4%-11% require surgery

• Extra-articular extensor tendon debridement
• Intra-articular: excise synovial fringe and portion of
orbicular ligament
• Tendon excision with origin reattachment
 Surgical: Open Debridement
• 8-10 cm incision over lateral epicondyle
• Subperiosteal detachment of common tendon
• Tendon debridement
• Decortication of epicondyle with rongeur
• Drill 2 v-shaped tunnels with horizontal mattress
reattachment
• Splint 7-10 days with progressive mobilization
Surgical: Open Limited Incision

Ahmed, Z., et al. (2013) Bone Joint J. 95-B: 1158-64

Van Hofwegen, C., et al. (2010) Clin Sports Med 29: 577-97
• 60 patients
• Randomized to injection with PRP, steroid or saline
• Neither PRP no steroid superior to saline
• Pain at 3 months
• Steroid decreased pain at 1 month, hypervascularity, and tendon
thickness
• 165 patients
• Randomized to 1. steroid injection, 2. placebo injection, 3.
steroid plus therapy, 4. placebo plus therapy
• Steroid injection worse than placebo
• Therapy did no change outcome

JAMA 2013
 PRP vers Placebo

• PRP versus placebo (AJSM 2013)

• No change 12 weeks
• PRP improved 24 weeks
• Pain
Medial Epicondylitis

Golfer’s Elbow
 Epidemiology

• Prevalence <1%
• 3.8 – 8.2% occupational settings
• 10-20% of epicondylitis patients

Nirav, HA, et al. (2015) JAAOS. 23.6: 348-55

 Anatomy

• Pronator Teres*
• Flexor Carpi Radialis
• Palmaris Longus
• Flexor Digitorum Superficialis
• Flexor Carpi Ulnaris
• Medial Collateral Ligament

Nirav, HA, et al. (2015) JAAOS. 23.6: 348-55

 Anatomy

Common flexor tendon

attaches to medial humeral
epicondyle anteriolrly and
attaches proximally to
anterior bundle of ulnar
collateral ligament, becomes
confluent with hyperplastic
section of anteromedial joint
capsule

Nirav, HA, et al. (2015) JAAOS. 23.6: 348-55

 Biomechanics

• Repetitive eccentric loading

• Wrist flexion, forearm pronation

• Valgus stress at elbow

Nirav, HA, et al. (2015) JAAOS. 23.6: 348-55

 Pathophysiology

• Peritendinous inflammation
• Angiofibroblastic hyperplasia
• Irreparable fibrosis or calcification
• Ulnar collateral ligament

Nirav, HA, et al. (2015) JAAOS. 23.6: 348-55

 History

• Sports: overhead throwing, golf, tennis, football,

weightlifting, bowling
• Occupational
• Forceful grip
• Loads >44lbs
• Constant vibratory force at elbow
• 84% have concomitant work-related disorder
• Carpal tunnel, lateral epicondylitis, rotator cuff tendinitis

Nirav, HA, et al. (2015) JAAOS. 23.6: 348-55

 Diagnosis
• Pain along medial elbow
• Radiation to proximal forearm
• Increased pain with resisted pronation and wrist flexion
• Tenderness 5-10mm distal and anterior to epicondyle
• Normal ROM
• Normal Sensation
• Resisted
weak
wrist flexion, forearm pronation, grip may be
• Valgus Stress  Ligamentous pain
• X-rays usually normal
• Concomitant ulnar neuritis
Nirav, HA, et al. (2015) JAAOS. 23.6: 348-55
 Imaging

MRI is standard of care when imaging needed

Nirav, HA, et al. (2015) JAAOS. 23.6: 348-55

 Treatment: Non-surgical

• Similar to Lateral Epicondylitis

• Rest
• 6-12 weeks off throwing

• NSAIDs
• Wrist flexor and forearm pronator stretching
• Night splinting
• Therapy: ROM, eccentric strengthening

Nirav, HA, et al. (2015) JAAOS. 23.6: 348-55

 Treatment: Surgical

Nirav, HA, et al. (2015) JAAOS. 23.6: 348-55

 Research

• No RCT in last 3 years