Shoulder and Elbow cases lateral epicondylitis

A 45-year-old, right-hand-dominant, male plumber presents with elbow pain of insidious onset. He denies any injury or trauma. He has lateral elbow pain with repetitive movements of the wrist at work. Examination of the shoulder and wrist is normal. He has tenderness to palpation about the elbow at the lateral epicondyle. His symptoms are reproduced with resisted wrist extension. Radiographs are normal.

What is the structure primarily affected by this condition?

1. Lateral ulnar collateral ligament

2. Extensor carpi radialis brevis

3. Extensor carpi radialis longus

4. Extensor digitorum communis

5. Extensor carpi ulnaris

 

Discussion

The correct answer is (B). This patient has lateral epicondylitis or tennis elbow, the most common cause for elbow pain presenting to an orthopaedic surgeon’s office. The condition most frequently develops during the fourth or fifth decade of life. The prevalence in the general population is 1% to 3%, and it is more commonly encountered in strenuous labor occupations. It affects males and females equally and presents more frequently in the dominant upper extremity. It is a very common ailment in tennis players, with up to 50% developing this condition at some point during life. The most commonly cited location of pathology is the proximal extensor carpi radialis brevis origin, although Nirschl and colleagues have reported 35% to 50% involvement of the extensor digitorum communis as well. Radiographs are typically normal.

What is the most commonly encountered histology within the affected tendon upon surgical treatment?

1. Acute inflammation

2. Calcium hydroxyapatite deposition

3. Angiofibroblastic tendinosis

4. Chondroblastic proliferation

5. Osteoblastic proliferation

 

Discussion

The correct answer is (C). The characteristic presentation of lateral epicondylitis

consists of repetitive microtearing of the tendon origin followed by repair attempts (Fig. 2–124). The typical histopathology of the involved tendon shows angiofibroblastic tendinosis with neovascularization, disordered collagen deposition and mucoid degeneration. Notably, acute inflammation is usually not encountered. Calcium hydroxyapatite deposition is seen with calcific tendonitis, not lateral epicondylitis. Chondroblastic and osteoblastic proliferation are also not characteristic for this disorder.

 

 

 

Figure 2–124 Figure showing focal hyaline degeneration and vascular proliferation in the proximal extensor carpi radialis brevis. (Regan W, Wold LE, Coonrad R, Morrey BF. Microscopic histopathology of chronic refractory lateral epicondylitis. Am J Sports Med. 1992;20(6):746–749.)

 

The patient has had symptoms for four weeks with no significant treatment to date. What is the most appropriate initial treatment?

1. MRI of the elbow

2. Splint immobilization of the elbow

3. Corticosteroid injection

4. Anti-inflammatory medication and physical therapy exercises

5. Arthroscopic or open tendon debridement

 

Discussion

The correct answer is (D). The patient has had symptoms of relatively short duration and has had no significant treatment to date. Rest, anti-inflammatory pain medication, and physical therapy are simple measures used to alleviate pain and promote natural tendon healing. Recent attention has focused in particular on eccentric strengthening of forearm muscles in order to induce hypertrophy of the muscle–tendon unit and reduce tension on the tendon itself. While MRI, injections,

or surgery might be indicated for recalcitrant disease, they are not used as a first line treatment. A variety of orthotic devices have been prescribed for lateral epicondylitis including forearm bands and cock-up wrist splints, with the goal being to reduce tension on the common extensor origin. While conflicting data exists on these devices, rigid immobilization of the elbow is not generally advocated.

Which of the following is a favorable prognostic indicator for success of nonoperative treatment in lateral epicondylitis?

1. Dominant arm involved

2. Manual laborer

3. Poor coping mechanisms

4. High baseline pain level

5. Short duration of symptoms at presentation

 

Discussion

The correct answer is (E). Previous literature shows that most patients with lateral epicondylitis improve with conservative management. Approximately 80% of patients report symptomatic improvement at 1 year, and only 4% to 11% of patients seeking medical attention for this condition require eventual surgery. Negative prognostic indicators for successful conservative treatment include: involvement of dominant arm, manual laborer, high baseline pain level, extended duration of symptoms, and poor coping mechanisms.

The patient returns after 6 weeks of physical therapy exercises and anti-inflammatory medications with continued pain and weakness of grip strength. In counseling him on the risks and benefits of injections for lateral epicondylitis, which of the following statements is correct?

1. Botulinum toxin injection has been shown to reduce pain and improve strength at long-term follow-up

2. Glucocorticoid, botulinum toxin, and blood product injection have all consistently been shown to be favorable to placebo in terms of pain relief and improved function

3. Injections are relatively safe second-line treatments with unproven long-term benefit

4. Injections are a risk-free treatment option for patients wishing to avoid surgical intervention

Discussion

The correct answer is (C). The literature varies widely on the efficacy of various injection therapies. Glucocorticoids have been in use for the longest period of time historically. Studies have shown initial pain relief (<6 weeks), followed by diminished benefit at long-term follow-up. Botulinum toxin injections have been shown to reduce pain but also exhibit weakness of finger and wrist extension strength. Finally, the data on platelet-rich plasma and autologous whole blood is mixed in comparing these injections to saline or local anesthetic. Large-scale systematic reviews and meta-analyses generally agree that the safety profile of these injections is reasonable for a second-line treatment option prior to surgery. However, injections are not risk free and can lead to infection, skin depigmentation, fat atrophy, and extensor tendon rupture.

 

Objectives: Did you learn...?

 

 

 

Understand the anatomy and pathology of lateral epicondylitis? Review conservative treatment strategies for lateral epicondylitis? Counsel patients on the efficacy of various injection therapies?