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Prof. Dr. Khalid Idris
Professor of Orthopedic Surgery,
Faculty of Medicine, Zagazig
University EGYPT
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Tennis elbow refers to a syndrome of pain
centered over the common origin of the
extensor muscles of the fingers and wrist at
the lateral epicondyle.
It affects 1% to 3% of adults each year.
It was first reported in the literature in 1873 by
Runge .
It occurs more commonly in non-athletes than
athletes and has a peak incidence in the fifth
decade.
It may be caused by repeated microtrauma to
the origin of extensor carpi radialis brevis
(ECRB) but the precise etiology is still unclear.
Collateral ligamentous complex ,joint capsule
and synovitis (with or without plica) also have
been implicated.
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The etiology of pain generation in tennis
elbow is multifactorial.
It is likely that both intra- and extra-articular
structures produce symptoms and that the
contribution of each varies between patients.
Regan et al in 1992
demonstrated that the initial
lesion of ECRB is a hypoxic
degenerative process (rather
than inflammatory) that can
be a normal part of aging or
the response to stress of
overload and overuse.
An incomplete healing response
characterized by vascular and
fibrous proliferation occurs in
the area of poor vascularity.
This may well represent the ‘‘angiofibroblastic
hyperplasia’’ coined by Nirschl (1994) to
describe the pathological invasion of blood
vessels, fibroblasts, and lymphatics into the
symptomatic area of the extensor carpi
radialis brevis.
As the degenerated areas enlarge, the tendon
weakens and eventually ruptures
(microrupture), which initiates the classic
inflammatory response and healing cascade,
explaining spontaneous recovery in some
cases.
Type I lesions appeared arthroscopically with
intact capsules;
Type II were linear tears at the undersurface of
the capsule; and
Type III were complete tears of the capsule with
partial or complete avulsions of the ECRB
tendon (Dlabach and Baker, 2001).
**Localized discomfort to the origin of ECRB
**Tenderness over the lateral epicondyle
approximately 5 mm distal and anterior
to its midpoint.
**Pain usually is exacerbated by resisted
wrist dorsiflexion and forearm
supination,
**pain when grasping objects.
Plain roentgenograms usually are negative;
Occasionally calcific tendinitis may be
present.
MRI demonstrates tendon thickening with
increased T1 and T2 signals but generally is
not indicated.
##Osteochondritis dissecans of the capitellum
##Lateral compartment arthrosis,
##Varus instability,
and perhaps most commonly,
## Radial tunnel syndrome.
The pain of radial tunnel syndrome is
located 3 to 4 cm distal to the lateral
epicondyle and may be reproduced with
long finger extension against resistance.
The latter finding is inconsistent, as are
abnormalities on EMG.
True tennis elbow and radial tunnel
syndrome may coexist in up to 5% of
patients.
Rest, ice, oral and topical NSAIDS,
Steroid injections (not through the tendon!!).
Physical therapy such as ultrasound,
iontophoresis, electrical stimulation,
manipulation, soft tissue mobilization,
friction massage, stretching and
strengthening (especially eccenteric)
exercises.
 Proximal
forearm band .
 Cock-up wrist splint.
As an adjunct to local injection an attempt to
"complete the lesion" by forcibly flexing the
wrist after local anesthetic injection to initiate
the inflammatory cascade and induce healing
can be done.
Preliminary data from studies reporting newer
treatment methods such as low-level laser
and extracorporeal shockwave therapy are
promising, but further investigation is
necessary.
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Botulinum toxin, a presynaptic acetylcholine
blocker, has recently
been proposed as a treatment.
The reported mechanism is partial paralysis
of the extensor apparatus, which allows the
tendinous origin to heal in a less tensioned
environment.
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Noncoherent light, which is thought to
act via improving local blood supply,
Topical nitric oxide, iontophoretic
dexamethasone, and autologous blood
injection.
The vast majority of cases usually resolve with
conservative treatment. Those who fail to
respond may require surgery. Most studies
reported that 5– 10% of patients require
surgery.
Operative treatment is considered if prolonged
(6 to 12 months) nonoperative treatment is
ineffective.
Surgery is effective in 90% of properly selected
patients.
The first and most frequently used procedure
is a release of the common origin of the
extensors by division of the origin at the
lateral epicondyle either with an open
procedure or with a percutaneous technique
or lengthening of ECRB to decrease the
tensile forces on the extensor origin .
In the second type of procedure, the area of
the rupture of the extensor origin is excised,
creating a longitudinal defect in the origin,
which is repaired by suturing.
The third procedure, which was used by
Kaplan {1959} and by Wilhelm and Gieseler
{1962}, is operative denervation of the lateral
epicondyle. This is accomplished by severing
of the sensory fibers of the radial nerve that
innervate the lateral epicondyle.
The fourth group comprises several types of
intra-articular procedures including partial or
complete division of the annular ligament,
synovectomy, with or without debridement of
an osteoarthrotic radial head and these
procedures are combined with release of the
extensor origin.
The fifth type of operative treatment is a
release of the posterior interosseous nerve
from the radial tunnel, combined with
division of the fibrous edge of the superficial
portion of the supinator muscle (the arcade of
Frohse).
The sixth and most recent group comprises
arthroscopic procedures. Arthroscopy allows
intraarticular examination for other pathology
and permits a shorter postoperative
rehabilitation period and an earlier return to
work.
Surgical technique for correction of tennis elbow. A, Skin
incision. B, Origins of extensor carpi radialis longus and extensor
digitorum communis are identified. C, Osteotome decortication. (Redrawn from
Nirschl RP, Pettrone F: J Bone Joint Surg 61-A:832, 1979.)
Surgery for tennis elbow (Boyd and McLeod). A, Approach and incision. B, Reflection
of conjoined extensor tendon, excision of proximal 2 mm of annular ligament,
and removal of strip of capsule containing synovial fold from radiohumeral joint.
(Redrawn from Boyd HB, McLeod AC Jr: J Bone Joint Surg 55-A:1183, 1973.)
Anconeus muscle transfer. A,B, Entire common extensor origin is excised C, Anconeus muscle rotated
into defect (Redrawn from Almquist EE, Necking L, Bach AW: J Hand Surg 23A:723, 1998).
Arthroscopic view of a capsular tear via a medial portal in a right elbow.
A, Initial view of the lateral capsule with a linear tear
(Baker type 2). B, Normal extensor carpi radialis brevis (ECRB)
tendon following débridement of degenerative deep tissue.
C, Final view of the ECRB and extensor carpi radialis longus
(ECRL), with a clear distinction marking the proximal extent of
Only a few patients
with tennis elbow (1%
to 2%) cannot be
treated successfully
by either
nonoperative or
operative methods.
Morrey divided these
failures into two
groups based on
postoperative
symptoms.
Patients in the
first group had
symptoms similar
to those
experienced before
surgery, whereas
patients in the
second group
reported a different
symptom complex
after surgery.
Treatment failed in patients in the first group
because of inadequate release or incorrect
initial diagnosis, most often related to radial
tunnel syndrome.
In the second group, treatment failed because
of capsular or ligamentous insufficiency that
resulted in either a capsular fistula or
posterolateral instability.
Elbow instability can occur in patients in either
group (especially those with traumatic origins
for their lateral elbow pain) after overzealous
release that includes the anterior band of the
lateral collateral ligament.
A careful physical examination to identify
instability, pain in the region of the
epicondyle, or radial tunnel syndrome is
essential.
The evaluation should be supplemented with
arthrograms to detect synovial fistula and
capsular insufficiency or with arthroscopy and
examination under anesthesia to detect
instability or arthrosis.