Lateral and medial epicondylitis

OVERVIEW

Chapter synopsis

Surgical intervention for medial and lateral epicondylitis should be performed only after a year of conservative, nonoperative management that has failed. Methods consist of anti-inflammatories, bracing, injections, and physical therapy. If a patient continues to have pain and loss of function after failing conservative management, open treatment of medial and lateral epicondylitis is appropriate. Debridement of the devitalized tendon to its bony insertion and creation of a bleeding vascular bed are imperative to successful outcomes.

Important points

Lateral Epicondylitis
- Identify the exact area of pathologic change by palpation preoperatively

Medial Epicondylitis
- Differentiate cubital tunnel syndrome from medial epicondylitis
- If a patient presents with signs and symptoms of cubital tunnel syndrome, the ulnar nerve should be addressed as well as the medial epicondylitis

Clinical/surgical pearls

Lateral Epicondylitis
- Completely release or excise diseased tissue
- Decorticate lateral epicondyle
- If the joint is exposed, repair the capsule to prevent fistula formation

Medial Epicondylitis
- Protect fibers of the medial collateral ligament during debridement
- Identify and protect the ulnar nerve
- Debride the degenerative tissue on the undersurface of the flexor-pronator mass

Clinical/surgical pitfalls

Lateral Epicondylitis
- Avoid excessive resection to minimize injury to the lateral collateral ligament

Medial Epicondylitis
- Avoid excessive resection to minimize injury to the medial collateral ligament

Lateral epicondylitis

Elbow pain is an extremely common problem, with lateral epicondylitis occurring in up to 4% of the general population. This condition can be exacerbated in athletic endeavors or activities involving heavy labor. Forceful activities, high force combined with high repetition, or awkward posture have been shown to increase the likelihood of developing lateral epicondylitis. Both in vivo and in vitro studies histologically illustrate an ongoing degenerative process followed by a reparative cycle. It is infrequent that a singular incident initiates a visit to the physician, rather patients experience a chronic sequence of injury, pain, healing, and resolution, followed by another inciting event. Prior investigations have found that up to 26% of patients with this diagnosis have chronic symptoms and up to 40% had prolonged minor discomfort. In a review, Wolf et al. found that “the vast majority of cases respond to conservative therapy, although it may take up to 18 months to attain full recovery.”

Numerous studies have reported 75% to 90% cure rates with a sufficient trial of nonoperative therapy. Initial treatment of lateral epicondylitis begins with activity modification. Patients are instructed to avoid lifting with the wrist extended and to lift objects with the elbow in flexion as close to the body as possible with the hand in supination or neutral position to avoid applying stresses to the wrist extensor muscles. Patients who actively participate in racket sports should consider rackets with better shock absorption and consult with their instructor on optimal mechanics to minimize persistent problems. Conservative treatment also includes physical therapy focusing initially on stretching and progressive light eccentric strengthening of the forearm wrist extensors. Orthotics, such as a nighttime wrist extension splinting, may be helpful for controlling pain.

In patients who fail to improve with the aforementioned nonoperative modalities, injections with either steroid or platelet-rich plasma (PRP) have been trialed as alternative treatments. Previous studies have shown that corticosteroid injections may improve short-term outcomes (<8 weeks) but have negative outcomes at 6 months and 1 year after the injection. However, the data regarding the benefits of PRP injections for lateral epicondylitis remain equivocal. In a recent meta-analysis, Chen et al. reported that PRP may reduce pain associated with lateral epicondylitis. However, in a systematic review of placebo-controlled clinical trials, the use of PRP was not shown to be superior compared to the placebo (saline injection) in relieving pain or improving functionality in patients with chronic lateral epicondylitis. Lack of PRP standardization contributes to the heterogeneity of evidence. Thus, further studies are necessary to determine the optimal preparation and dosage of PRP in order to maximize its potential therapeutic efficacy.

If nonoperative treatment for a period of 12 to 18 months fails, operative treatment is indicated for persistent pain and disability. Many techniques have been described for the release of the extensor carpi radialis brevis (ECRB), including open, percutaneous, and arthroscopic approaches. Recent research has shown no significant difference in clinical outcomes between open release and arthroscopic release, although a recent systematic review demonstrated that open treatment led to a greater percentage of patients being pain-free at final follow-up. The authors prefer open excision of the pathologic portion of the ECRB tendon, stimulation of bleeding bone, and repair of the defect, given the reproducibility of the postoperative results and relative straightforwardness of the procedure.

Preoperative considerations

History and physical examination

Evaluation of the athlete with lateral elbow pain begins with a thorough history. The history focuses on types of racket sports as well as any recent changes in equipment. A history of repetitive activity or overuse can often be elicited.

Athletes typically present with lateral elbow pain, frequently extending into the dorsal forearm and decreased grip strength. Symptoms are exacerbated by activities involving wrist extension against gravity. The key finding during physical examination is localized tenderness at the origin of the ECRB. Additionally, there is pain with wrist extension and long finger extension when the elbow is maintained in an extended position due to the fact that the ECRB origin is at the base of the long finger metacarpal.

Key physical findings

Pain at the lateral elbow
Exacerbation of pain with resisted wrist extension
Pain localized to the anterior portion of the lateral epicondyle, which is the ECRB origin
Decreased grip strength with the elbow fully extended compared with the elbow flexed
Pain occasionally radiates along dorsum of forearm

Radiography

Standard radiographs of elbow (anteroposterior, lateral, oblique)
- Evaluate for calcifications, osteochondral defect, exostosis, and degenerative changes of the radiocapitellar joint

Indications

The best candidate for operative intervention has had approximately 12 months of conservative treatment. This includes rest, nonsteroidal anti-inflammatory medication, bracing, and therapy. Other modalities such as extracorporeal shockwave therapy, botulinum toxin injection, corticosteroid injection, and PRP injection have been reported, but the evidence that these interventions are successful is limited. Other causes of lateral elbow pain, such as radiocapitellar arthritis should be considered. Results after surgical intervention reveal that 40% to 97% of patients who undergo open ECRB release or debridement have decreased pain and improved function.

Key indications

Cases that have failed conservative treatment for 12 months
Highly competitive athletes
Multiple cortisone injections (>2)
Lateral epicondyle bone exostosis or calcification of common extensor tendon

Surgical technique

Several surgical techniques have been described for the treatment of lateral epicondylitis. Surgical treatment ranges from resection of the epicondyle to percutaneous or open division of the common extensor origin to tendon lengthening techniques. The most common technique involves identification and excision of the abnormal ECRB origin with the creation of a vascular bone bed to promote healing.

The authors prefer open excision of the pathologic portion of the ECRB tendon, stimulation of bleeding bone, and repair of the defect for initial surgical management. Retrospective results have revealed high success rates, with 83% to 94% of patients having pain relief.

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