ARTICLE IN PRESS
Current Orthopaedics (2003) 17, 386 --389
c 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0268 - 0890(03)00111-7
ELBOW
Lateral epicondylitis.What is it really?
J.-P. Goguin and Fr. Rush
Orthopaedic Department of The Cliniques du Sud Luxembourg (C.S.L.), Rue des d!eport!es,137, Arlon 6700, Belgium
INTRODUCTION
Lateral epicondylitis (LE) is the most common lesion of
the elbow. Its prevalence is said to be from 1% to 3% and
seems more common in women.
Less than 50% of the patients with lateral elbow pain
are taken care of medically, this means that a large num-
ber of patients resolve spontaneously.
The peak prevalence of LE is in the fourth decade of
life, when it is four times commoner than in any other
decade and the lateral epicondyle is involved seven times
more often than is the medial epicondyle.1 This pathology
is reported more frequently in assembly line workers
having to repeate pro-supination movements, the
repeated motion is apparently more important than the
strength used to do the movement.
LE is usually defined as a tendinitis of the extensor car-
pi radialis brevis (ECRB) and occurs in connection with
acute or chronic strain. Extensor digitorum communis
(EDC) and extensor carpi radialis longus (ECRL) may also
be involved.
Two other theories exist: entrapment of the radial
nerve and intra-articular or osseous disorders. LE has
also been described in people being treated by Fluoro-
quinolone.2,3
Despite being first described in 1873, the etiology and
treatment are still uncertain.4 The termTennis elbow is
a too restricted title, LE can occur very commonly in pa-
tients who have never played tennis.Golf players can suf-
fer LE, but medial epicondylitis is more common in that
group.
DIAGNOSIS
The diagnosis is essentially a clinical one. The range of
movement (ROM) of both elbows and wrists should be
compared as well as the strength of the ECRB and EDC.
Tenderness on the lateral epicondyle and on the radial
head may be elicited for. ECRB and ECRL should be
tested by forced extension of the wrist with the shoulder
Correspondence to: J-PG.Tel.: 32- 63/23.11.11; fax: +32- 63/23.17.15
flexed at 601, elbow extended, forearm in pronation and
wrist at 301 flexion when pressure is exerted on the sec-
ond and third metacarpal bones, in a flexed and a ulnar
direction, (Tomsen test). The EDC is tested in the same
position but opposing active extension of the middle fin-
ger. For the chair test,5 the patient is asked to lift a chair
with the shoulder flexed at 601, elbow extended, forearm
pronated. A positive coffee-cup test may be found, in
which grasping or pinching with the wrist in extension
reproduces the pain at the point of maximum tender-
ness.6 The lidocaine injection test at the origin of the
ECRB should give pain relief. If done 4 finger breadths
distal to the lateral epicondyle this will cause a tempor-
ary posterior interosseous nerve (PIN) palsy and if the
pain is also relieved the PIN syndrome is suspected.
Other entities that can produce pain in this general vi-
cinity are osteochondritis dissecans of the capitellum,
lateral compartment arthrosis, varus instability, pos-
tero-lateral plica of the elbow, radial head arthritis, bone
tumour, carpal tunnel syndrome and perhaps most com-
monly, radial tunnel syndrome. Radial tunnel syndrome
(PIN syndrome) is a compressive neuropathy of the pos-
terior interosseous nerve caused by any of four different
anatomical structures in the radial tunnel, including a fi-
brous band near the anterior aspect of the radial head, a
vascular leash of the recurrent radial artery, the exten-
sor carpi radialis brevis tendon margin, or the supinator
margin at the arcade of Frohse.
Characteristically, the pain of radial tunnel syndrome
is located 3-- 4 cm distal to the lateral epicondyle and
may be reproduced with long finger extension against
resistance. The latter finding is inconsistent, as are ab-
normalities on EMG. True lateral epicondylitis and radial
tunnel syndrome may coexist in up to 5% of patients.
Other entities with elbow pain can be C6 --C7 cervical
root compression and shoulder periarthritis.
IMAGING
X-rays should be taken routinely in order to rule out
other conditions such as intra or extraarticular calcifica-
tions or elbow osteoarthritis.
 ARTICLE IN PRESS
LATERAL EPICONDYLITIS. WHAT IS IT REALLY?
Electromyography studies are usually normal, even for
patients who have radial tunnel syndrome.
Sonography of the common extensor origin can be
used to confirm lateral epicondylitis and provide informa-
tion about the severity of the disease, but that examina-
tion is examiner-dependant.7
Scintigraphy may confirm the diagnosis. MR findings in
epicondylitis are questionable.8 The specificity and the
sensitivity of these techniques are still not well defined.
ANATOMY
Gross anatomy and microscopic anatomy both confirm
the difficulty in isolating the origin of ECRB. It appears
that ECRB brevis and EDC are indistinguishable at the
bone tendon origin.9 For most authors the aetiology of
what is known as TE is a degeneration of the origin of
the ECRB.
Biopsies obtained on the ECRB show moth-eaten
fibres, fibrous necrosis and signs of muscle fibre regen-
eration over the whole of the muscle. Mechanical and
metabolic overload associated with pain could explain
the muscular performance diminution in cases of LE.
In chronic refractory lateral epicondylitis vascular
proliferation, fibroblastic invasion and focal hyaline
degeneration is observed, which is characteristic of a
degenerative process and not that of an inflammatory
process (few inflammatory cells such as macrophages or
polymorphonuclear leukocytes). This suggests that in
chronic lateral epicondylitis requiring surgery, a degen-
erative process is present, rather than an inflammatory
process. It could explain the lack of positive response to
rest and anti-inflammatory medication in chronic epi-
condylitis. Biopsies have only been done in operations
for chronic lesions, none have been done in patients
who did well with a non-surgical treatment. These pa-
tients could well have had a true tendinitis and patients
who need a surgical treatment a tendinosis.
Could we put this in parallel with Neers classification
of rotator cuff tendinopathy, with an initial reversible
inflammatory grade, then micro tears and finally tendon
rupture? Is it really in opposition with what Regan and Al
demonstrated: i.e. The initial lesion is not inflammatory
but a hypoxic degenerative process?10 This is in response
to the stress of overload and overuse. A poorly vascu-
larised area presents an incomplete healing response
where vascular and fibrous proliferation occurs. In nearly
all tendons (97%) that ruptured spontaneously, degen-
erative changes were found initially.11 The bodys immune
system perceives as subclinical, a cyclically applied cumu-
lative tendon injury because of the lack of involvement of
the haematopoietic system, therefore it bypasses the
normal inflammatory response. This leads to degenera-
tion in a poorly vascularised area with histology showing
cellular atrophy, diminished protein synthesis and cyst
387
formation. This degenerated area enlarges, with tendon
weakening and microruptures appearing. This then initi-
ates a classic inflammatory response with its healing
events. Nirschl described this as the angiofibroblastic
hyperplasia in the symptomatic area of the insertion of
the ECRB.19
TREATMENT
More than 40 different treatments are known.
Conservative
Conservative treatments are still the gold standard,
especially when the disease is recent, but do not seem
very effective when it has been there for many months
or even years.
There is no reason to treat a degenerative disease as if
it were an inflammatory disease. The problem is: when
has it become degenerative?
In the conservative treatments we find cryotherapy,
NSAIDs, Cyriax manipulations, physiotheraphy (includ-
ing ionophores and laser) plaster cast, acupuncture, me-
sotheraphy, local corticosteroid injections, orthoses,
and shock waves.
Local corticosteroid injection which is one of the
most popular treatments, seems to be superior to
Cyriax treatment, with a maximum of three injections
during a period of1 year.12
No definitive conclusions can be drawn concerning the
effectiveness of orthotic devices since there is a lack of
well-designed and well-conducted randomised clinical
trials.13 However, biomechanical and electromyographi-
cal analysis has shown an inhibition of the maximum
contraction of the wrist and fingers extensors by use of
counterforce braces on tennis players.14 Laser therapy
does not seem to be more efficient than a placebo.15
Shock wave therapy still needs scientific proof of its effi-
ciency and cannot be proposed as the only alternative to
surgery.16
Muscle stretching can reduce the incidence of new
painful occurrences, as well as promoting the proper
use of the arm in sports or work. Sometimes a change
of work may be required. The tennis player may use a
more suitable racket with less tension in the strings or
even use lower pressure balls, will equip himself with
shock absorbers and will play on slower surfaces such as
red pile.
Surgical
Surgical treatment is needed in the 5--10% of patients
who do not respond after many months to conservative
treatment. Many techniques are known with good
results for most procedures.
 ARTICLE IN PRESS

388 CURRENT ORTHOPAEDICS

An historical survey of operative treatments of tennis evidence for radial nerve entrapment in his patients.17
elbow is shown inTable 1. Beenisch and Wilhelm found evidence of a supinator
The different operations can be grouped as follows: syndrome in 53% of their patients.18
In the procedure described by Nirschl and Pettrone,
(1) simple percutaneus or open technique release of the
opening of the articular capsule is done routinely and al-
extensor tendons;
lows the exploration of the lateral elbow compart-
(2) suture of the linear and circular tears found in the
ment.19 They have noted intra-articular pathologies in
common tendon and capsule;
11% associated with lateral condyle pain.
(3) excision of granulated and degenerative tissues with
Usually the elbow is splinted for 1--3 weeks after
repair;
surgery but some put the arm in a sling for 1 week and
(4) excision, suture and fixation of the common exten-
recommend gentle rehabilitation for 6 weeks. Patients
sors aponeurosis;
can return to sports activities 4 -- 6 months after the op-
(5) excision, decortication, drilling, arthrotomy, suture
eration. Physical therapy is sometimes prescribed if the
and fixation to the common extensor aponeurosis;
patient has a lack of extension.
(6) PIN neurolysis possibly associated with one of the
Most studies show a success rate of over 80% and
procedures described above;
therefore, techniques with low morbidity should be se-
(7) arthroscopy with degenerative tissue excision and
lected. Therefore the simple extensor lateral release
partial release of extensor tendons;
seems to be the chosen procedure. It can be done under
(8) denervation of the radiohumeral joint associated
local anesthesia, knowing that radial tunnel syndrome
possibly associated with one of the procedures
may exist and that intra-articular problems must be
described above.
excluded.

Many of these treatments are appropriate for two if

not the three aetiologies (tendinitis of the ECRB, entrap-
ment of the radial nerve, intra-articular or osseous
disorders).
Two controversial studies exist about the PIN decom-
pression surgery, Van Rossum17 found no clinical or EMG
FAILURE
The first cause of failure is incorrect diagnosis.
Elbow instability can occur when the collateral
ligament has been damaged. The muscles on the lateral

Table 1
Cauterisation of the Runge 1873
tender area
Excision of the Osgood 1922
radiohumeral bursa
Fasciotomy of the Fisher 1923
forearm extensors
Division of the Hohmann 1926
extensor origin
Excision of the Trethowan 1929
synovial fringe
Exploration of the Hughes 1950
subtendinous space
Resection of the Boxworth 1955
annular ligament
Removal of calcium Van Demark 1956
deposits
Denervation of the Kaplan 1959
radiohumeral joint
Lengthening of the Garden 1961
ECRB tendon
Excision of scar Goldie 1964
tissue in the
subtendinous space
Release of the radial Roles 1972
nerve
TABLEAU.Verhaar Jan; Surgical techniques in orthopaedics and traumatology.Edition scientifique et M!edicale Elsevier. 55-230 -C-10.
 ARTICLE IN PRESS
LATERAL EPICONDYLITIS. WHAT IS IT REALLY?
condyle must be released anteriorly, not going beyond
the thick aponeurotic band.
Workers who have a compensation claim, have a lower
success rate.
Wound healing problems, haematoma, infection,
synovial fistula, restriction of function of the elbow joint
are all quite low.
CONCLUSION
It is rather odd that:
* this disease known as a tendinitis may not be one,
* the common name of tennis elbow is more than
often not correct,
* the anatomy cannot make the distinction between
the different tendons attached to the lateral condyle,
but surgical techniques do !,
* there is no consensus on the treatment, although the
initial description of this application goes back to1873,
* there are more than 40 ways of treating it, all or
nearly all of them really effective according to their
authors.
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