Saturday, August 19, 2006

Tennis / Badminton Elbow

Lateral epicondylitis, or tennis elbow, is a commonly encountered problem in orthopedic practice.


Lateral epicondylitis is an overuse injury involving the extensor/supinator muscles that originate on the lateral epicondylar region of the distal humerus.

Lateral epicondylitis has been demonstrated to occur in up to 50% of tennis players. However, this condition is not limited to tennis players and has been reported to be the result of overuse from many activities. Lateral epicondylitis is extremely common in today's active society.


Any activity involving wrist extension and/or supination can be associated with overuse of the muscles originating at the lateral epicondyle. Tennis has been the activity most commonly associated with the disorder. The risk of overuse injury is increased 2-3 times in players with more than 2 hours of play per week and 2-4 times in players older than 40 years. Several risk factors have been identified, including improper technique, size of racquet handle, and racquet weight.


Many proposed etiologies for this condition have involved inflammatory processes of the radial humeral bursa, synovium, periosteum, and the annular ligament. However, in 1979, Nirschl and Pettrone attributed the cause to microscopic tearing with formation of reparative tissue (ie, angiofibroblastic hyperplasia) in the origin of the extensor carpi radialis brevis (ECRB) muscle. This microtearing and repair response can lead to macroscopic tearing and structural failure of the origin of the ECRB muscle.

Concomitant intra-articular lesions (eg, loose bodies, synovitis, ulnohumeral osteophytes, chondral lesions) have been visualized during elbow arthroscopy in patients with lateral epicondylitis. However, while concomitant intra-articular pathology has been noted, this process is currently considered an extra-articular process.


Patients present complaining of lateral elbow and forearm pain exacerbated by use. The typical patient is a man or woman aged 35-55 years who either is a recreational athlete or one who engages in rigorous daily activities.

Upon examination, the patient has a point of maximal tenderness just distal (5-10 mm) to the lateral epicondyle in the area of the ECRB muscle. Wrist extension or supination (but not flexion or pronation) against resistance with the elbow extended should provoke the patient's symptoms. Another helpful test is the chair raise test. The patient stands behind their chair and attempts to raise it by putting their hands on the top of the chair back and lifting. In patients with lateral epicondylitis, pain results over the lateral elbow.

Medical therapy:

Nonsurgical treatment is the mainstay of care for patients with lateral epicondylitis. The goal of initial treatment is cessation of the offending activity. Rest, use of a counterforce brace, and nonsteroidal anti-inflammatory drugs (NSAIDs) often provide relief of symptoms. Often, wrist splinting and/or corticosteroid injections are necessary.

When the patient is free of pain through a full range of motion, begin strengthening therapy in a very slow and progressive way. When the patient regains strength and nears resumption of activity, place the emphasis on preventing future irritation (eg, correct technique or address equipment concerns in athletes who participate in racquet sports, modify jobs or activities in patients who are not athletes).

Despite some excitement about the use of extracorporeal shock wave therapy, a recent prospective, randomized, blinded, multicenter European trial showed no benefit of this intervention over placebo.

Surgical therapy:

A myriad of surgical procedures has been described for the treatment of lateral epicondylitis. However, most surgical procedures involve debridement of the diseased tissue of the ECRB muscle with decortication of the lateral epicondyle. This procedure has been performed through open, percutaneous, endoscopic, and arthroscopic approaches. While the classic open approach provides excellent reproducible results, the mentioned minimally invasive approaches are reported to allow earlier rehabilitation and resumption of activities.


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