Elbow tendinopathy: tennis elbow

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Etiologic factors

The common denominator of all tendinosis (eg, rotator cuff, patellar tendon, Achilles tendon, and plantar fascia) is overuse, with focus on the elbow in this article. The characteristics most likely to result in elbow tendon overuse are:

  • Over 35 years of age

  • High activity level (sports or occupational)

    • 3 times per week or greater

    • 30 minutes or greater per session

  • Demanding activity technique

The characteristic patient age for onset of classical uncomplicated tennis elbow is between 35 and 50 years

Multiple sites of tendon pain (mesenchymal syndrome)

In certain patients, the existence of multiple painful tendon sites can be explained by mechanical overuse. Some patients merely compensate by switching the activity from one extremity to the other; in others, the activity is bilateral. For example, in golf, the leading elbow is susceptible to lateral tennis elbow and the trailing arm is subject to medial tennis elbow. In these situations, overuse trauma is probably the key etiologic factor. We have observed, however, that the etiologic factors

Pathology (angiofibroblastic tendinosis)

The term “tendinosis” is used rather than tendinitis because it more accurately defines the histopathological presentation of the degenerative process. The term “tendinitis” has been used to describe the theoretical chronic inflammatory changes in the overused tendon. Histologic examination of excised pathological tendons has consistently failed to reveal the presence of inflammatory cells, however. If chronic inflammatory cells are evident in the tendon, they are those of traumatic repair, and

Diagnostic evaluation

The keys to diagnosis of elbow tendinosis are initial signs and symptoms of activity-related pain followed by rest pain once pathologic change becomes more extensive. Palpable tenderness in the typical anatomic areas, whether lateral, medial, or posterior, is present in the early stages. Pain with provocative manual stress testing in the usual pathologic area confirms the site of the lesion. Functional strength losses are common, and can be measured with objective dynamometer testing.

Treatment concepts

The basic concepts of the treatment of elbow tendinosis are designed to work with and enhance the natural biologic healing response. The healing response after injury follows a natural sequence: (1) inflammatory exudation; (2) cellular invasion; (3) collagen and ground substance production; and (4) maturation and strengthening.

To achieve these concepts, implementation of treatment takes the following form: (1) relief of pain with control of exudation or hemorrhage; (2) promotion of specific

Principles of tendon surgery

The principles of surgery are: (1) identification of the pathology which is symptom producing, (2) resection of the pathologic symptom-causing tissue, (3) protection of normal tissues and their attachments, and (4) quality postoperative rehabilitation.

Lateral tennis elbow surgery

Historically, surgical release or a slide of the extensor aponeurosis, often combined with release of the orbicular ligament has been advocated [7]. The concept of release has never been adequately articulated by prior authors but our presumption has been that the force generators are weakened, thereby decreasing stress to the sensitized tissues. With release of the extensor aponeurosis and the orbicular ligament, the origin of the ECRB is also undoubtedly released or altered. Garden advocated

Medial tennis elbow surgery (Nirschl mini-open technique)

The surgical concepts for medial tennis elbow are the same as those for the lateral (Fig. 6). In addition, ulnar nerve dysfunction may be an associated problem, and surgical decompression may be required. Medial collateral ligament attrition or rupture has also been observed on occasion, and surgical repair or reconstruction is indicated in these circumstances.

In the typical medial elbow tendinosis, the majority of pathologic changes are present in the origin of the pronator teres, palmaris

Failed medial elbow surgery

As with failed lateral elbow surgery, the most common reason for unsuccessful medial elbow surgery is failure to identify and resect the offending tendinosis tissue. This usually occurs when an ill-advised release technique or epicondylectomy has been used. Release of the common flexor origin also invites iatrogenic instability. With the technique of elliptical excision of pathologic tissue these issues of failure are eliminated. An additional factor that leads to a lack of surgical success is

Triceps tendinosis—surgical considerations

Isolated triceps tendinosis is uncommon. The histopathology is the same as with lateral and medial tendinosis. A small longitudinal posterior incision centered over the palpably sensitive area with elliptical excision is the recommended approach. If a spur at the tip of the olecranon is present, this should be removed as well. More commonly, especially in the throwing athlete, triceps tendinosis is associated with olecranon fossa synovitis, chondromalacia, ostephytes, or loose bodies.

Postoperative management

Postoperative management is similar for lateral, medial, and posterior tennis elbow. The surgery is with few exceptions done on an outpatient basis. A light adaptable elbow immobilizer holding the elbow at 90° with the forearm in neutral position wrist and hand free is used for 48 hours (Fig. 7). Wrist and hand movement is encouraged in the immediate postoperative period. Active motion exercises are started at 48 hours. The immobilizer is used intermittently for protection for another 3 to 5

Surgical results

The senior author's experience with the described surgical techniques now exceeds 1300 cases (1000 lateral and 300 medial). Of the lateral group, 85% experience complete pain relief and full-strength return. An additional 12% experience significant pain relief and strength return but not total normalcy. Of the 12% group, the relief usually allows return to vigorous sports. The remaining 3% (including workman's compensation patients) have experienced no pain relief or strength improvements. Of

Summary

The pathoanatomy of overuse tendinopathy is noninflammatory angiofibroblastic tendinosis. The areas of elbow abnormality are specific, including the ECRB-EDC complex laterally, the pronator teres, flexor carpi radialis medially, and triceps posteriorly. The goals of nonoperative treatment are to revitalize the unhealthy pain-producing tendinosis tissue. The key to nonoperative treatment is rehabilitative resistance exercise with progression of the exercise program. If rehabilitation fails, the

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