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Tennis elbow is a common painful condition that affects the lateral epicondyle, with tendinopathy of the common extensor origin (the combined insertion of many of the extensor tendons onto the lateral epicondyle of the distal humerus), where degeneration occurs, particularly involving the entheses (the specialised element of tendon where it inserts into the bone), in particular the extensor carpi radialis brevis tendon.
The reported prevalence ranges from 1-10%, although is generally expected to be in the order of 3%, with individuals in their 30s, 40s and 50s predominantly being affected.
Although referred to as tennis elbow, lateral epicondylitis can be brought on by many activities, usually developing progressively without a clear “one-off” injury, although patients can develop symptoms after an episode of trauma, such as forced gripping and pulling. Pain from tennis elbow interferes with many activities of daily living, including in particular tasks that involve dorsiflexion of the wrist (given the predominant involvement of the enthesis of extensor carpi radialis brevis), so affecting activities that involve firm grips (which necessarily involves dorsiflexion of the wrist to maximise tension in the flexor tendons), and holding the wrist in a dorsiflexed position for prolonged periods (such as for typing).
For many patients, tennis elbow will run a course to resolution, although this may be slow. Improvement to resolution over 6-24 months is the pattern in most with 90% of cases resolving in the first year. Non-surgical interventions are important and useful and include activity modification (either avoiding activities that bring on pain, or finding ways of conducting these that are more comfortable, such as changing the grip used – using a hook grip with the fingers rather than a grasp to hold handles of things that are being carried; using a wrist splint to hold the wrist dorsiflexed rather than activating the muscles for tasks such as typing.
Surgical intervention to remove the degenerate tendon from the common extensor origin, encouraging healing of the enthesis of the tendon can be helpful, either with or without repair/reconstruction of the common extensor origin. The operation and recovery period (3-6 months for most patients) will produce good and lasting improvements in 80-95% of patients, but it is important to recognise that the operation is being undertaken for a condition that has a natural history to resolve in most patients. Given that most patients with tennis elbow will see their symptoms resolve within a year of onset, surgery is generally reserved for patients who have had symptoms which are not settling over at least a 6 month period despite appropriate and adequate non-surgical treatments.
Author: Chris Little FRCS (Tr & Orth)
Institution: The Nuffiled Orthopaedic centre, Oxford, UK.
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