Tennis Elbow- Lateral EpicondylitisCAITLIN GARDINER

Anatomy

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-The Common Extensor Origin is a tendinous insertion onto the lateral epicondyle of the humerous of

-Extensor Digiti Minimi-Extensor Carpi Radialis

Brevis-Extensor Carpi Ulnaris -Extensor Digitorum

Communis (1)

Physiology

Repetitive traction on the osteotendinous attachment of the common extensor tendon

Results in microtrauma to the tendon causing progressive degeneration and/or partial tears or damage to the bony insertion (enthesopathy)

Angiofibroblastic infiltration occurs due to migration of vascular granulation

Crystal deposition may occur

Early abnormalities are confined to superficial fibres

Most commonly the extensor carpi radialis brevis deep fibres are involved (1,2)

Presentation

Gradual onset of symptom

Pain at the location of the lateral epicondyle

Generally a sharp pain exacerbated with gripping activities

Pain in the morning and at times when the wrist is held in flexion

Inability to grip objects.

Reduced strength with resisted grip, supination and extension of the wrist (3)

Two simple clinical tests include Chair test: Patient is asked to lift themselves out of a chair with a pronated hand.

Pain at lateral epicondyle may indicates Tennis elbow

Coffee cup test: Patient is asked to hold a cup in their hand. Pain at the lateral elbow may indicates Tennis Elbow (4)

Common Causes

Can occur at any age, but typically between the ages of 40-50

Any activity involving repetitive use of extensor muscle of the forearm

Particularly if gripping with the thumb and first two finger

Can occur in tennis players, due to extension during back stroke

Commonly occurs in occupations with highly repetitive hand tasks (4)

Symptoms

Tendinopathy: Localised pain over the CET during or after repetitive muscle activation, radiating down the lateral aspect of the elbow

Enthesopathy: Pain is confined to insertional area

Pain is exacerbated with radial deviation and pronation with the elbow extended particularly when performed with resistance (1,4)

Ultrasound Findings

Pre-insertional hypoechoic swelling

Focal or diffuse areas of decreased reflectivity

Loss of fibrillary pattern related to tendinosis

Fluid adjacent to the tendon

Ill-defined margins of the tendon

Hypervascularity in high-grade tendinosis

Spurring and cortical irregularities (1, 4, 5)

Case Presentation

Presentation: A 56 year-old male presents with severe pain of his left lateral elbow for the past three weeks. He recently began a new job where he unpacked large boxes. He finds opening the boxes, which requires significant force, increasingly painful.

Ultrasound Technique:

Use a high-frequency linear probe and/or a hockey-stick probe with the appropriate pre-set. When using colour Doppler, ensure that gain is adjusted just prior to aliasing. Be prepared to alter the patient arm to view maximum hyperaemia and apply very minimal pressure.

The patient is positioned across from the sonographer with his arms extended onto the table, with hands in a ‘praying’ position. This allows the CEO to be imaged in a lateral coronal position and has the contralateral arm in the same position for comparison (2)

Ultrasound Findings

-Thickening of the tendon-Loss of reflection of the deep fibres-Distortion of fibrillary pattern-No enthesopathy noted

-Marked hyperaemia of the deep fibres

Partial tear vs. Tendinosis

Partial tears: The CEO may appear thinned

Longitudinal splits oriented from the distal bony insertion

Anechoic cleavage planes with no fibres visible

Tendinosis Diffusely or focal (usually deep) hypoechoic

Usually has some associated hyperaemia (1)

Alternative Diagnosis

Posterior Interosseous nerve entrapment/Radial Tunnel Syndrome

Radial Humeral bursitis

Lateral Collateral Ligament injury

Dysfunction of the cervical spine at levels C5-6 or C6-7 referring as elbow pain

Osteochondral radiocapitellar lesion (1, 3)

Management

Conservative treatment Rest

Anti-inflammatories

Local steroid injections

Autologous blood injections

Saline Injections (6, 7)

Surgical intervention Removal of degenerative tissue, resection of CET, release of annular

ligament (1)

Alternative Imaging Modalities

Usually clinical diagnosis is suffice

Imaging reserved for complicated cases, assisting injections, progression of damage

MRI shows sensitivity of MRI between 90-100% for Tennis Elbow. Also able to assess intra-articular processes, radial collateral ligament and to grade the tear of the extensor origin

Ultrasound shows high sensitivity but low specificity in detection of lateral epicondylitis in symptomatic cases (1) Sensitivity ranging from 72-88%

Specificity ranging from 36-48.5% (3)

References

1. Bianchi S and Martinoli C, 2007. Ultrasound of the Musculoskeletal System. Springer, New York.

2. McNally EG, 2005. Practical Musculoskeletal Ultrasound. Elsevier, London.

3. Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: Pathogenesis, imaging, and treatment. Radiographics. 2010;30(1):167-184

4. Levin D, Nazarian LN, Miller TT, et al. Lateral epicondylitis of the elbow: US findings. Radiology. 2005;237(1):230-234

5. Lin CL, Lee JS, Su WR et al, 2011. Clinical and Ultrasonographic Results of Ultrasonographically Guided Percutaneous Radiofrequency Lesioning in the Treatment of Recalcitrant Lateral Epicondylitis. Am J Sports Med; Aug 11.

6. Wolfe JM, Oxer K, Scott F et al, 2011. Comparison of Autologous Blood, corticosteroid, and Saline Injections in the Treatment of Lateral EpicondylitisL a Prospective, Radomized, Controlled Multicenter Study. J Hand Surg Am; 36(8):1269-72.

7. Altan L and Kanat E, 2008. Conservative Treatment of Lateral Epicondylitis: Comparison of Two Different Orthotic Devices. Clin Rheymatol; 27(8): 1015-1019.