Condition

Lateral Elbow Tendinopathy

Editors: Angelo R. Dacus MD; Zbigniew Fedorowicz PhD, MSc, DPH, BDS, LDSRCS; Alan Ehrlich MD, FAAFP

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Background Information

Description

  • PubMed33438935Instructional course lecturesInstr Course Lect2021010170551-562551Tendinopathy is an umbrella term encompassing degenerative or inflammatory alterations in nonruptured tendons, typically worsened by mechanical loading (Instr Course Lect 2021;70:551, J Orthop Sports Phys Ther 2015 Nov;45(11):833).
  • Lateral elbow tendinopathy (tennis elbow) is an overuse injury of the common extensor origin at the lateral epicondyle of the elbow, characterized by pain during wrist extension or forearm supination.
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  • The extensor carpi radialis brevis is most often affected.
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Also Called

  • Tennis elbow
  • Lateral epicondylitis
  • Lateral epicondylosis
  • Lateral epicondylalgia
  • Tendonitis of the common extensor origin
  • Tendonitis of the extensor carpi radialis brevis (ECRB) muscle
  • Radial epicondylitis
  • Extensor tendinosis at the elbow
  • Peritendinitis of the elbow
  • Rowing elbow

Definitions

  • Terminology for disorders affecting tendons:
    • Tendinopathy: an umbrella term encompassing degenerative or inflammatory alterations in nonruptured tendons, typically worsened by mechanical loading
    • PubMed22553479International journal of therapeutic massage & bodyworkInt J Ther Massage Bodywork201201015114-714Tendonitis/tendinitis: inflammation of the tendon caused by microtrauma to the musculotendinous unit due an acute overload with a tensile force that is too heavy and/or too sudden
    • Tendinosis: degeneration of tendon collagen without significant inflammation, resulting from chronic overuse where the tendon is not allowed to rest/heal
    • PubMed29078821Foot and ankle clinicsFoot Ankle Clin20171201224665-676665Tenosynovitis: inflammation of both the tendon and tendon sheath
    • References - Foot Ankle Clin 2017 Dec;22(4):665, Int J Ther Massage Bodywork 2012;5(1):14, Instr Course Lect 2021;70:551, J Orthop Sports Phys Ther 2015 Nov;45(11):833
  • An overuse tendon injury should be considered tendinopathy, not tendonitis.
    • Tendinopathy is clinical syndrome describing an overuse tendon injury characterized by pain, swelling, and/or functional limitation.
    • Tendinopathy could be tendinosis (absence of inflammation) or tendonitis (presence of inflammation).
    • Inflammation is not considered to be a part of pathology in most clinical cases of tendinopathy (anti-inflammatories may have no benefit), except in acute tendinopathy.
    • PubMed29078821Foot and ankle clinicsFoot Ankle Clin20171201224665-676665References - Foot Ankle Clin 2017 Dec;22(4):665, BMJ 2002 Mar 16;324(7338):626

Types

  • Lateral elbow tendinopathy can be classified as acute or chronic.
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    • The presence of symptoms for less than 3 months is classified as acute lateral elbow tendinopathy.
    • The presence of symptoms for more than 3 months is classified as chronic lateral elbow tendinopathy.

Epidemiology

Incidence/Prevalence

  • Lateral elbow tendinopathy is most common in adults between the ages of 35 and 54 years.
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  • Prevalence among adults is reported to be between 1%-3%.
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  • Among tennis players, lateral elbow tendinopathy is more common among those who play recreationally.
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  • STUDY SUMMARY
    annual incidence of lateral elbow tendinopathy decreased from 4.5 cases per 1,000 persons in 2000 to 2.4 cases per 1,000 persons in 2012 in Olmsted County, United States
    COHORT STUDY: Am J Sports Med 2015 May;43(5):1066

Risk Factors

  • Risk factors for lateral elbow tendinopathy include:
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    • Participation in sports or occupations requiring repetitive gripping, wrist extension, forearm supination, and/or radial deviation, especially if loads increase and/or rest periods decrease
    • New or sudden overuse of an upper extremity (taxing the common extensor tendon) in previously sedentary persons
    • Older age
    • Increased body mass index (BMI)
    • History of smoking
    • Oral corticosteroid use
    • Comorbidities, such as:
      • Rotator cuff pathology
      • De Quervain tenosynovitis
      • Carpal tunnel syndrome
  • STUDY SUMMARY
    female sex associated with increased risk of lateral elbow tendinopathy
    SYSTEMATIC REVIEW: Surgeon 2020 Apr;18(2):122

  • STUDY SUMMARY
    work-related exposure to repetitive bending or twisting of the wrist associated with increased risk of lateral elbow tendinopathy
    SYSTEMATIC REVIEW: Arthritis Care Res (Hoboken) 2016 Nov;68(11):1681

  • STUDY SUMMARY
    handling heavy loads and engaging in repetitive movements each associated with increased risk of lateral elbow tendinopathy
    SYSTEMATIC REVIEW: Rheumatology (Oxford) 2009 May;48(5):528

  • STUDY SUMMARY
    diabetes mellitus associated with increased risk of lateral elbow tendinopathy
    CROSS-SECTIONAL STUDY: Springerplus 2015;4:407

Associated Conditions

  • Intra-articular pathology may be associated with lateral elbow tendinopathy.
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Normal Anatomy and Function

  • The elbow is made up of 3 bones (the humerus, radius, and ulna). The lateral epicondyle is located at the lateral distal end of the humerus (Am Fam Physician 2014 Apr 15;89(8);649).
  • Articulations include:
    • The radioulnar (radius and radial notch of ulna) and radiohumeral (capitellum and radial head) joints, which allow forearm rotation through supination and pronation
    • The ulnohumeral joint (trochlea and ulna), which allows flexion and extension of the elbow
    • PubMed28095019AJR. American journal of roentgenologyAJR Am J Roentgenol201703012083W110-W120W110Reference - AJR Am J Roentgenol 2017 Mar;208(3):W110
  • The common extensor tendon is the origin for the active supinators and extensors of the forearm at the lateral epicondyle.
    • It includes 5 muscles:
      • Extensor carpi radialis longus
      • Extensor carpi radialis brevis (ECRB)
      • Extensor digitorum communis
      • Extensor digiti minimi
      • Extensor carpi ulnaris
    • The ECRB is the central wrist extensor.
      • It originates from the lateral epicondyle and from multiple deep structures, including the lateral collateral ligament, the annular ligament, and the intermuscular septum.
      • It inserts at the base of the third metacarpal.
    • Functions of the common extensor tendon include gripping, wrist extension, and supination.
    • PubMed23398951The American journal of medicineAm J Med201304011264357.e1-6357.e1References - Am Fam Physician 2014 Apr 15;89(8):649, Am J Med 2013 Apr;126(4):357.e1
  • The wrist and finger extensors originating from the lateral epicondyle are innervated by the radial nerve or its branch of the posterior interosseous nerve (Tech Hand Up Extrem Surg 2003 Dec;7(4):168).
Elbow anatomy

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Elbow anatomy

Anterior view of right elbow illustrating bony anatomy and articulations.

Common extensor tendon

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Common extensor tendon

Posterior view of right forearm illustrating muscles that make up the common extensor tendon.

Muscles involved in lateral elbow tendinopathy

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Muscles involved in lateral elbow tendinopathy

Posterior view of right arm illustrating the origin and insertion of the extensor carpi radialis brevis and extensor digitorum muscles.

Etiology and Pathogenesis

Causes

  • Lateral elbow tendinopathy is caused by repetitive microtrauma and overload of the common extensor tendon at the lateral epicondyle of the elbow, often due to repetitive wrist extension and forearm supination.
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Pathogenesis

  • PubMed33414454Nature reviews. Disease primersNat Rev Dis Primers202101077111Tendinopathy likely occurs due to a failed healing response; the pathogenesis behind this failed healing response varies, and it is likely a combination of several proposed hypotheses.
    • Mechanical theory (most common):
      • Mechanical theory is primarily based on the relationship between tendon cells and their direct mechanical environment.
      • An increase in mechanical demand through repetitive tensile compression or tensile loads or noxious trigger of tenocytes leads to inadequately repaired tendon and progressive cell death.
      • The end result is degenerative changes in the tendon.
    • Inflammation theory:
      • Inflammation theory is based on the role of molecular inflammation and the immune system in the development of tendinopathy, and it is characterized by complex immunological interactions.
      • An infiltration of innate and adaptive immune cells may cause a release of inflammatory cytokines and chemokines, alter tendon microstructure, and lead to chronic symptomatic disease.
    • Apoptosis theory:
      • Apoptosis theory associates high doses of repetitive load with oxidative stress, acquisition of a cartilage phenotype, and activation of metalloproteinases with the development of degenerative pathologies.
      • Tenocyte strain can produce stress-activated protein kinases which are capable of triggering tenocyte apoptosis.
      • Apoptosis may also be caused by oxidative stress, which results from reactive oxygen species and oxygen free radicals in degenerative tendon and leads to a progressive loss of intrinsic tendon cells.
      • An increase in apoptotic tenocytes may result in weakened tendon tissue and lead to tendinopathy or tendon rupture.
    • Vascular theory:
      • Tendinopathy commonly occurs in hypovascular areas of a tendon due to the inability to form a clot and initiate the appropriate inflammatory stage of healing.
      • Neovascularization often occurs as an attempt to establish a healing environment, resulting in capillary formation and abnormal thickening of the tendon walls which may cause symptoms of tendinopathy.
      • The increase in vascular growth in the tendon may also weaken tendon structure and potentially lead to rupture.
    • Neurogenic theory: The neurogenic theory proposes that neurogenic inflammation may interrupt the ability of tendon to adapt to mechanical overload.
    • The continuum model consists of 3 stages.
      • Reactive tendinopathy:
        • Reactive tendinopathy is a noninflammatory proliferative response in the cell and matrix that occurs following acute tensile or compressive overload.
        • It leads to short-term thickening of a portion of the tendon which reduces stress or allows for adaptation to compression.
      • Tendon disrepair:
        • Tendon disrepair is a process of attempted tendon healing involving greater extracellular matrix degeneration compared to reactive tendinopathy.
        • It is characterized by increased proteoglycan and collagen production resulting in a disorganized matrix.
        • Tendon disrepair may also involve neovascularization and neural ingrowth.
      • Degenerative tendinopathy:
        • Degenerative tendinopathy is an end stage characterized by areas of cell death due to apoptosis, trauma, or tenocyte exhaustion.
        • Areas of acellularity form as well as large, unorganized areas of matrix consisting of vessels, byproducts of matrix breakdown, and low amounts of collagen.
        • There is minimal ability for reversible change by this stage.
    • References - Nat Rev Dis Primers 2021 Jan 7;7(1):1, Ann N Y Acad Sci 2021 Apr;1490(1):29, Fac Rev 2020;9:16, Foot Ankle Clin 2017 Dec;22(4):665, Br J Sports Med 2009 Jun;43(6):409, J Bone Joint Surg Am 2005 Jan;87(1):187
  • In lateral elbow tendinopathy, the persistent cycle of repetitive or excessive tendon loading leads to tissue microtrauma and degenerative changes in the origin of the common extensor tendon.
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    • The extensor carpi radialis brevis tendon is primarily affected.
    • The extensor digitorum communis tendon may also be affected.
  • The degenerative process behind lateral elbow tendinopathy involves noninflammatory angiofibroblastic hyperplasia, formation of new blood vessels, and collagen scaffold disruption by fibroblasts and vascular granulation tissue.
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Lateral elbow tendinopathy

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Lateral elbow tendinopathy

Anterolateral view of right arm illustrating site of pain (reddened area).

Normal Tendon Healing

  • In response to mechanical stress, a tendon typically progresses through a predictable cycle of repair consisting of 3 stages (if in a suitable environment).
    • The acute inflammatory stage is characterized by:
      • Clot formation (bringing platelets to the region)
      • An inflammatory response consisting of predominately macrophages, neutrophils, growth factors, matrix metalloproteinases, and cytokines
      • A duration of about 2 days
    • The proliferative stage is characterized by:
      • Production of a highly cellular but weak scar consisting of more randomly organized type III collagen (compared to mature tendon)
      • A duration around 6 weeks
    • The remodeling stage is characterized by:
      • Replacement of scar by normal tendon with a decrease in cellularity, an increase in type I collagen, greater longitudinal organization, and increased strength
      • A duration lasting up to 1-2 years
    • Reference - Foot Ankle Clin 2017 Dec;22(4):665
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