Tennis elbow, or lateral epicondylitis, is a condition characterized by pain and tenderness at the lateral epicondyle of the elbow, primarily affecting individuals engaged in repetitive wrist motions, with 95% of cases occurring in non-tennis players. Diagnosis is typically clinical, utilizing tests like Cozen's, Mill's, and Maudsley's tests, while management revolves around conservative treatments, with most cases resolving spontaneously within 6-12 months. For persistent cases, operative options such as open debridement or injections may be considered.

1. Tennis Elbow
Presented by – Unit II (PGT 1)
Moderator – Dr Sushant Srivastava
Assistant professor

2. What is tennis elbow?
• Tennis elbow/lateral epicondylitis is the tendinopathy
of the common extensor-supinator tendon.
• Lateral periepicondylar pain and tenderness that is
exacerbated by forceful repetitive wrist extension.

3. History
In 1883, H.P.Major noted that this condition commonly
affected tennis players, the complaint became popularly
known as 'tennis elbow' (Nirschl 1974).
• Seen in 13% of elite tennis players and 50% of non elite
players.
• But 95% of cases occur in those who do not play tennis and
are associated with manual occupations.

4. Pathology
● Degenerative microtears in common extensor-supinator
tendon due to repetitive mechanical overload.
● The tendinous origin of Extensor carpi radialis brevis most
commonly affected.
Microscopic feature of surgical specimen:
● Hyaline degeneration
● Fibroblastic and vascular proliferation- angiofibroblastic
hyperplasia
● Microscopic calcification

7. Etiology
● Tennis players: due to faulty playing techniques
mostly a late mechanically poor backhand.
● Non tennis players:
● 95% of cases seen
● Housewives, carpenters, miners, drill workers, other
sports.
● Use of computer

9. Clinical features
● Usually an Active individual of 30 or 40 years.
● Pain and tenderness over lateral epicondyle of elbow.
● Acute or insidious onset of pain.
● History of over use, involving forceful gripping, repetitive
flexion- extension at wrist or pronation-supination activity.
● Pain aggravated by movements like pouring out tea, turning
stiff door handle, shaking hands, lifting weights, etc.
● Elbow looks normal and flexion and extension are full and
normal.

10. Diagnosis

11. ● Mostly clinically diagnosed
Different tests to diagnose tennis elbow
● Cozen’s test
● Mill’s test
● Maudsley’s test

12. Cozen's Test
• Procedure: Patient seated. Stabilize forearm. Patient should
make a fist and extend it against resistance.
• Rationale: The tendons that extend the wrist attach to the
lateral epicondyle. Forcing the extended wrist into flexion will
exacerbate the pain if the tendons are inflamed.

14. Maudsley's Test
To perform the test place patient in a comfortable position.
Stabilize the humerus, and palpate for the lateral epicondyle.
Then ask your patient to pronate his forearm and then resist
extension of the third digit of the hand, distal to the proximal
interphalangeal joint.
Pain exacerbates if extensor tendons are inflamed.

16. MILL'S TEST
With the elbow in full extension, the wrist and fingers are fully
flexed and forearm is maximally pronated.
A positive sign is indicated by sudden severe pain in the
lateral epicondyle of humerus

18. Imaging
Not routinely performed
Diagnostic ultrasound features include:
● In active severe disease- neovascularisation
● Local fluid collection
● In chronic cases- dystrophic calcification at tendon
insertion

19. Differential Diagnosis

20. ● Radial tunnel syndrome: posterior interosseous nerve
entrapment between the fibres of supinator muscle.
Clinically pain will increase with resisted supination. Pain
is located 3- 4cm distal to lateral epicondyle.
● Osteochondritis dissecans of the elbow: patient may
complaint of snapping or locking. Maximum tenderness
found posterior to lateral epicondyle.

21. Management

22. Conservative Treatment
● 90% of 'tennis elbow' cases will resolve spontaneously within
6-12 months.
● First step is to identify and restriction or modification of the
activities which cause pain.
● In acute stages use of ice pack, use of NSAIDS(preferably
topical) can be useful.
● Compression strap applied distal to bulk of extensor mass (to
reduce maximum contraction) is helpful. It is used only during
aggravating activity.
● Injection of tender area with corticosteroids and local
anaesthetic relieves pain but is not curative.
● Physical therapy: ultrasound therapy, remedial exercises may
be effective in long term

26. ● Ultrasonography is thought to have thermal
and mechanical effects on the target tissue
leading to increased metabolism, circulation,
extensibility of connective tissue, and tissue
regeneration.
● The ultrasound therapy is helpful to relieve
pain for tennis elbow patients, but is not much
effective in long term

27. Operative treatment
Indicated in sufficiently persistent or recurrent cases usually
after 6- 12 months of failed conservative management.
Options:
1.Open debridement of the diseased tissue of the ECRB
4.Percutaneous release
3.Arthroscopic debridement

31. Newer experimental treatments
• Injections: autologous blood, platelet rich
plasma, botulinum toxin
• Laser therapy
• Extra corporeal shock wave therapy

33. 1) Rockwood 9th
edition - page 1411
2) Kaplan EB – the etiology and treatment
3) Cohen MS, Romeo AA, Hennigan SP, et al. Lateral epicondylitis:
anatomic relationships of the extensor tendon origins and
implications for arthroscopic treatment. J Shoulder Elbow Surg.
2008;17(6):954–960.
References