The elbow is prone to painful maladaptive degeneration of the tendon attachments. These are typically of insidious onset but precipitating factors may be identified from a careful history.

  • Lateral epicondylitis
  • Medial epicondylitis
  • Distal biceps tendinopathy
  • Baseball pitcher’s elbow

Lateral Epicondylitis

  • Also known as tennis elbow
  • This is the most common tendinopathy
  • Pain originates from the origin of ECRB (extensor carpi radialis brevis) at the lateral epicondyle
  • Most cases occur in those with a history of racquet use
  • Sudden traumatic onset of pain -> tendon rupture -> often requires repair
  • Usually occurs in active person aged 40-55 years

Clinical features

  • Lateral elbow pain
    • Often after a period of unaccustomed activity
    • Radiation down the forearm
    • Elbow stiffness in the morning
    • Pain is aggravated by lifting objects
  • ROM - full
  • Tenderness
    • Palpation over the front of the lateral epicondyle
    • Maudsley’s test -> resisted middle finger extension
    • Mill’s sign -> elbow extension in pronation with a flexed wrist

Diagnosis

  • Imaging is not required except
    • At the extremes of age
    • History of trauma
    • History of mechanical symptoms e.g. locking
  • USG / MRI
    • In patients with long-standing symptoms, not responding to treatment
    • To exclude radial tunnel syndrome, radiocapitellar plica or PLRI (postero-lateral rotator instability)

Treatment

It spontaneously resolves within 12 months in 90% cases.

Non-operative

  • Activity modification -> identify and avoid precipitating factors
  • Physiotherapy -> eccentric loading regime for the common wrist extensors
  • Static wrist splint wrist-and-forearm-splint-tynor.png
  • Steroid injection
    • Provides short-term pain relief
    • Recurrence rates are high
    • The elbow is more likely to be painful in the long term

Operative

  • Tendon debridement

Medial Epicondylitis

  • Also known as golfer’s elbow
  • More resistant to treatment
  • Pain at the medial epicondyle from the origin of the pronator teres
  • Tenderness
    • Over the medial epicondyle
    • On resisted forearm pronation in extension
  • Treatment is same as lateral epicodylitis, outcome of surgery is less predictable and more prone to complications

Distal Biceps Tendinopathy

  • In individuals going to the gym to lift weights into their forties and fifties
  • Anterior elbow pain & pain on resisted forearm supination
  • Treatment is as for tennis elbow, except that, if surgery is required, the tendon is reattached after debridement.