A 44-year-old car mechanic comes to the office due to a 4-week history of right elbow pain. The pain is worse when grasping tools with the right hand and is not relieved by over-the-counter nonsteroidal anti-inflammatory drugs. He has had no acute trauma to the elbow. On examination, the elbow is not swollen and has full range of motion. There is tenderness on palpation around the lateral distal humerus. Pain is reproduced when testing grip strength and with resisted wrist extension. Which of the following is the best next step in management?
Lateral epicondylitis | |
Pathophysiology |
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Clinical |
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Management |
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NSAIDs = nonsteroidal anti-inflammatory drugs. | |
This patient has subacute lateral elbow pain reproduced by resisted contraction of the wrist extensors, findings consistent with lateral epicondylitis (LE), sometimes referred to as lateral elbow tendinopathy. LE is classically seen in tennis players due to repeated backhand strikes (ie, "tennis elbow") but may occur with the use of hand tools, as in this patient, or other overuse of the wrist extensors. Although the name implies an inflammatory process, LE is more accurately characterized as angiofibroblastic tendinosis (disorganized tissue and neovessels), and true inflammatory infiltrates are typically scant.
LE primarily affects the conjoined tendon of the extensor carpi radialis brevis and extensor digitorum at the lateral epicondyle of the humerus. Maximal pain and tenderness are typically seen approximately 1 cm distal to the lateral epicondyle, and the pain may be reproduced by passive wrist hyperflexion, resisted wrist extension, or making of a fist (eg, grip strength testing), all of which transmit force through the affected tendons.
The diagnosis is usually made clinically. Initial management involves activity modification and use of a counterforce elbow brace (tendinosis strap). The brace is applied just distal to the elbow, reducing the load transmitted to the tendon origin. Some patients prefer a compression sleeve.
(Choice B) Musculoskeletal ultrasound can visualize tendon damage and assist the diagnosis of LE if the presentation is ambiguous. X-ray is useful for suspected fractures (eg, traumatic fall) but does not visualize soft tissue (eg, tendon) injury.
(Choice C) Short courses (eg, 1-2 weeks) of acetaminophen or low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) can be used as adjunctive treatment for pain relief in LE. However, because LE is a degenerative rather than an inflammatory process, the benefit of NSAIDs is uncertain; high doses and extended courses are not recommended due to potential side effects (eg, gastrointestinal bleeding).
(Choice D) Corticosteroid injection can be used for short-term pain relief in LE but does not provide long-term benefits or prevent recurrence. It may also lead to tendon rupture. Oral (systemic) corticosteroids are not used due to side effects (eg, hyperglycemia, immunosuppression).
(Choice E) Surgery can be considered for patients with prolonged (ie, >6 months), severe symptoms but is rarely necessary.
Educational objective:
Lateral epicondylitis is a tendinopathy of the wrist extensors at the lateral epicondyle origin. The pain is most severe 1 cm distal to the lateral epicondyle and is elicited by resisted wrist extension. Initial treatment includes activity modification and use of an elbow counterforce brace. NSAIDs are of limited value, given that the underlying pathology is chronic tendinosis rather than inflammation.