Lateral Epicondylitis-Narrative Review on Surgical Options for Recalcitrant Cases

Abstract

Purpose

Lateral epicondylitis or lateral elbow tendinopathy is a common condition which needs to be addressed appropriately. This condition usually responds well to non-operative treatment. However, an orthopaedic physician needs to be aware of the recalcitrant cases and equip surgical armamentarium to provide adequate care.

Methodology

The literature search was performed on PubMed, Medline and Google scholar using the keywords Tennis elbow, recalcitrant, thorntons technique, surgical options, for this narrative review.

Conclusion

This article focuses on the causes for recalcitrant tendinopathy and review of its surgical options.

Introduction

A painful elbow is distressing and affects the prehensile movement of the limb in everyday life and indirectly contributes to a significant number of workdays lost. One such cause is Lateral Epicondylitis (LE) or Tennis Elbow. It was Innes in 1882 who recognised this condition, but the term lawn tennis elbow was coined by Morris, the same year. He described this condition occurring frequently in Tennis Players who perform the backhand stroke [1]. However, this condition was not isolated to sports but, in fact, was more common in manual labourers and homemakers. Hence, the better terminology was proposed to be Lateral Elbow Tendinopathy [2, 3]. Vast studies have been performed to understand the origin of pain and various management strategies. Although largely responsive to non-operative treatment, surgical options are reserved for the recalcitrant cases. In this narrative review, we have focused on factors causing LE and treatment in recalcitrant cases. In addition, a surgical technique using knotless suture anchors while reattaching the extensor tendon is described.

Pathophysiology

The pathogenesis of Lateral Epicondylitis still remains elusive. The widely accepted theory is that of angiofibroblastic tendinosis proposed by Nirschl et al. [4]. The microscopic features of the pathologic tendon consisted of immature fibroblast amidst non-functional vascular beds. This is coupled with a lack of inflammatory cells. The histopathological findings include glycosaminoglycan infiltration and fibrocartilaginous transformation [5]. Similar degenerative changes were also reported in degenerated rotator cuff lesion in a comparative histological study by Chard et al. [6]. However, molecular studies have demonstrated that the presence of fibrocartilage in older age groups were found to be normal [7].

(a) Role of ECRB

The Extensor Carpi Radialis Brevis (ECRB) is often attributed to the origin of pain in LE. This is partly due to its anatomic location, blood supply and its variations. The ECRB is subjected to shearing stress in all movements of the forearm, especially those involving power movements at the wrist [8, 9]. The muscle is at its maximum length in a pronate forearm and palmar flexed wrist. The ECRB is predisposed to tendon injury due to double lengthening of sarcomere which leads to intense eccentric contraction within the muscle which causes degeneration [10]. Anatomical studies have demonstrated that ECRB being the deepest of the extensor mechanism experiences constant abrasion from the underlying capitellum and leads to degeneration followed by attrition tears[11].

(b) Role of Vascular Supply

Decreased sympathetic vascular flow has been detected in the Cutaneous and intramuscular (ECRB) planes through laser doppler flow meter. A reduced perfusion in the ECRB leads to intramuscular hypoxia and hastens anaerobic metabolism in situ which leads to the accumulation of lactic acid at the cellular level. This in turn leads to an increase in intramuscular pressure and further decrease in blood flow, thereby contributing to a vicious cycle which leads to tendon degeneration [12–14].

(c) Role of Extra Tendinous Structures

The cause of pain in Lateral Epicondylitis is largely attributed to tendinogenic origin and the presence of articular and neurogenic sources. Of importance is the presence of a tendinous/muscular arch of the ECRB over the posterior branch of the radial nerve branch which leads to compression and thereby intractable pain. Musculogenic pain sources include anomalous ECRB origin [9, 15, 16]. Intraarticular causes for pain include chondromalacia of radio capitellar joint, loose bodies, intraarticular ganglionic cyst, and hypertrophic posterolateral synovial plica [17–19]

Clinical Presentation

The common age of presentation is between 30 and 50 years. Patients usually present with localised pain over the lateral aspect elbow occasionally radiating to forearm and hand [20]. On examination, there is point tenderness over the lateral epicondyle and lateral supracondylar ridge. Active range of movements remains unhindered mostly. However provocative tests such as resisted wrist extension with an elbow in full extension can reproduce the pain. Also, there can be reduced grip secondary to pain or entrapment neuropathies. The special tests for LE include Cozens test, Mills test and Maudsley’s test. ROC curve analysis has demonstrated that the mills test has a good diagnostic accuracy whereas a low diagnostic accuracy was associated with the Cozens test and Maudsley’s test [21]. The forearm extensors can also be tested for their strength by the Tennis Elbow Testing System developed by the Orthopaedic Training Institute [22].

Nirschl and colleagues have stratified the presentation of Lateral Epicondylitis based on the effects on functional limitations (Table 1) [23].

Table 1.

Phases of lateral epicondylitis

I	Mild pain after exercise, lasting less than 24 h
II	Pain after exercise, lasting greater than 48 h, resolves with warm up
III	Pain with exercise, does not alter ability to exercise
IV	Pain with exercise that alters ability to exercise
V	Pain caused by heavy activities of daily living
VI	Pain caused by light activities of daily living;
VII	Constant rest pain and pain that disturbs sleep

Differential Diagnosis

Not all lateral-sided elbow pain can be attributed to lateral epicondylitis. The possible differentials are summarised in Table 2. The pathology could originate as referred pain from the cervical spine, intraarticular causes, entrapment neuropathies or ligament insufficiencies. Although rare in occurrence, Myositis ossificans of the mobile wad have also shown to mimic lateral epicondylitis [24]. Patients with radial tunnel syndrome, or entrapment of the posterior interosseous nerve at the leading edge of the supinator, often have coexisting lateral epicondylitis and require careful examination to determine if one or both diagnoses apply [25, 26].

Table 2.

Differential diagnosis of lateral elbow pain [26]

Occult fracture

Osteochondral lesions of the capitellum

Degenerative joint disease

Posterolateral rotatory instability, LUCL injury

Radio humeral synovial plica

Synovitis of the radio humeral joint

Radial tunnel syndrome

Diagnostic Imaging

Plain radiographs seldom yield the pathological lesions in LE, except for calcifications. Although vast majority of the cases do not require further imaging, certain recalcitrant cases require identification of the source of pain.

Ultrasound and MRI are the most widely used imaging modalities. The Ultrasound (USG) Scan has a sensitivity that ranged from 64 to 82% whereas that of MR imaging ranged from 90 to 100% [25].

In MRI Assessment, the lateral epicondyle is best assessed in axial and coronal sections. A normal ECRB tendon shows uniform low-intensity signal in all the sequences [26]. The findings of tendinosis include intermediate signal intensity within the substance of tendon on T1 and T2 weighted images.

Treatment

A variety of treatment options have been recommended for LE. Despite these advancements, there is no single modality which can be used in the various phases of LE. However, the treatment of LE usually has five therapeutic goals: controlling elbow pain, preserving movement of the affected limb, improving grip strength and endurance, restoring normal function of the affected limb, and preventing further deterioration [27]. Non-operative treatment remains the priority and main stay for most patients with LE [20]. A brief summary of the different non-operative treatment modalities is tabulated in Table 3. Surgical intervention is reserved for recalcitrant cases.

Table 3.

Non operative treatment options and their mechanism of action [20]

S. no.	Non operative treatment strategy	Proposed mechanism of action
1.	Physiotherapy	Loading the ECRB both concentrically and eccentrically
2.	Anti-inflammatory medications	Relieves pain and inflammation in acute phase
3.	Counterforce brace	Unloading of ECRB, improving proprioception
4.	Extra corporeal Shock wave therapy	Hyperstimulation mechanism blocking the GATE control
5.	Prolotherapy	Stimulation healing following injection of irritant (normal saline)
6.	Botulinum Toxin	Relax the ECRB muscle for duration of toxin effect
7.	Acupuncture	Relive pain
8.	Autologous blood injection	Induction of growth factors and promote collagen formation
9.	Platelet rich plasma	Enhance tendon healing

Operative Treatment

Lateral Epicondylitis usually responds to non-operative treatment modalities, however, there exist about 4–11% recalcitrant cases [27].

Surgical treatment is usually reserved for those who have failed conservative management.

The principles of operative treatment are usually based on identifying the pathological lesion and involves either (1) extensor origin release, (2) nerve release, (3) radio-humeral joint debridement and (4) excision/debridement of a defect in the extensor carpi radialis brevis. These procedures can be done either by open surgical methods or by Arthroscopy.

Open Procedures

Nirschl and Pettrone were the proponents of releasing the extensor tendon from its origin and removing the scar tissue [28]. The series of cases performed by Nirschl and Colleagues were studied by Dunn et al. in their 14-year follow-up study [29]. 93% of patients who were available for a minimum of 10-year follow-up had returned to their sporting activities. A brief review of the open procedures performed in the last 15 years i.e., (2005 onwards) is provided in Table 4 [31–43].

Table 4.

Studies which performed open extensor tendon releases (2005 onwards)

S. no	Study authors/year	Year	Study design	Number of elbows	Mean age of the patients	Mean follow-up duration (months)	Outcome measured
1.	Barth et al. [31]	2013	Cohort	54	44	33	DASH VAS Outcome
2.	Manon-Matos et al. [32]	2013	Retrospective case–control study	56	51.4	NR	VAS Recurrence
3.	Solheim et al. [33]	2011	Retrospective cohort	80	46	48	Quick DASH
4.	Reddy et al. [34]	2011	Cohort	27	47	16	Patients satisfaction Time for returning to work
5.	Coleman et al. [35]	2010	Retrospective cohort	171	42	117.6	Hospital for special surgery Mayo score
6.	Dwyer et al. [36]	2010	Retrospective cohort	21	49.3	24	Outcome Patients satisfaction
7.	Rayan et al. [37]	2010	Retrospective cohort	40	43.7	24	VAS Outcome
8.	Cho et al. [38]	2009	Retrospective cohort	42	47.5	13.4	VAS Outcome
9.	Svernlov et al. [39]	2009	Retrospective cohort	53	45	90	Vehaar score Self assessment
10.	Dunn et al. [29]	2008	Retrospective cohort	92	46	151.2	VAS Outcome Patients satisfaction
11.	Thomas and Broome [40]	2007	Retrospective cohort	24	NR	NR	Patients’ satisfaction
12.	Zingg et al. [41]	2006	Retrospective cohort	21	NR	15	Grip strength Patient satisfaction
13.	Balk et al. [42]	2005	Retrospective cohort	63	NR	50	Patients’ satisfaction
14.	Thornton et al. [43]	2005	Cohort	22	47.3	50.2	VAS DASH

However, the release of ECRB were fraught with the weakness of handgrip [30, 41]. Hence, procedures which aimed at the reconstruction of the tendon following debridement were in place and they too demonstrated good results.

One of the earliest reattachment series were reported by Pruzansky et al. with a follow-up to 19 years. Pruzansky hypothesised that reattaching the tendon to its anatomical origin results in better outcomes than reattachment to the musculotendinous units.

The follow-up spanning 19 years yielded favourable outcomes [44].

Thornton in 2005 demonstrated a new technique for reattachment using suture anchors in his case series of 20 cases. The daycare procedure lasted for 23 min on an average and involved careful dissection of the degenerated granulation from the ECRB followed by its detachment from the lateral epicondyle, then debridement of the lateral epicondyle till bony bleed occurred was performed and then suture anchor was used for reattachment. Favourable results were reported with regards to strength, return to previous activities, and pain relief [43].

Recent meta-analysis data suggests that there was similar effectiveness for both open surgery and arthroscopic procedure for relieving pain and improving self-reported function and there was no difference in complication rates. It was also noted that arthroscopic surgery had a longer surgical time than open surgery [45].

In our experience, we have modified the Thornton procedure by way of using knotless suture anchors ameliorating the need for a suture knot and bulky thread ends (Figs 1, 2, 3). The operative technique involves positioning the patient supine after anaesthesia. Approximately, 3 cms incision centred over the lateral epicondyle, careful deep dissection and exposing the origin of ECRB. It is then detached, debrided and the bone surface is freshened till bony bleed is achieved. Following this, the knotless suture anchor is placed in the tunnel and ECRB is repaired, thereby avoiding knot prominence [46].

Fig. 1.

Detachment and debridement of the lateral epicondyle

Fig. 2.

Repositioning the ECRB tendon to its origin

Fig. 3.

Insertion of knotless suture anchor for reattachment

Arthroscopy

In 1995, Grifka et al. had reported success using arthroscope for LE debridement [47]. Cohen et al. had demonstrated the safe limits to be observed while performing arthroscopy release of ECRB [48]. Arthroscopic treatment modalities had gained popularity and a new intraoperative classification system was devised. Mullet et al. and Baker et al. had reported good functional outcome results and early return to work [49, 50]. However, varying results have been associated with arthroscopic procedures for LE. The steep learning curve also seems to hinder the deployment of arthroscopy in these cases.

Complications

These include movement restriction, revision surgery, superficial wound infection, hematoma, seroma, elbow instability, synovial fistulae, posterior interosseous nerve palsy, reactive bone formation and need for further glucocorticoid injections. Among these, the major complications include serious deep infection, minor complications such as prolonged drainage, persistent minor contracture of 20° or less transient nerve palsies. The most significant risk factor for neuropraxia is an underlying diagnosis of rheumatoid arthritis and contracture. Both arthroscopic and open surgeries are associated with these complications but not statistically significant [51–53].

Conclusion

Lateral Epicondylitis is a common condition which is seen routinely in general practice. Although the pathology can be attributed to various causes, it is imperative to be prudent of the treatment options available. The recalcitrant cases need to be identified and treated appropriately with intervention. The surgical options are many and are associated with positive clinical outcomes. The usage of knotless suture anchor while performing Thornton’s technique can avoid potential complications due to bulky knots. However, a cautious approach needs to be tread which should be complimented well with rehabilitation.

Compliance with Ethical Standards

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical standard statement

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed consent

For this type of study informed consent is not required.