Lateral Epicondylitis: Débridement, Repair, and Associated Pathology

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CHAPTER 3 Lateral Epicondylitis: Débridement, Repair, and Associated Pathology

Champ L. Baker, Jr., Champ L. Baker, III

Lateral humeral epicondylitis was first described in the German literature by Runge in 1873.¹ Ten years later, Morris reported an association between lateral epicondylitis and lawn tennis, leading to its common designation as tennis elbow.² Since these original descriptions were published, multiple causes and various treatments for this condition have been proposed.

Despite advances in our understanding of the pathoanatomy of lateral epicondylitis, controversy remains regarding its optimal nonoperative and operative management. Most patients respond successfully to a variety of conservative methods. In the studies reported by Boyd and McLeod,³ Coonrad and Hooper,⁴ and Nirschl and Pettrone,⁵ 4% to 11% of patients ultimately required operative intervention for recalcitrant symptoms. Many different operative procedures have been described in the orthopedic literature: percutaneous,⁶^–¹¹ endoscopic,¹²^,¹³ and myriad open techniques, such as excision of abnormal degenerative tissue with simple suture repair^{4,5,7,10,14-17} or formal repair of the extensor tendons back to the lateral epicondyle.¹⁸^–²⁰ Clinical outcomes of arthroscopic treatment have been reported.¹⁰^,¹⁶^,²¹^–²⁹ In one study, we found high rates of clinical success for our patients with lateral epicondylitis treated arthroscopically using the technique described in this chapter.²¹^,²²

ANATOMY

Nirschl and associates detailed the most commonly accepted theory of the pathogenesis of lateral epicondylitis.⁵^,³⁰ Building on the previous findings of Cyriax,³¹ Goldie,³² and Coonrad and Hooper,⁴ Nirschl observed that the basic underlying lesion was in the origin of the extensor carpi radialis brevis (ECRB) tendon. Repetitive overuse leads to microtears in the ECRB origin. Tendinous nonrepair and replacement with immature reparative tissue often follow. Histopathologic examination revealed an absence of inflammatory cells and the presence of a degenerative process, with tissue first characterized as angiofibroblastic hyperplasia and later modified to angiofibroblastic tendinosis.⁵^,³⁰^,³³^,³⁴

In a cadaveric study, Cohen and associates ³⁵ characterized the ECRB origin as diamond shaped and as beginning just anterior to the most distal aspect of the lateral supracondylar ridge. The anatomic ECRB footprint is located between the most proximal aspect of the capitellum and the midline of the radiocapitellar joint (Fig. 3-1). The lateral collateral ligamentous complex, consisting of the radial collateral ligament, annular ligament, accessory collateral ligament, and lateral ulnar collateral ligament, lies posterior to the ECRB origin. This lateral collateral ligamentous complex is not disrupted during arthroscopy as long as resection of the ECRB and elbow capsule is kept anterior to a line bisecting the radial head.³⁶

FIGURE 3-1 Anatomic origin of the extensor carpi radialis brevis tendon between the top of the capitellum and the midpoint of the radiocapitellar joint.

PATIENT EVALUATION

History and Physical Examination

Typically, patients with lateral epicondylitis present with lateral elbow pain. The pain may extend proximally or distally into the dorsal forearm. Lifting or gripping movements encountered with activities of daily living often exacerbate the pain. During physical examination, the patient may wince or give submaximal effort with a handshake. Tenderness is typically localized to an area slightly anterior and distal to the lateral epicondyle. Provocative testing reveals pain localized to the lateral epicondyle with resisted wrist extension or passive wrist flexion with the elbow in full extension. Examination of the cervical spine should be performed to exclude cervical radiculopathy as a source of elbow pain.

Diagnostic Imaging

Lateral epicondylitis is a clinical diagnosis. We routinely obtain plain anteroposterior, lateral, and axial radiographic views of the elbow as part of the initial evaluation in the patient presenting with elbow pain. Although they are frequently normal, the radiographs may show radiocapitellar arthrosis, which should be included in the differential diagnosis. Plain radiographs may show soft tissue calcification adjacent to the lateral epicondyle in approximately 25% of patients, especially if the patient previously had steroid injections. Although unnecessary for the diagnosis, magnetic resonance imaging (MRI) can provide additional information regarding suspected intra-articular pathology, the integrity of the lateral collateral ligamentous complex, and the presence and extent of extensor tendon tearing.³⁷

TREATMENT

Indications and Contraindications

Indications for surgical intervention for lateral epicondylitis include persistent, disabling symptoms despite an appropriate course of nonoperative management. Relative contraindications to the arthroscopic technique include previous medial elbow surgery with an ulnar nerve transposition or the presence of a subluxating ulnar nerve. In these instances, the ulnar nerve should be exposed and protected before the creation of the proximal medial portal to prevent iatrogenic injury. An absolute contraindication is the presence of an active infection.

Conservative Management

Many nonoperative treatments have been reported. A regimen that includes activity modification, physical therapy, nonsteroidal anti-inflammatory medications, counterforce bracing, and corticosteroid injections is usually successful in reducing symptoms and allowing a progressive return to unrestricted activities. Novel approaches include injections of buffered platelet-rich plasma ³⁸ or botulinum toxin³⁹ and application of extracorporeal shock wave therapy.⁴⁰

Arthroscopic Technique

For the arthroscopic procedure, the patient can be placed in the supine, lateral decubitus, or prone position. We prefer the prone position with the use of a general anesthesia to allow accurate postoperative neurovascular assessment. A well-padded tourniquet is applied to the upper arm, which is then placed into a commercially available arm holder (Fig. 3-2). The extremity is then prepared and draped in standard fashion. A compressive dressing is wrapped around the forearm to help prevent leakage of fluid into the distal soft tissues. Several bony anatomic landmarks and important structures are outlined with a marking pen to assist in proper portal creation: medial and lateral epicondyles, radial head, olecranon tip, and ulnar nerve (Fig. 3-3).

FIGURE 3-2 The patient is in the prone position with the right arm placed in an arm holder.

FIGURE 3-3 Landmarks outlined include the medial epicondyle, ulnar nerve, olecranon tip, lateral epicondyle, and radial head.

The limb is exsanguinated, and the tourniquet is inflated to 250 mm Hg. An 18-gauge spinal needle is introduced into the lateral soft spot, which can be found in the center of a triangle formed by the palpable radial head, lateral epicondyle, and olecranon. The joint is injected with approximately 20 to 30 mL of saline (Fig. 3-4). Joint distention pushes the neurovascular structures more anterior, thereby protecting them from iatrogenic injury.

FIGURE 3-4 To distend the joint and displace the neurovascular structures anteriorly, the lateral soft spot is injected with 20 to 30 mL of saline.

The proximal medial portal is created approximately 2 cm proximal to the medial epicondyle and 1 cm anterior to the medial intermuscular septum (Fig. 3-5). To protect against injury to the sensory nerves, we use a nick and spread technique, in which only the skin is incised, and a hemostat is used to spread the subcutaneous tissues. Stothers and colleagues⁴¹ found the proximal medial portal to be, on average, 2.3 mm away from the medial antebrachial cutaneous nerve, 7.6 mm away from the median nerve, and 18 mm away from the brachial artery with the elbow in flexion. The ulnar nerve is typically located 12 mm from this portal and lies anterior to and is protected by the medial intermuscular septum.

FIGURE 3-5 The proximal medial portal and surrounding neurovascular structures.

A blunt trocar is inserted through the portal. The surgeon should aim toward the center of the joint and maintain contact with the anterior surface of the humerus. Backflow of fluid through the cannula confirms entry into the joint (Fig. 3-6).

FIGURE 3-6 Leaking of fluid confirms joint entry.

The 4-mm, 30-degree arthroscope is inserted into the joint. The lateral capsule and radiocapitellar articulation are easily inspected. According to Baker’s classification system,²¹ the condition of the capsule is classified as type 1 (i.e., intact capsule), type 2 (i.e., linear capsular tears), or type 3 (i.e., capsular rupture) (Fig. 3-7). Irregular extension of the annular ligament overlying the radial head, or synovial fringe, can be appreciated in some cases. We believe that this structure can be a source of lateral elbow symptoms that often mimic lateral epicondylitis and that it should be removed concomitant with the ECRB resection.²⁶

FIGURE 3-7 View from the proximal medial portal shows a complete Type III capsular tear.

The proximal lateral portal is typically located 1 to 2 cm proximal to the lateral epicondyle along the anterior humeral surface (Fig. 3-8). This portal is established after needle localization using an outside-in technique (Fig. 3-9). Stothers and coworkers⁴¹ found the radial nerve to be 9.9 mm away from this portal and the posterior branch of the antebrachial cutaneous nerve to be an average of 6.6 mm away from the portal with the elbow flexed.

FIGURE 3-8 The proximal lateral portal and surrounding neurovascular structures.

FIGURE 3-9 The proximal lateral portal is created with an outside-in technique for correct portal localization.

A blunt trocar is used to enter the joint, followed by a small, motorized shaver. A portion of the lateral capsule is resected to reveal the underlying common extensor origin (Fig. 3-10). The ECRB tendon lies between the common extensor origin and the removed capsule. The shaver is exchanged for a monopolar radiofrequency device (Fig. 3-11) The ECRB origin is then completely released from its insertion and the tendinosis tissue ablated (Fig. 3-12). To protect the lateral ligamentous structures, care is taken not to extend the release posterior to a line bisecting the radial head. Early in our experience, we decorticated the lateral epicondyle; however, several patients developed postoperative bony tenderness that was not present preoperatively. We no longer routinely decorticate the lateral epicondyle.

FIGURE 3-10 A portion of the lateral capsule is removed to reveal the underlying extensor carpi radialis brevis tendon.

FIGURE 3-11 We prefer to use a radiofrequency device to resect the extensor carpi radialis brevis origin from its insertion.

FIGURE 3-12 Completed resection.

If the patient had preoperative concurrent posterior or posterolateral pain on terminal elbow extension, we inspect the posterior compartment through the posterior and direct lateral portals. If no such symptoms were present at the preoperative evaluation, we do not routinely examine the posterior compartment. The portal sites are closed with simple nylon sutures, and a sterile dressing is applied.

PEARLS& PITFALLS

PEARLS

• If a concurrent open procedure is planned, a side board can be affixed to the table.

• The tourniquet and arm holder should be placed as far proximally as possible to allow easy joint access with instrumentation.

• The nick and spread technique decreases the likelihood of injury to the medial sensory nerves during the creation of the proximal medial portal.

• Annular ligament extension with synovial tissue can become entrapped between the radial head and capitellum, and it can be a source of lateral elbow pain. It should be excised concurrently with the tendinosis resection.

PITFALLS

• Before the procedure, the surgeon must identify a prior ulnar nerve transfer or subluxating ulnar nerve.

• Using cannulas with side ports allows fluid extravasation into the soft tissues. We use cannulas without side ports to decrease extravasation.

• If visualization becomes difficult, a second, more proximal lateral portal can be created to insert a retractor.

• To prevent iatrogenic posterolateral rotatory instability, resection should not extend posterior to a line bisecting the radial head with the elbow in 90 degrees of flexion.

Postoperative Rehabilitation

All procedures are performed on an outpatient basis. Initially, the arm is placed in a sling for comfort only. The patient is encouraged to begin immediate active and passive range-of-motion exercises of the elbow.

The first postoperative visit is scheduled within 7 days of surgery. Sutures are removed at that time. If potential motion loss is a concern or the patient has difficulty regaining full extension, formal physical therapy is prescribed. Home exercises, including simple stretching and strengthening, are initiated as the patient’s symptoms allow. Patients typically return to light activities at 2 weeks after surgery and to sports at approximately 6 weeks postoperatively.

OUTCOMES

We reviewed the long-term outcomes of our initial series of patients who were treated with arthroscopic resection of the ECRB origin for recalcitrant lateral epicondylitis.²² Thirty elbows in 30 patients were evaluated at a mean follow-up of 130 months. Patients were asked to rate their level of pain using a numeric scale from 0 (no pain) to 10 (severe pain). They were also asked to rate their elbows according to the 12-point functional portion of the Mayo Clinic Elbow Performance Index.

The mean pain score was 0 at rest, 1.0 for activities of daily living, and 1.9 of 10 for work or sports. The mean functional score was 11.7 of a possible 12 points. No patient required repeat injections or surgery. One patient did continue to wear a counterforce brace during heavy activities. When asked to rate their overall results, 87% of patients were satisfied, and 97% of patients stated they were “much better” or “better” at the final follow-up evaluation.

The high rate of success in Baker’s initial series of patients was maintained at long-term follow-up. Other investigators also reported high rates of success with this technique in limited follow-up studies.¹⁰^,²⁵^,²⁷^–²⁹

CONCLUSIONS

Lateral epicondylitis is a common cause of lateral elbow pain. Although controversy exists regarding the optimal treatment for this condition, in our hands, arthroscopic release of the ECRB origin with resection of the pathologic tendinosis tissue provides reproducible pain relief and allows patients to return to unrestricted activities. Other surgeons have reported similar short-term success with this technique with minor modifications.^{10,16,25,27-29} We have documented maintenance of successful outcomes at long-term follow up.²¹^,²²

Cadaveric studies have demonstrated the ability to resect the entire ECRB origin safely without violation of the important lateral ligamentous complex.³⁵^,³⁶^,⁴² The arthroscopic technique enables identification and treatment of coexistent intra-articular pathology. Successful operative treatment of lateral epicondylitis primarily depends on proper patient selection, identification of pathology, and complete resection of the ECRB tendinosis.

REFERENCES

1. Runge F. Zur genese und behandlung des schreibekrampfes. Berl Klin Wochenschr. 1873;10:245-248.

2. Morris HP. Lawn-tennis elbow. Br Med J. 1883;2:557.

3. Boyd HB, McLeod ACJr. Tennis elbow. J Bone Joint Surg Am. 1973;55:1177-1182.

4. Coonrad RW, Hooper WR. Tennis elbow: its course, natural history, conservative, and surgical management. J Bone Joint Surg Am. 1973;55:1183-1187.

5. Nirschl RP, Pettrone FA. Tennis elbow: the surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61:832-839.

6. Baumgard SH, Schwartz DR. Percutaneous release of the epicondylar muscles for humeral epicondylitis. Am J Sports Med. 1982;10:233-236.

7. Dunkow PD, Jatti M, Muddu BN. A comparison of open and percutaneous techniques in the surgical treatment of tennis elbow. J Bone Joint Surg Br. 2004;86:701-704.

8. Grundberg AB, Dobson JF. Percutaneous release of the common extensor origin for tennis elbow. Clin Orthop Relat Res. 2000;376:137-140.

9. Savoie FH 3rd. Management of lateral epicondylitis with percutaneous release. Tech Shoulder Elbow Surg. 2001;2:243-246.

10. Szabo SJ, Savoie FH 3rd, Field LD, et al. Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment. J Shoulder Elbow Surg. 2006;15:721-727.

11. Yerger B, Turner T. Percutaneous extensor tenotomy for chronic tennis elbow: an office procedure. Orthopaedics. 1985;8:1261-1263.