S P E C I A L F O C U S
Elbow
Lateral epicondylitis
Rebecca E. Clinton and Anand M. Murthi
ABSTRACT
Purpose of review
The present article reviews the most recent research into the
anatomy, pathophysiology, and treatments, including nonsurgi-
cal and surgical options, of lateral epicondylitis.
Recent findings
Despite numerous studies of lateral epicondylitis, much regard-
ing the pathophysiology and best treatment options remains
uncertain. Recent research has improved understanding of the
etiology of lateral epicondylitis, suggesting anatomic and vas-
cular components of its development. Additionally, research in
nonsurgical treatment has indicated that the short-term benefit
of corticosteroids might be reversed in the long term, has
suggested that physical therapy might be the best of the estab-
lished options, and has presented several novel treatments. It is
clear that all common surgical approaches yield good-to-excel-
lent results, but it remains unclear which surgical treatment is
best.
Summary
Lateral epicondylitis is a common cause of lateral elbow pain, first
described more than 100 years ago. The condition has not been
well characterized, although it has been frequently studied.
Recent research has shed more light on the complex etiology
of this disorder, which is helping to elucidate the best method of
treatment.
Keywords
extensor carpi radialis brevis tendinosis, lateral epicondylitis,
tennis elbow
Department of Orthopaedics, University of Maryland School of Medicine,
Baltimore, Maryland, USA
Correspondence to Anand M. Murthi, MD, University of Maryland
Orthopaedics, 2200 Kernan Drive, Suite 1154, Baltimore, MD 21207, USA
Tel: +1 410 448 6416; fax: +1 410 448 6387;
e-mail: amurthi@umoa.umm.edu
1940-7041 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
612 Current Orthopaedic Practice
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
INTRODUCTION
L
ateral epicondylitis is one of the most common elbow
injuries, affecting 13% of the population, with onset
typically occurring during the 4th or 5th decade of
life.1 A condition first described in the late 1800s, lateral
epicondylitis, also known as tennis elbow, has been the
subject of numerous studies and research projects.2,3,4
Nevertheless, it has remained a somewhat poorly understood
condition and it is unclear which treatment option is best.
Fortunately, interest in and research regarding lateral epi-
condylitis have experienced a resurgence, which has helped
to establish a better understanding of the difficult condition.
ANATOMY AND PATHOPHYSIOLOGY
Ironically, lateral epicondylitis is not an inflammatory con-
dition as originally thought, nor is it most often associated
with tennis. Only 510% of cases occur in tennis players.5
However, up to 50% of tennis players in the United States will
at some point be affected with lateral epicondylitis.6 The
lateral epicondyle of the humerus is the origin of wrist and
finger extensors, including the extensor carpi radialis brevis
(ECRB), extensor carpi radialis longus, extensor digitorum
communis, and extensor carpi ulnaris. The ECRB tendon is
deepest as the muscles insert into the common extensor
origin. Numerous studies have shown the origin of the ECRB
to be the tissue involved in lateral epicondylitis and have
shown a degenerative process related to microscopic tendon
tears with infiltration of fibroblasts, vascular hyperplasia, and
disorganized collagen progressing to tendinosis.2,5,7,8
Thus, the condition might have more aptly been named
ECRB tendinosis. In dispelling the idea of an inflammatory
condition, Nirschl and Pettrone7 were the first to propose a
primarily mechanical cause of lateral epicondylitis and
coined the term angiofibroblastic dysplasia to describe
the microscopic appearance of the tendon.
Recent research, however, points toward a multifactorial
genesis of the disorder, with anatomy and vascularity of the
region playing important roles. In an extensive anatomic
cadaver study, Bunata et al.8 showed contact of the ECRB
with the capitellum as the elbow moves into extension and
further showed that the overlying extensor carpi radialis
longus presses on the ECRB, perhaps increasing abrasive
forces between the underside of the ECRB and the capitellum.
Additionally, the same study found considerable variations
in capitellar shape and size and in tendon origin location. It
might, therefore, be possible that anatomic variations exist
and lead to more abrasion between the capitellum and ECRB,
predisposing some patients to the development lateral
Volume 19  Number 6  November/December 2008
Current Orthopaedic Practice
epicondylitis. In another cadaver study, Bales et al.9
examined the microvascular pattern of the common exten-
sor mass and lateral epicondyle and found two hypovascular
zones: one between the lateral epicondyle and the supra-
condylar ridge and the other on the deep surface of the
common extensor tendon 23 cm distal to the lateral epi-
condyle. The decreased vascular supply might make it more
difficult for inflammatory cells to reach the area and might,
therefore, make it more difficult for microtears in the region
to heal, similar to the way in which hypovascularity of the
supraspinatus has been implicated in the etiology of tendi-
nopathy in the shoulder.9 Additionally, in a clinical case-
controlled study using gray-scale ultrasonography and color
Doppler ultrasonography, Zeisig et al.10 showed increased
vascularity in the extensor origin in patients with lateral
epicondylitis. Vascular hyperplasia has occurred in associ-
ation with other types of tendinopathy, including that of the
Achilles, patellar, and rotator cuff tendons, and likely
represents attempted healing of repetitive microtrauma in
areas with inadequate blood supply.9,10 Unfortunately,
previous studies have shown the ingrowing vessels to be
dysfunctional and not correlated with healing.9 However,
gray-scale ultrasonography-guided and color Doppler ultra-
sonography-guided injection of local anesthetic and epi-
nephrine as close to the vessels as possible, with
disappearance of blood flow shown after injection, led to
complete pain relief, implicating the area of hypervascularity
in the pain of the condition.10
DIAGNOSIS
Lateral epicondylitis is diagnosed clinically by the presence
of tenderness over the lateral epicondyle and increased pain
with resisted wrist and finger extension with the elbow in
extension. Patients typically complain of maximal tender-
ness 25 mm distal and anterior to the midpoint of the lateral
epicondyle in the common extensor tendon origin and
describe a history of gradual onset with overuse or repetitive
straining activities.2 Additionally, weakness of grip strength
with the elbow in extension, two-pinch grip, and ECRB
weakness in radial deviation and maximal dorsal extension
might be present.3,11 Although lateral epicondylitis is the
most common cause of lateral elbow pain, care should be
taken to rule out other possible causes, such as radial tunnel
syndrome, intra-articular pathological abnormality (radio-
capitellar plica, chondromalacia), lateral collateral ligament
sprain or insufficiency, triceps tendonitis, iatrogenic injuries,
and referred pain from cervical spine or shoulder surgery.
Diagnostic imaging, although not required for diagnosis of
lateral epicondylitis, might be helpful in ruling out other
diagnoses. Additionally, magnetic resonance imaging
might prove helpful for establishing the extent of disease
in preoperative planning for chronic lateral epicondylitis
resistant to treatment.1
TREATMENT
The vast majority of cases of lateral epicondylitis are self-
limited, with 7080% of patients improving within
12 months, with or without treatment.4 Considering the
typical natural history of the condition, the first line of
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
613
treatment is conservative, including activity modification,
rest, application of ice, physical therapy, and short courses of
nonsteroidal anti-inflammatory drugs.2,12 Interestingly, it
was previously thought that inappropriate grip size of tools
and tennis rackets contributed to the development of lateral
epicondylitis; however, a recent electromyographic study of
tennis players, conducted by Hatch et al.,13 suggested no
difference in muscle activity with variation in grip size.
Therefore, equipment modification might not be an effec-
tive conservative treatment. If initial treatment fails, many
more involved and invasive methods of treating lateral
epicondylitis can be performed, culminating in surgical
options for severe, chronic, debilitating lateral epicondylitis.
However, the best treatment is not clear.
Nonsurgical Treatment
As noted, many nonsurgical treatments are available for lateral
epicondylitis. If initial nonsurgical management fails, several
more involved modalities can be considered, such as bracing,
corticosteroid and other injections, ultrasound therapy, and
extracorporeal shock wave therapy. The mechanism of most is
poorly understood. For instance, it is not clear why nonster-
oidal anti-inflammatory medications are of benefit in a con-
dition thought not to be inflammatory. The effectiveness of
many of the treatment modalities also is largely unproven.
Several recent studies have evaluated the methods and
proposed novel treatments. Perhaps the most intriguing have
been randomized trials comparing some of the most com-
mon treatments: corticosteroid injection, physical therapy,
and observation. Tonks et al.4 and Bisset et al.14 conducted
randomized controlled trials of patients with lateral epicon-
dylitis of at least 6 weeks duration. The studies showed the
short-term results (after 7 and 6 weeks of therapy, respect-
ively) of corticosteroid therapy to be superior to those
of physical therapy or observation alone. Additionally,
Tonks et al.4 studied one group that received both corticos-
teroid injection and physiotherapy. The authors found no
synergistic effect or improvement in that group compared
with the group of patients who received corticosteroid injec-
tion alone. Although Tonks et al.4 offered no longer term
data, Bisset et al.14 continued following patients and found
that at 1 year, the physiotherapy group performed signifi-
cantly better than did either of the other groups, and the
corticosteroid group fared worse than the wait-and-see
group. The trial presented by Bisset et al.14 also found
significantly higher recurrence rates long term in their
corticosteroid group, with 47 of 65 successes experiencing
relapse. It should also be noted that the trial presented by
Bisset et al.14 included more patients (198 patients) than the
trial presented by Tonks et al.4 (48 patients). The long-term
data call into question whether the short-term benefit of
corticosteroid injection is worth the long-term con-
sequences, although it remains true that most cases improve
in the long term regardless of the treatment modality.
Other notable studies of nonsurgical treatments have
recently been conducted. In a multicenter randomized con-
trolled trial, Placzek et al.12 found botulinum toxin A to
be more effective than placebo in treating chronic lateral
epicondylitis. They also found no significant difference in
614
wrist extension strength or fist closure strength between
groups. They did find significantly weaker third finger exten-
sion in the botulinum toxin A group, which recovered by
18 weeks. No patient lost time from work because of forearm
muscle weakness. A double-blind randomized controlled trial
by DVaz et al.6 found no benefit in pulsed low-intensity
ultrasound therapy over placebo for lateral epicondylitis of
more than 6 weeks duration, suggesting that ultrasound
therapy is not an effective treatment for lateral epicondylitis.
Faes et al.15 conducted a randomized controlled trial of
dynamic extensor bracing and no brace treatment and found
significant pain reduction, improved function, and improved
pain-free grip strength in patients in the bracing group,
which persisted even 12 weeks after discontinuation of the
brace. Additionally, Takahashi et al.16 conducted a laboratory
study of rats that suggested a possible explanation for pain
relief with bipolar radiofrequency microtenotomy. The
authors found that the therapy caused acute degeneration
or ablation of sensory nerve fibers in the foot pads of rats, a
possible mechanism for the pain relief noted in patients. In a
cohort study, Mishra and Pavelko17 achieved improvement
in patients with chronic lateral epicondylitis with injection
of platelet-rich plasma. That study included only 20 patients
and lacked a randomized control group; however, it
presented an interesting idea for treatment, considering
that recent studies suggested that vascular deficiency of
the area plays a role in development of lateral epicondylitis.
Despite all the active research into nonsurgical treatment
modalities for lateral epicondylitis, the best course of
action remains unclear. It is likely that as the cause of the
condition is better understood, treatments will continue
to improve.
Surgical Treatment
If nonsurgical treatment fails, several surgical options for the
treatment of chronic lateral epicondylitis are available. It is
important to remember that more than 90% of patients will
recover with nonsurgical treatment.7 The many surgical
techniques described can be broadly divided into open,
arthroscopic, and percutaneous approaches. No prospective,
randomized controlled trials comparing the three techniques
have been conducted.
Certain strengths and weaknesses are inherent to each
technique. An open technique allows for the best exposure
but might involve the longest recovery because it is the most
invasive. A percutaneous approach lends itself to rapid recov-
ery because it is minimally invasive but does not allow
expsosure afforded by an open procedure. Although arthro-
scopic treatment theoretically allows for an adequate view
and treatment of intra-articular pathological abnormality
while being minimally invasive, improved results have not
been reported in the literature.
The surgical treatment technique originally presented by
Nirschl and Pettrone7 involves open debridement and repair
of the tendons along with decortication through drilling of the
lateral epicondyle. Khashaba18 compared a Nirschl tennis
elbow release with and without drilling of the lateral epicon-
dyle and found significantly more bleeding, stiffness, and
pain in patients who underwent drilling. A more recent
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Volume 19  Number 6  November/December 2008
retrospective review reported painful and slow recovery in
patients who underwent drilling of the lateral epicondyle
and debridement without repair.19 St. Pierre and Nirschl20
instead advocated a mini-open surgical approach, which is a
less invasive modification of the initial successful technique
presented by Nirschl and Pettrone7 and caution against
drilling the lateral epicondyle. Additionally, because the open
technique was the first to be used, it is the only technique with
long-term data that include 1014 years of follow-up results.
Although their results were impressive, with 84% of patients
maintaining good-to-excellent results during long-term
follow-up, it is unknown how the data will compare in the
future with long-term data regarding other approaches. The
biases of retrospective, nonrandomized studies bring into
question the true outcomes in this patient population.
Many studies have shown good results with arthroscopy,
including a recent study of 20 patients conducted by Jerosch
and Schunck.21 However, some evidence indicates that the
ability to see pathology with arthroscopy is inferior to open
procedures, and debridement of areas of tendinosis often is
incomplete, which may result in poorer outcomes.22 Despite
the drawbacks, the need for access to treat concomitant intra-
articular pathological abnormalities should keep the option
of arthroscopy viable.
Good studies comparing the techniques are lacking. A
randomized controlled trial of the open technique originally
presented by Nirschl and Pettrone7 and the percutaneous
technique was published in 2004, and showed a quicker
return to work in the percutaneous group.23 A recent retro-
spective review of 109 patients compared the three major
methods of surgical treatment and found all three to be
highly effective treatments for chronic resistant lateral epi-
condylitis.24 Although advancement in surgical techniques
continues, it remains unclear whether open, arthroscopic, or
percutaneous treatment is best.
CONCLUSION
Recent studies of lateral epicondylitis have brought more
insight into the biology of the condition, which likely will
help to improve treatment. The natural history of lateral
epicondylitis is one of nearly complete recovery for the
majority of patients regardless of treatment, rendering a com-
parative study of different treatments difficult. Recent research
suggests that physical therapy might be the most effective
nonsurgical treatment, although many interesting and novel
treatments are being studied. All surgical approaches have
yielded good results; however, a randomized controlled trial
of the most commonly used techniques would be beneficial.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of
review, have been highlighted as:
 of special interest
 of outstanding interest
1. Faro F, Wolf JM. Lateral epicondylitis: review and current con-
 cepts. J Hand Surg [Am]. 2007; 32:12711279.
The above study is an excellent and thorough recent review of lateral
epicondylitis and its treatment choices.
Current Orthopaedic Practice
2. Jobe FW, Ciccotti MG. Lateral and medial epicondylitis of the
elbow. J Am Acad Orthop Surg. 1994; 2:18.
3. Oskarsson E, Gustafsson BE, Pettersson K, Aulin KP. Decreased
intramuscular blood flow in patients with lateral epicondylitis.
Scand J Med Sci Sports. 2007; 17:211215.
4. Tonks JH, Pai SK, Murali SR. Steroid injection therapy is the
 best conservative treatment for lateral epicondylitis: a prospec-
tive randomised controlled trial. Int J Clin Pract. 2007; 61:240
246.
The above randomized controlled trial studied corticosteroid injec-
tion alone versus injection and physiotherapy versus physiotherapy
alone versus observation only in patients with lateral epicondylitis of
at least 6 weeks duration with results determined after 7 weeks of
treatment. This study found corticosteroid injection to be the most
effective treatment.
5. Bishai SK, Plancher KD. The basic science of lateral epicon-
dylosis: update for the future. Tech Orthop. 2006; 21:250
255.
6. DVaz AP, Ostor AJ, Speed CA, et al. Pulsed low-intensity
ultrasound therapy for chronic lateral epicondylitis: a rando-
mized controlled trial. Rheumatology (Oxford). 2006; 45:566
570.
7. Nirschl RP, Pettrone FA. Tennis elbow: the surgical treatment
 of lateral epicondylitis. J Bone Joint Surg Am. 1979; 61:832
839.
This landmark study of 1213 cases of lateral epicondylitis provides
the first characterization of the histologic appearance of tissue in
the condition known as angiofibrotic hyperplasia, describes a
successful surgical technique, and provides insight into the natural
history of the condition considering the large number of patients
followed.
8. Bunata RE, Brown DS, Capelo R. Anatomic factors related to
 the cause of tennis elbow. J Bone Joint Surg Am. 2007; 89:1955
1963.
A cadaver anatomic study of the lateral elbow under static
and dynamic conditions, this study provides evidence for an
anatomic cause for tennis elbow by showing ECRB contact with
the capitellum.
9. Bales CP, Placzek JD, Malone KJ, et al. Microvascular supply of the
 lateral epicondyle and common extensor origin. J Shoulder Elbow
Surg. 2007; 16:497501.
A cadaveric study of the microvascular supply to the common
extensor mass and lateral epicondyle, this study indicates two
hypovascular areas that might contribute to the cause of lateral
epicondylitis.
10. Zeisig E, O hberg L, Alfredson H. Extensor origin vascularity
related to pain in patients with tennis elbow. Knee Surg Sports
Traumatol Arthrosc. 2006; 14:659663.
11. Dorf ER, Chhabra AB, Golish SR, et al. Effect of elbow position on
grip strength in the evaluation of lateral epicondylitis. J Hand Surg
[Am]. 2007; 32:882886.
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
615
12. Placzek R, Drescher W, Deuretzbacher G, et al. Treatment of
 chronic radial epicondylitis with botulinum toxin A: a double-
blind, placebo-controlled, randomized multicenter study. J Bone
Joint Surg Am. 2007; 89:255260.
The above randomized controlled trial that studied botulinum toxin
A versus placebo in the treatment of chronic lateral epicondylitis of a
mean duration of 9 months found significant improvement in pain
score throughout the study. Additionally, patients and doctors
global assessments significantly improved from the 6th week of
treatment with botulinum toxin A onward.
13. Hatch GF III, Pink MM, Mohr KJ, et al. The effect of tennis racket
grip size on forearm muscle firing patterns. Am J Sports Med. 2006;
34:19771983.
14. Bisset L, Beller E, Jull G, et al. Mobilisation with movement and
 exercise, corticosteroid injection, or wait and see for tennis
elbow: randomised trial. BMJ. 2006; 333:939944.
This is a randomized controlled trial that studied corticosteroid
injection versus physiotherapy versus observation in patients
with lateral epicondylitis of at least 6 weeks duration with results
determined at 6 weeks and at 1 year. The study found that at 6 weeks,
corticosteroid injection yielded the best results but that by 1 year the
corticosteroid injection group performed worst and suffered the
highest relapse rates. At 6 weeks, the physiotherapy group did better
than the wait and see group, and at 1 year the physiotherapy group
performed the best of all groups.
15. Faes M, van den Akker B, de Lint JA, et al. Dynamic extensor brace
for lateral epicondylitis. Clin Orthop Relat Res. 2006; 442:149157.
16. Takahashi N, Tasto JP, Ritter M, et al. Pain relief through an
antinociceptive effect after radiofrequency application. Am J
Sports Med. 2007; 35:805810.
17. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with
buffered platelet-rich plasma. Am J Sports Med. 2006; 34:1774
1778.
18. Khashaba A. Nirschl tennis elbow release with and without
drilling. Br J Sports Med. 2001; 35:200201.
19. Zingg PO, Schneeberger AG. Debridement of extensors and dril-
ling of the lateral epicondyle for tennis elbow: a retrospective
follow-up study. J Shoulder Elbow Surg. 2006; 15:347350.
20. St. Pierre P, Nirschl RP. Mini-open surgical management of tennis
elbow pathology. Tech Orthop. 2006; 21:266275.
21. Jerosch J, Schunck J. Arthroscopic treatment of lateral epicondy-
litis: indication, technique and early results. Knee Surg Sports
Traumatol Arthrosc. 2006; 14:379382.
22. Cummins CA. Lateral epicondylitis: in vivo assessment of arthro-
scopic debridement and correlation with patient outcomes. Am J
Sports Med. 2006; 34:14861491.
23. 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; 86:701704.
24. Szabo SJ, Savoie FH III, Field LD, et al. Tendinosis of the extensor
carpi radialis brevis: an evaluation of three methods of operative
treatment. J Shoulder Elbow Surg. 2006; 15:721727.