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Soft Tissue & Overuse

Lateral & medial epicondylitis, ulnar collateral ligament injury: pathophysiology, non-operative management, and surgical options.

Overview

Evaluation of acute cervical soft-tissue injury requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury [2]. Confirmatory imaging is warranted when abnormal findings suggest severe soft tissue injury to guide management [1]. Emerging surgical techniques based on improved management have resulted in decreased rates of soft-tissue complications associated with closed fractures [4]. Understanding the current evidence and appropriate indications of emerging technologies in orthopaedic trauma is of critical importance for their utilization [64].

Nonsurgical treatment typically allows safe return to sport for chronic/overuse elbow disorders, while surgical intervention is reserved only for the few cases with recalcitrant symptoms [7]. Most cases of lateral epicondylitis respond to appropriate nonoperative treatment protocols, but when unsuccessful, surgical interventions may be performed with a high rate of success [20]. Routine use of radiographs is not recommended for lateral epicondylitis to avoid overinterpretation of findings [6]. Arthroscopic treatment of lateral epicondylitis offers advantages including the ability to address other intra-articular sources of pain, a potentially faster return to work and sports, and a smaller incision [62]. Ultrasonic percutaneous tenotomy is one of the few procedures to demonstrate positive sonographic evidence of tissue-healing response and is an attractive alternative to surgical intervention for definitive treatment of recalcitrant elbow tendinopathy [65].

Prolotherapy has shown positive results for several upper extremity conditions, has an excellent safety profile and low cost, although further investigation with well-designed study protocols is necessary prior to its widespread use [23]. Complication rates are low for endoscopic treatment of both acute and chronic proximal hamstring pathology with attention to detail [8]. Non-surgical treatment is a viable option for proximal hamstring tendon avulsion in lower physical demand patients [15].

Anatomy & Pathophysiology

Osseous & Articular Pathology

Osteochondritis dissecans of the elbow involves specific aetiology, clinical presentation, diagnostics, surgical techniques, complications, and clinical outcomes [16]. Management is dictated by lesion stability: Stable lesions are generally treated conservatively [16], whereas unstable lesions require surgical management [16].

Posteromedial elbow impingement is the most common diagnosis for posterior elbow pain in Japanese high school baseball players [18]. In contrast, posterolateral elbow impingement in professional boxers is caused by hyperextension trauma without valgus overload [47].

Soft Tissue & Tendinopathy

The multifactorial etiology of lateral elbow tendinopathy involves tendon pathology, the pain system, and proprioception [54]. Clinical parameters of lateral epicondylitis may be influenced by several factors [46]. Instability can coexist with and may be associated with refractory lateral epicondylitis [55].

Imaging findings must be interpreted with caution regarding age and symptom status. Increased MRI signal in the extensor carpi radialis brevis (ECRB) origin is common in both symptomatic and asymptomatic elbows [22]. This increased signal is more common with age [22].

Predisposing Factors & Diagnostic Challenges

Misdiagnosis of lateral elbow pain can occur in patients with longstanding symptoms [3]. Differing anatomy in the lateral elbow may be a predisposing risk factor for radial head stress fractures in pediatric female gymnasts [29].

Classification

Lateral Elbow Tendinopathy Grading: Lateral elbow tendinopathy is graded into four distinct grades based on pathophysiology to guide management [12].

MRI-Based Classification: A six-stage MRI-based classification for lateral epicondylitis, utilizing grade and location of injury, demonstrates substantial to near-perfect agreement among fellowship-trained observers [24].

Failed Surgical Treatment Classification: An expanded classification system for failed surgical treatment of lateral epicondylitis has been presented to guide evaluation and salvage surgery [11].

Diagnostic Considerations: A misdiagnosis of lateral epicondylitis can occur in patients with longstanding lateral elbow pain [3].

Achilles Tendon Classification: There is no clear consensus on the definition of a chronic Achilles disorder or a uniform classification and treatment scheme [44]. The classification of midportion and insertional tendinopathy and retrocalcaneal bursitis in the Achilles tendon should be strictly used as a clinical diagnosis, as more specific pathologies may be identified during surgical evaluation [51].

Clinical Presentation

Evaluation of acute cervical soft-tissue injury requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury [2]. In the elbow, full-thickness triceps tears can be misdiagnosed as olecranon bursitis [1]. Misdiagnosis can also occur in patients with longstanding lateral elbow pain [3].

Lateral epicondylitis is a common tendinosis affecting patients aged 35 to 55 years [10]. Overuse activity is more strongly associated with lateral epicondylitis than metabolic factors [13]. Medial epicondylitis results from repetitive eccentric loading and valgus overload [36].

The most common diagnosis for posterior elbow pain in Japanese high school baseball players is posteromedial elbow impingement [18].

Investigations

Plain radiography: Routine use of radiographs is not recommended for lateral epicondylitis to avoid overinterpretation of findings [6]. Evaluation of acute cervical soft-tissue injury requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury [2]. Misdiagnosis can occur in patients affected by longstanding lateral elbow pain [3]. Physicians should be aware of Charcot joint disease presentation in patients with insensate joints to avoid overtreatment [17]. Pseudogout can mimic synovial chondromatosis clinically and roentgenographically due to extensive calcification of synovial tissue, despite having different treatments [66].

MRI: Increased MRI signal in the extensor carpi radialis brevis (ECRB) origin is common in both symptomatic and asymptomatic elbows [22]. MRI findings suggestive of pathology at the common extensor tendon are prevalent in an asymptomatic population, increasing with age and body mass index (BMI) [48]. Confirmatory imaging is warranted when abnormal findings suggest severe soft tissue injury to guide management [1]. MRI should be performed if healing does not occur by a reasonable time despite successful bony healing to assess potential cartilage damage in osteochondritis dissecans of the capitellum [39].

Ultrasound: Ultrasound (USI) and MRI provide variable diagnostic accuracy for lateral elbow tendinopathy depending on the entities reported and should be recommended with caution when differential diagnosis is necessary [49]. Elastography-ultrasound (EUS) can be used as the initial modality to screen for tendon pathology in athletes and non-athletes prior to advanced imaging such as magnetic resonance imaging (MRI) [52].

Other Considerations: An arthrographic study is indicated in any case in which the diagnosis is doubtful [69].

Treatment

Non-Operative

Confirmatory imaging is warranted when abnormal findings suggest severe soft tissue injury to guide management [1]. Evaluation of acute cervical soft-tissue injury requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury [2]. Routine use of radiographs is not recommended for lateral epicondylitis to avoid overinterpretation of findings [6].

Nonsurgical treatment typically allows safe return to sport in chronic/overuse elbow disorders, with surgical intervention reserved only for cases with recalcitrant symptoms [7]. Non-surgical treatment is a viable option for proximal hamstring tendon avulsion in patients with lower physical demands [15]. Conservative treatment remains the mainstay for spontaneous resorption of calcification at the long head of the biceps tendon, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy [30]. Nonoperative treatment is almost always initiated for primary and posttraumatic arthritis of the elbow, although surgical treatment may be indicated in cases refractory to conservative management [31].

Most patients with lateral epicondylitis experience relief with non-operative management, though controversy remains regarding the optimal modality for quickest recovery and the role of surgical intervention for refractory cases [32]. Most patients with lateral epicondylitis resolve spontaneously or with standard conservative management, but refractory cases may benefit from interventional therapies or surgical approaches [40]. There is little clear consensus on which modality works best for both conservative and operative options for lateral epicondylitis, indicating that the understanding of the disease process is currently incomplete [38]. Extracorporeal shock wave therapy has mixed results in the management of lateral epicondylitis and has not been effective in managing noncalcific tendinosis of the supraspinatus [41]. Reviewed studies have shown positive results for several upper extremity conditions treated with prolotherapy, which has an excellent safety profile and low cost, although further investigation with well-designed study protocols is necessary prior to its widespread use [23]. Physical therapy management of osteochondritis dissecans can incorporate a full spectrum of conservative, nonoperative, and postoperative care [42].

Operative

Indications: Surgical intervention is reserved for lateral epicondylitis cases that fail appropriate nonoperative treatment protocols [20]. Endoscopic treatment is indicated for both acute and chronic proximal hamstring pathology [8]. Ankle arthroscopy appears to give good results when used for appropriate indications [58].

Surgical Approach / Technique: A pathophysiology-based treatment algorithm grading tendinopathy into four distinct grades is proposed to guide management and future investigation for lateral elbow tendinopathy [12]. An expanded classification system and a systematic approach to evaluation, including a salvage surgery technique to address common etiologies of failure, are presented for failed surgical treatment of lateral epicondylitis [11].

Adjuncts: SS-31 may be a useful strategy to promote healing of tendinopathy and might be most effective when combined with surgical treatment [60].

Other Considerations: Both surgery and placebo procedures improved patient-rated pain frequency and severity, elbow stiffness, difficulty with picking up objects, twisting motions, and overall elbow rating over 6 months and maintained benefits after 12 months in a randomized trial for lateral epicondylitis [19]. A prospective, randomized, double-blinded, placebo-controlled clinical trial failed to show additional benefit of surgical excision of the degenerative portion of the ECRB over placebo surgery for the management of chronic tennis elbow [57].

Complications

Diagnostic Errors: Misdiagnosis of full-thickness triceps tears as olecranon bursitis can occur [1]. Misdiagnosis of lateral elbow pain as lateral epicondylitis can occur in patients with longstanding symptoms [3]. Evaluation for soft-tissue injury requires adequate roentgenograms, careful physical examination, and a high degree of suspicion to avoid late deformity [2].

Surgical Technique-Related Complications: Emerging surgical techniques based on improved management have resulted in decreased rates of soft-tissue complications associated with closed fractures [4]. Endoscopic treatment of acute and chronic proximal hamstring pathology has low complication rates with attention to detail [8].

Recovery

Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years [10]. The transient symptoms of tennis elbow reflect the natural course of a self-limiting condition [25].

Light activity (weeks): In most cases, a period of several weeks of wrist immobilization and activity modification leads to a favorable outcome for extensor carpi ulnaris tendon pathology [76].

Full activity (months): Physiotherapy, shockwave therapy, prolotherapy, and platelet-rich plasma are effective nonsurgical options for long-standing lateral epicondylosis with 2-year follow-up [67].

Complete recovery / outcome plateau (months): Favorable short-term outcomes such as reduction of pain and increase in function from arthroscopic treatment of lateral epicondylitis are maintained over long-term follow-up [21]. Ultrasound-guided percutaneous tenotomy demonstrates sustained pain relief and functional recovery, accompanied by sonographic evidence of tissue healing, at 7.5 years [26]. Radiofrequency microtenotomy for epicondylitis has strong clinical support based on long-term follow-up [70].

Rehabilitation protocol: Tendinopathy associated with statins usually occurs within the first year of use and improves after the drug therapy is stopped [27]. Pain sensitization during the early stages of lateral epicondylitis correlates with initial symptom severity and duration and is associated with persistently increasing disability after 1 year of nonsurgical treatment [74].

Functional milestones: Forty-seven (96%) of 49 shoulders had a good clinical result after distal release of deltoid muscle contracture [68]. Endoscopic treatment of acute and chronic proximal hamstring pathology has low complication rates with attention to detail [8].

Key Evidence

  • [Case_report] Confirmatory imaging is warranted when abnormal findings suggest severe soft tissue injury to guide management. (10.1016/j.xrrt.2024.02.002)
  • [Case_report] Evaluation requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury. (10.2106/00004623-197961020-00031)
  • [L4] A misdiagnosis can occur in patients affected by longstanding lateral elbow pain. (10.1177/03635465251319545)
  • [L5] Emerging surgical techniques based on improved management have resulted in decreased rates of soft-tissue complications. (10.5435/00124635-200311000-00007)
  • [L4] Thus, patients and surgeons should be careful to avoid overinterpretation of such findings, and routine use of radiographs is not recommended. (10.1016/j.jhsa.2017.03.016)
  • [Commentary] With attention to detail, complication rates are low for endoscopic treatment of both acute and chronic proximal hamstring pathology. (10.1016/j.arthro.2021.05.051)
  • [L5] Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years. (10.1302/0301-620x.95b9.29285)
  • [L5] The authors present an expanded classification system and a systematic approach to evaluation, including a salvage surgery technique to address common etiologies of failure. (10.1016/j.xrrt.2023.07.006)
  • [L5] The authors propose a pathophysiology-based treatment algorithm grading tendinopathy into four distinct grades to guide management and future investigation. (10.1177/2325967116670635)
  • [L3] The study results suggest that overuse activity is more strongly associated with lateral epicondylitis than are metabolic factors. (10.1177/23259671211007734)
  • [L5] Non-surgical treatment is a viable option for lower physical demand patients. (10.1136/jisakos-2019-000420)
  • [L5] The article explores osteochondritis dissecans of the elbow regarding aetiology, clinical presentation, diagnostics, surgical techniques, complications, clinical outcomes, and future directions, noting that stable lesions are generally treated conservatively while unstable lesions require surgical management. (10.1136/jisakos-2015-000008)
  • [Case_report] Physicians should be aware of this presentation in patients with insensate joints to avoid overtreatment. (10.2106/00004623-199274090-00017)
  • [L3] The most common diagnosis for posterior elbow pain was posteromedial elbow impingement, and all players returned to competitive sports activity levels within 77 ± 47 days. (10.1016/j.jse.2016.05.004)
  • [L1] Both the surgery and placebo procedures improved patient rated pain frequency and severity, elbow stiffness, difficulty with picking up objects, twisting motions and overall elbow rating over 6 months and maintained the benefits after 12 months. (10.1016/j.jse.2017.06.019)
  • [L4] Most cases of lateral epicondylitis respond to appropriate nonoperative treatment protocols, but when unsuccessful, surgical interventions may be performed with a high rate of success. (10.1016/j.jse.2009.12.016)
  • [L4] Increased MRI signal in the ECRB origin is common in symptomatic and in asymptomatic elbows. (10.1016/j.jse.2016.01.033)
  • [L4] Reviewed studies have shown positive results for several upper extremity conditions treated with prolotherapy, which has an excellent safety profile and low cost, although further investigation with well-designed study protocols is necessary prior to its widespread use. (10.1016/j.jhsa.2018.05.021)
  • [L4] The newly proposed six-stage MRI-based classification utilizing grade and location of the injury was found to have substantial to near perfect agreement between and within fellowship-trained observers. (10.1016/j.jse.2019.04.030)
  • [L4] The transient symptoms of tennis elbow seen in these two cases reflect the natural course of a self-limiting condition. (10.1007/s00167-012-1939-0)
  • [L4] At long term follow up, ultrasound-guided percutaneous tenotomy demonstrates good sustainability of pain relief and functional recovery that was previously achieved, accompanied with sonographic evidence of tissue healing at 7.5 years. (10.1177/2325967120s00420)
  • [L4] Tendinopathy usually occurs within the first year of statin use and improves after the drug therapy is stopped. (10.2106/jbjs.rvw.15.00072)
  • [L4] Additionally, differing anatomy in the lateral elbow may be a predisposing risk factor for radial head stress fractures and merits further investigation. (10.1016/j.arthro.2020.12.128)
  • [L4] Conservative treatment remains the mainstay, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy. (10.1177/1758573214567559)
  • [L5] Nonoperative treatment is almost always initiated although surgical treatment may be indicated in cases refractory to conservative management. (10.1155/2013/473259)
  • [L5] This article serves to provide an updated review of the various treatment options and management for lateral epicondylosis, noting that while most patients experience relief with non-operative management, controversy remains regarding the optimal modality for quickest recovery and the role of surgical intervention for refractory cases. (10.1016/j.jhsa.2024.07.003)
  • [L5] Medial epicondylitis is a common pathology resulting from repetitive eccentric loading and valgus overload, typically managed initially with nonsurgical supportive care including activity modification and rehabilitation, with surgical treatment reserved for persistent symptoms. (10.5435/JAAOS-D-14-00145)
  • [L4] Although many treatments have been advocated for lateral epicondylitis, there is little clear consensus on which modality works best for both conservative and operative options, indicating that the understanding of the disease process is currently incomplete. (10.1016/j.jhsa.2007.07.019)
  • [Case_report] The authors recommend performing an MRI if healing does not occur by a reasonable time despite successful bony healing to assess potential cartilage damage. (10.1007/s00402-005-0018-0)
  • [L4] Most patients with lateral epicondylitis resolve spontaneously or with standard conservative management, but refractory cases may benefit from interventional therapies or surgical approaches. (10.5397/cise.2019.22.4.227)
  • [L5] Results have been mixed in the management of lateral epicondylitis, and this therapy has not been effective in managing noncalcific tendinosis of the supraspinatus. (10.5435/00124635-200604000-00001)
  • [Paper] Physical therapy management of osteochondritis dissecans can incorporate a full spectrum of conservative, nonoperative, and postoperative care. (10.1016/j.csm.2014.01.001)
  • [L5] There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme. (10.5435/00124635-200901000-00002)
  • [L4] The clinical parameters of lateral epicondylitis may be influenced by several factors. (10.1186/s13018-021-02406-5)
  • [L4] Posterolateral elbow impingement in boxers is caused by hyperextension trauma without valgus overload. (10.1177/0363546507308937)
  • [L4] MRI findings suggestive of pathology at the common extensor tendon are prevalent in an asymptomatic population, increasing with age and BMI. (10.1177/17585732221146731)
  • [L1] USI and MRI provide variable diagnostic accuracy depending on the entities reported and should be recommended with caution when differential diagnosis is necessary. (10.1016/j.jht.2021.02.002)
  • [L4] The classification of midportion and insertional tendinopathy and retrocalcaneal bursitis in AT should strictly be used as a clinical diagnosis, as more specific pathologies may be identified during surgical evaluations. (10.1177/2325967114562371)
  • [L4] EUS can be used as the initial modality to screen any tendon pathology both in athlete and non-athlete, prior to advance imaging such as magnetic resonance imaging (MRI). (10.1177/2325967119s00483)
  • [L5] The multifactorial etiology of lateral elbow tendinopathy makes finding one effective treatment intervention elusive; a multifaceted treatment method addressing tendon pathology, the pain system, and proprioception may be the answer to resolving symptoms and eliminating recurrence. (10.1016/j.jht.2018.04.002)
  • [L1] Instability can coexist and may be associated with refractory lateral epicondylitis. (10.1177/0363546520980133)
  • [L2] With the number of available participants, this study failed to show additional benefit of the surgical excision of the degenerative portion of the ECRB over placebo surgery for the management of chronic tennis elbow. (10.1177/0363546517753385)
  • [L5] When used for the appropriate indications, ankle arthroscopy appears to give good results. (10.5435/00124635-199601000-00004)
  • [L5] SS-31 may be a useful strategy to promote healing of tendinopathy and might be most effective when combined with surgical treatment. (10.1177/2325967121s00661)
  • [L4] Advantages include the ability to address other intra-articular sources of pain, a potentially faster return to work and sports, and a smaller incision. (10.1016/j.jhsa.2009.02.027)
  • [L4] It is one of the few procedures to demonstrate positive sonographic evidence of tissue-healing response and is an attractive alternative to surgical intervention for definitive treatment of recalcitrant elbow tendinopathy. (10.1177/0363546515612758)
  • [L4] Pseudogout can mimic synovial chondromatosis clinically and roentgenographically due to extensive calcification of synovial tissue, but the two diseases have different treatments. (10.2106/00004623-197557060-00030)
  • [L2] The findings support the potential of these therapies as effective nonsurgical options for long-standing cases. (10.1177/03635465251361515)
  • [L3] Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture. (10.2106/00004623-199802000-00010)
  • [L4] An arthrographic study is indicated in any case in which the diagnosis is doubtful. (10.2106/00004623-195739060-00004)
  • [L4] There appears to be strong clinical support for this micro-invasive procedure based on longterm follow-up. (10.1016/j.arthro.2008.04.065)
  • [L3] Pain sensitization during the early stages of lateral epicondylitis correlated with initial symptom severity and duration and was associated with persistently increasing disability after 1 year of nonsurgical treatment. (10.1016/j.jhsa.2018.06.013)
  • [L4] In most cases, a period of several weeks of wrist immobilization and activity modification will lead to a favorable outcome. (10.2106/jbjs.rvw.n.00070)

See Also

References

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[7] Chapter 8 Chronic/Overuse Elbow Disorders. 2019.

[8] Editorial Commentary: Endoscopic Proximal Hamstring Repair Is Safe and Effective for Refractory Tendinosis and Partial Tears: “Pain in the Butt” Has an Endoscopic Solution!. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2021.05.051

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[26] Ultrasound-guided Percutaneous Tenotomy Shows Sustained Clinical and Sonographic Outcomes for Recalcitrant Lateral Elbow Tendinopathy at 7.5 Years. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120s00420

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[55] Systematic Review of Elbow Instability in Association With Refractory Lateral Epicondylitis: Myth or Fact?. The American Journal of Sports Medicine. 2021. DOI: 10.1177/0363546520980133

[57] Surgical Treatment of Lateral Epicondylitis: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546517753385

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[62] Arthroscopic Treatment of Lateral Epicondylitis. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.02.027

[64] Chapter 3 Emerging Technologies in Orthopaedic Trauma. 2021.

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[66] Pseudogout mimicking synovial chondromatosis. The Journal of Bone & Joint Surgery. 1975. DOI: 10.2106/00004623-197557060-00030

[67] Comparing the Use of Physiotherapy, Shockwave Therapy, Prolotherapy, and Platelet-Rich Plasma for Chronic Lateral Epicondylosis: A Prospective, Randomized Controlled Trial With 2-Year Follow-up. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251361515

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