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Tendinopathies

Lateral & medial epicondylitis: pathophysiology, conservative management, and indications for surgical intervention (debridement, release).

144 citationsUpdated Sep 2026

Overview

Tendinopathy encompasses a spectrum of degenerative and inflammatory conditions affecting tendons, with precise distinctions between tendinopathy, tendinosis, and peritendinitis established by the Spanish Consensus Statement [4]. This consensus provides recommendations for clinical management based on expert agreement and current scientific data [4]. For lateral elbow tendinopathy, no single nonoperative treatment reliably achieves outstanding results, likely due to the inclusion of heterogeneous patient groups rather than categorization by disease severity [2]. Similarly, while numerous treatment options exist for epicondylitis, no single universally accepted protocol has emerged [11]. Despite a wealth of research, there is no true consensus on the most efficacious management of tennis elbow, especially for effective long-term outcomes [16]. The BESS patient care pathway provides a guidance summary for the management of lateral elbow tendinopathy using the GRADE system, establishing recommendations based on the quality of available evidence and the balance between desirable and undesirable consequences of alternative management options [32].

Nonoperative treatment remains the initial strategy for tendinopathy and for low-demand patients with partial tears of the distal biceps tendon [24]. 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 [67]. However, pooled data from RCTs indicate a lack of intermediate- to long-term clinical benefit after nonsurgical treatment of lateral epicondylitis compared with observation only or placebo [12]. Persistent tennis elbow symptoms are a poor indication for surgery as the majority of patients experience symptom resolution without it, and surgeons are unable to reliably predict who will or will not improve with nonoperative treatment [152]. In the group treated nonoperatively for patellar tendinopathy, results were better in patients who had stage 2 tendinopathy than in those with stage 3 [7].

Surgical treatment for chronic patellar tendinopathy leads to substantial improvements in functional outcomes [10]. For lateral epicondylitis, complete resection of the tendinosis tissue with the sparing of normal tissue can lead to durable results at long-term follow-up [17]. A prospective, randomized, double-blinded, placebo-controlled clinical trial 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 [62]. In recovered and unrecovered groups following arthroscopic debridement for refractory lateral epicondylitis, improvement of tendinopathy area was 60% versus 16%, indicating that postoperative MRI findings reflect clinical outcomes [9]. A large percentage of patients who fail conservative treatment for medial humeral epicondylitis (tendinosis) can obtain pain relief and return to activities with the described operative technique [165]. Ultrasound-guided tenotomy with TenJet is a safe, effective, and well-tolerated treatment for common extensor tendinopathy [46]. In a series of seven patients with refractory chronic lateral elbow tendinopathy treated with ultrasonic percutaneous tenotomy, ASES scores significantly improved from 55.6 preoperatively to 94.1 at 2 years (P < 0.001) [75]. 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 [166]. Autologous tenocyte injection provides evidence for the midterm durability of treatment for lateral epicondylitis tendinopathy [8]. The use of extracorporeal shock wave therapy in alternative doses and/or different dosage intervals in the management of tendinopathies warrants further research before it can be advocated for such conditions [36]. Evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited [20]. Clearly defined minimal important differences should be used with consistency in tendinopathy management studies in the future [14]. The Patient-Rated Tennis Elbow Evaluation is not recommended for use as an outcome measure in studies evaluating interventions for lateral epicondylitis until further development and validation are performed [158]. The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair [60].

Anatomy & Pathophysiology

Bony Anatomy

The elbow is a trocho-ginglymoid joint comprising medial and lateral articulations that provide bony stability [86]. The ulnohumeral joint forms where the trochlea articulates with the ulna within the greater sigmoid notch, while the radiocapitellar joint forms at the articulation of the capitellum with the radial head [86]. The proximal radioulnar joint is defined by the articulation of the radial head with the lesser sigmoid notch of the ulna [86]. The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [86]. The distal humeral articular surface is angled 30° from the longitudinal axis of the humerus [86] and is angled 30 degrees anterior to the humeral shaft axis [93]. The axis of rotation is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side more distal than the lateral side [86].

The distal humeral shaft is triangular in cross-section with its apex directed anteriorly [99]. The medial column of the distal humerus diverges approximately 45 degrees from the humeral shaft in the coronal plane, while the lateral column diverges at approximately 20 degrees from the shaft in the coronal plane [99]. The lateral column curves anteriorly, creating a 35 to 40 degrees angle with the shaft in the sagittal plane [99]. In the coronal plane, the trochlea is more distal than the capitellum, resulting in a valgus alignment of 4 to 8 degrees [99]. The overall valgus angle of the elbow in extension, including the ulna, is 10 to 17 degrees [99]. The distal humerus articular surface is internally rotated 3 to 8 degrees axially [99]. The trochlea is covered by articular cartilage anteriorly, inferiorly, and posteriorly, creating an arc of almost 270 degrees [99]. The olecranon fossa and coronoid fossa are separated by a thin bony septum [99]. The posterior aspect of the lateral column is relatively flat and wide, allowing for the application of a posterolateral plate [99].

The medial epicondyle serves as the origin for the flexor-pronator muscle group and the medial collateral ligament [96]. The lateral epicondyle is the origin of the extensor-supinator muscle group and the lateral collateral ligament complex [96]. The ulnar nerve lies in a bony groove covered and restrained by the arcuate ligament posterior to the medial epicondyle [96]. The sublime tubercle, located just distal and medial to the coronoid, provides the attachment site for the anterior bundle of the medial ulnar collateral ligament [86]. The less prominent lateral epicondyle is the origin of the lateral extensor musculature [86]. The origin of the lateral ulnar collateral ligamentous complex is located just distal to the lateral epicondyle at the geometric center of the radiocapitellar articulation [86]. The olecranon provides a broad attachment site for the triceps posteriorly [86]. The ulna bends approximately 8° medially at 8 cm from the tip of the olecranon [86]. The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [86].

Ligamentous Anatomy

The medial ulnar collateral ligament (MUCL) is the primary restraint to valgus stress within functional elbow range of motion [93]. The MUCL is comprised of the anterior bundle, posterior bundle, and transverse ligament [83]. The anterior bundle of the MUCL originates on the posterior medial epicondyle and inserts on the sublime tubercle of the medial coronoid process [93]. It is the strongest component of the ligamentous complex and the primary restraint to valgus stress [83]. The anterior band of the MUCL is tight in extension, while the posterior band is tight in flexion [83]. The posterior bundle of the MUCL is the primary restraint to valgus stress with the elbow in maximal flexion [93] and becomes taut at flexion beyond 120 degrees [87]. Stability in full elbow extension is provided by the MCL, joint capsule, and ulnohumeral articulation [93].

The lateral collateral ligament complex consists of the radial collateral ligament, the lateral ulnar collateral ligament (LUCL), and the annular ligament [99]. The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch [99]. The radial collateral ligament originates from an isometric point on the lateral epicondyle and fans out to attach to the annular ligament [99]. The lateral ulnar collateral ligament arises from an isometric point on the lateral epicondyle and attaches to the crista supinatoris of the proximal ulna [99]. The LUCL origin center is 10.7 mm from the lateral epicondyle, and its insertion is 3.3 mm from the apex of the supinator crest [83]. The lateral collateral ligament complex functions as an important restraint to varus and posterolateral rotatory instability [99].

Tensile forces are present at the medial elbow, while compressive forces are present at the lateral elbow [87]. The elbow capsule allows maximum distension at approximately 70 to 80 degrees of flexion [87]. The anterior capsule attaches at a point approximately 6 mm distal to the tip of the coronoid [87]. Osborne’s ligament stabilizes the ulnar nerve in the cubital tunnel [87]. The ligament of Struthers is a variant anatomy arising from the supracondylar process to attach to the medial epicondyle and is a potential site of median nerve compression [87].

Muscular Anatomy

The brachialis is the strongest elbow flexor and attaches to the coronoid 11 mm distal to the tip [87]. It inserts on the coronoid process and the tuberosity of the ulna anteriorly [95]. The biceps brachii inserts at the ulnar margin of the radial tuberosity, with the long head inserting proximally and the short head distally [87]. The biceps brachii is a powerful supinator of the forearm [87]. The triceps is the primary elbow extensor and inserts on the olecranon process [87]. The triceps has a broad tendinous insertion into the olecranon posteriorly [95]. The distal triceps tendon has three distinct insertional areas to the olecranon: posterior capsular insertion, deep muscular portion, and superficial tendinous portion [83]. The deep muscular head of the triceps corresponds to the medial head, while the tendinous portion corresponds to the long and lateral heads [83]. The width of the triceps insertion is 2.6 cm and is located 1.1 cm from the tip of the olecranon [83].

The mobile wad consists of the brachioradialis, extensor carpi radialis longus (ECRL), and extensor carpi radialis brevis (ECRB) [87]. The flexor-pronator mass consists of the pronator teres, flexor carpi radialis (FCR), palmaris longus, flexor carpi ulnaris (FCU), and flexor digitorum superficialis (FDS) [87]. The common origin of the extensor muscles is attached to the lateral epicondyle [89]. The supinator-extensor muscle group attaches to the lateral epicondyle, which is slightly proximal and lateral to the capitellum [95].

The radial nerve enters the interval between the brachialis and brachioradialis muscles in the proximal angle of the lateral approach wound [89]. The deep branch of the radial nerve enters the supinator muscle near the radiohumeral joint [89]. The radial nerve splits into the superficial sensory branch and the posterior interosseous nerve on the anterolateral side of the elbow [101]. The posterior interosseous nerve is just superficial to the anterior joint capsule at the level of the radiocapitellar joint and courses longitudinally along the medial side of the capitellum [101]. At the level of the radial neck, the posterior interosseous nerve may come in direct contact with the joint capsule [101]. The median nerve and brachial artery are located just superficial to the anteromedial joint capsule and brachialis muscle [101]. The ulnar nerve is located just superficial to the posteromedial joint capsule [101]. The ulnar nerve passes through the cubital tunnel at the medial column of the elbow [95]. The ulnar nerve enters the anterior forearm by traveling between the two heads of the flexor carpi ulnaris [95].

Pathophysiology

Lateral elbow tendinopathy is a degenerative condition representing a failed healing tendon response rather than an inflammatory process [79]. It is characterized by disorganized collagen, an increased presence of fibroblasts, the absence of prostaglandins, and the absence of inflammatory cells [79]. Chronic overuse tendon injuries result from multiple microtraumatic events that cause disruption of the internal structure of the tendon and degeneration of cells and matrix [162]. Histopathological studies of chronic overuse tendons show an absence of large numbers of macrophages, lymphocytes, or neutrophils [162]. Tendinosis is characterized by dense populations of fibroblasts, vascular hyperplasia, and disorganized collagen [162]. The histopathological constellation of fibroblast hyperplasia and vascular changes in tendinosis is termed angiofibroblastic hyperplasia [162]. Chronic tendinopathy is a process of degradation involving neovessel formation, neoinnervation, and synovitis [18].

Overuse is considered the initial disease factor in tendinopathy, leading to microruptures of tendon fibers [38]. In tendinopathy, several molecules are expressed following microruptures, some promoting healing while others, including inflammatory cytokines, act as disease mediators [38]. Low-grade inflammation plays a role in the pathogenesis of tendinopathy, with proinflammatory cytokines, proteolytic enzymes and growth factors exerting a negative influence on tendon healing [161].

Tendons act as springs to make muscle movement more efficient, with recoil increasing with higher load [151]. Tendons are most efficient when close to, but not quite at, their failure point [151]. Healthy tendons can strengthen in response to gradual increases in load but can fail if the loading increase is too sudden or too great [151]. Sudden overload may alter tendon structure and initiate a degenerative process [151]. Tendinopathy exists on a continuum of injury phases: initial reactive tendinopathy, tendon disrepair, and degenerative tendinopathy [151]. The phase of tendinopathy injury is largely dependent on the length of time the tendon has been unable to cope with increased load [151].

Decreased muscular performance in lateral epicondylitis is associated with both elbow pain and physical damage to the extensor carpi radialis brevis (ECRB) muscle [200]. Muscle strain on the ECRL and ECRB is greatest during elbow extension with forearm pronation and wrist flexion-ulnar deviation [222]. In patients with lateral epicondylitis, grip strength decreases as the elbow moves from a position of flexion to a position of extension [194]. Lateral elbow tendinopathy is characterized by an adaptive motor pattern involving increased relative activation and coactivation of the anconeus muscle depending on grip force [188].

An association exists between biomechanical exposure involving the wrist and/or elbow at work and the incidence of lateral epicondylitis [126]. Combined physical exertion and elbow movements are strongly associated with lateral epicondylitis [156]. Strenuous biomechanical hand and elbow exposures are relevant to the management and prevention of lateral epicondylalgia [160]. Lower racquet string-tensions transmit less force to the elbow in backhand strokes [219]. Tennis biomechanics, player characteristics, and equipment are important factors in preventing lateral epicondylitis [218].

Pathogenesis and Terminology

Tendinopathies of the hand and wrist are common conditions diagnosed by history and examination [1]. Lateral epicondylitis is a degenerative tendinopathy rather than an inflammatory process [5] or an inflammatory tendinitis [19]. Patellar tendinopathy is a degenerative disorder (tendinosis) rather than an inflammatory one [55]. Peritendinitis and degenerative tendinopathy or tendinosis appear to make up the majority of chronic resistant tendon problems [13]. Chronic tendinopathy should be regarded as a process of degradation which appears to involve many aspects of the chronic injury–repair response [18]. The degradation process in chronic tendinopathy has characteristic features of neovessel formation, neoinnervation and synovitis [18]. In the context of overuse as an initial disease factor, microruptures of tendon fibers occur and several molecules are expressed, some promoting healing while others act as disease mediators [38]. Achilles tendinopathy is a chronic, degenerative process [180].

Clinical Diagnosis and Staging

Diagnosis of lateral epicondylitis is primarily clinical, while imaging serves mainly to exclude other pathologies [19]. The BESS patient care pathway provides a guidance summary for the management of lateral elbow tendinopathy using the GRADE system [32]. Clearly defined minimal important differences (MIDs) should be used with consistency in tendinopathy management studies [14].

In patellar tendinopathy, nonoperative results were better in patients with stage 2 tendinopathy than in those with stage 3 [7]. The severity of symptoms in volleyball players with patellar tendinopathy was classified as grade I in 6 knees, grade II in 18 knees, and grade IIIa in 9 knees [197]. Blazina’s classification categorizes symptomatic patellar tendinopathy patients into phase I (pain only after activity), phase II (discomfort during activity), phase III (pain during activity that interferes with participation), and phase IV (complete tendon disruption) [208]. The Victorian Institute of Sport Assessment–Patella (VISA-P) score ranges from a maximum of 100 in asymptomatic patients to a theoretical minimum of 0 [208]. A VISA-P score between 80 and 100 points might be considered as the optimal outcome category for patellar tendinopathy [208]. The Roles and Maudsley score classifies patient satisfaction as Excellent (no pain, full movement and full activity), Good (occasional discomfort, full movement and full activity), Fair (some discomfort after prolonged activity) or Poor (pain limiting activities) [208].

Imaging Classifications

A proposed MRI classification has emerged as one of the most reliable methods to define stages of chronic lateral epicondylitis [59]. The type and extent of pathologic changes within the common extensor tendon can be evaluated using a dedicated low-field MR system [64]. MRI findings for lateral epicondylitis are evaluated in four categories: signal changes in the common extensor tendon origin, signal change of the radial collateral ligament, signal change of the lateral ulnar collateral ligament, and plica [77].

MRI Classification for Common Extensor Tendon Injuries: * Grade 0: Complete homogenous low signal intensity without tendon thickening [77]. * Grade 1: Isointense signal intensity relative to muscle, indicating tendinosis or low-grade partial tear [77].

Modified Steinborn Classification: * Grade 0: A dark tendon with no signal intensity changes [205]. * Grade 1: A focal area of increased signal intensity without tendon thickening [205]. * Grade 2: An area of increased signal intensity involving < 50% of tendon cross section with tendon thickening [205]. * Grade 3: An area of increased signal intensity involving > 50% of tendon cross section with tendon thickening [205].

Rabago Classification: * Grade 0: A normal tendon with uniform low signal intensity [205]. * Grade 1: Mild tendinopathy which is thickened and has intermediate signal intensity [205]. * Grade 2: Moderate tendinopathy which is thinned and shows focal areas of intense fluid-like signal intensity comprising less than 50% of the tendon thickness [205]. * Grade 3: Severe tendinopathy which is thinned and shows focal areas of intense fluid-like signal intensity comprising more than 50% of the tendon thickness [205].

Walz Classification: * Grade 0: Complete homogenous low intensity [205].

Walton’s classification of ECRB tendon injury by preoperative MRI includes grades I through IV [191]. In a study of refractory lateral epicondylitis, 23.1% of patients were classified as grade I, 42.3% as grade II, 26.9% as grade III, and 7.7% as grade IV according to Walton’s classification [191].

Other Classifications

The Snyder classification system is reproducible and can be used in future research studies in analyzing the treatment options of partial rotator cuff tears [147]. A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further [82]. The arthroscopic identification of the 3 types of Baker lesions helps the surgeon to confirm the presence of pathology commonly seen intra-articularly in patients with lateral epicondylitis [143].

Clinical Presentation

Terminology and Pathophysiology

The term "tendinopathy" is defined as persistent tendon pain with associated loss of shoulder function [51]. The label 'subacromial impingement' is no longer recommended for rotator cuff tendinopathy; instead, 'subacromial pain syndrome' and 'RC-related shoulder pain' are commonly used descriptors [51]. In the context of statin use, tendinopathy usually occurs within the first year of therapy and improves after the drug is stopped [15]. Calcifying tendonitis appears to be the most frequent pathologic condition associated with the onset of infraspinatus myotendinous junction tears [23].

Epidemiology and Natural History

Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years [26], with an estimated prevalence of 3% and a peak incidence between ages 35 and 65 [27]. The natural history is favorable, with 70% to 80% of patients resolving symptoms within 1 year without treatment [25], and the condition is usually self-limited, resolving over a 12- to 18-month period [57]. Medial elbow tendinopathy also has a favourable natural history, with resolution in approximately 80% of cases within 1 to 3 years [6]. Rotator cuff tendinopathy prevalence in the general population ranges from 2.4% to 14% [51], rising to 45% in manual repetitive workers [51]. While common, uncertainty remains regarding the true extent and risk factors for onset [49]. In volleyball, tendinopathy is a common problem but not a common cause of injury [28]. Heel pain is the most common foot-related symptom, with plantar fasciitis being the most common cause [117].

Diagnostic Methods and Criteria

Lateral epicondylitis is traditionally a clinical diagnosis based on history and examination [27], which is the most commonly used method of diagnosis [100]. However, almost half of patients (46.5%) presenting with lateral elbow pain receive a diagnosis other than lateral epicondylitis [43, 97]. Sonography of the common extensor origin can confirm clinical suspicion and exclude other causes of lateral elbow pain [48]. Specific diagnostic tests include: * Cozen’s test: Reported high sensitivity (91%) [92]. * Grip strength difference: A 5%-10% difference between elbow flexion and extension showed high sensitivity (78%-83%) and specificity (80%-90%) [92]. * Sonoelastography: Showed the highest sensitivity (75-100%) and specificity (85-96%) [92]. * MRI: Performed better for tendon thickening and enthesopathy, with sensitivity and specificity of 81%-100% [92].

The diagnostic and prognostic value of MRI findings in lateral epicondylitis has been repeatedly challenged due to a lack of evidence on the prevalence of these imaging findings in an asymptomatic population [27]. Nevertheless, changes in the common extensor tendon such as high signal intensity, oedema, thinning, thickening, and tears can be reliably identified on MRI [27]. Quantitative assessment of ECRB tendon degeneration using CT hounsfield units offers an objective measure of tendon pathology that may complement current diagnostic approaches [58].

For patellar tendinopathy, diagnosis is made by clinical examination and confirmed by MRI [109]. Clinical features include tenderness to palpation at the inferior pole of the patella with the knee fully extended and the quadriceps relaxed [109]. Consistent MRI features include enhanced signal intensity in the proximal patellar tendon, increased tendon size in the anteroposterior direction, and poor definition of the posterior tendon border [109].

Diagnosis of subacromial shoulder pain is based on history and examination [41]. Passive external rotation is emphasized as important in making a diagnosis of rotator cuff tendinopathy/impingement [41]. Those diagnosed with painful supraspinatus tendinopathy demonstrated increased thickening with delayed return to baseline following loading [22].

Clinical Features and Patient Factors

Lateral epicondylitis is often self-limiting, but 20% of patients experience disabling pain with resultant restriction in their professional and social lives [27]. The high prevalence within a working-age population imparts a significant socioeconomic burden [27]. Patients typically report pain on the lateral side of the elbow, aggravated by pressure on the lateral epicondyle of the humerus and resisted dorsiflexion of the wrist [103].

Features of importance in the diagnosis of subacromial shoulder pain include: * Patient factors: Expectation, hand dominance, occupation, and level of activity or sports [41]. * Pain characteristics: Location, radiation, onset, duration, exacerbating and relieving factors [41]. * History: Trauma, involvement of other joints, systemic illnesses, comorbidities, and red flags [41].

Investigations

Clinical Diagnosis and Differential Diagnosis: Tendinopathies of the hand and wrist are diagnosed by history and examination [1]. Lateral epicondylitis is primarily a clinical diagnosis [19], traditionally based on history and examination [27]. The physical exam for the elbow is directed by history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect [39]. Almost half of patients (46.5%) presenting with lateral sided elbow pain were diagnosed with a condition other than lateral epicondylitis [43].

MRI: MRI is increasingly utilized to gauge the severity of lateral epicondylar tendinopathy and justify decisions about treatment, including surgical intervention [27]. MRI changes in the common extensor tendon are identified in nearly all cases of symptomatic lateral epicondylar tendinopathy [27]. However, a clear correlation between the degree of change on MRI and clinical symptoms in lateral epicondylar tendinopathy has not been possible to define [27]. The diagnostic and prognostic value of MRI findings in lateral epicondylar tendinopathy has been challenged due to a lack of evidence on the prevalence of these imaging findings in an asymptomatic population [27]. Increased MRI signal in the extensor carpi radialis brevis origin is common in both symptomatic and asymptomatic elbows [184]. MRI is a reliable tool in determining the radiological severity of lateral epicondylitis [144]. The routine use of MRI for the diagnosis of lateral epicondylitis is low, although its use is associated with downstream effects [141]. MRI can help differentiate chronic lateral epicondylitis and may be useful in clinical management, preoperative planning, and evaluating the degree of degeneration at the common extensor tendon insertion [142]. MRI is an important decision-making tool in the surgical treatment of refractory tennis elbow [174]. The use of MR imaging in patients with recalcitrant lateral epicondylitis assists in surgical planning [149]. Continuous tendon recovery assessed by MRI was found during a 2-year period after platelet-rich plasma treatment for lateral epicondylitis [74]. Despite MRI evidence of a partial extensor carpi radialis brevis tear, nonsurgical treatment may be a viable option for some patients with recalcitrant lateral epicondylitis [190]. A reproducible MRI-based assessment technique for lateral tendinopathy enhances diagnostic precision and treatment evaluation [120]. MRI can be used to evaluate ligaments and tendons of the elbow, but it is rarely indicated for elbow stiffness [105]. The clinical use of MRI in the management of patients with enthesopathy of the extensor carpi radialis brevis origin merits further study [135]. MRI-defined patellar tendinopathy is common in community-based adults and is associated with current and past history of obesity assessed by BMI or body weight, but not fat mass [68]. Among patients with symptomatic rotator cuff tendinopathy that remained symptomatic at a minimum of 1 year and obtained a follow-up MRI, 39% progressed to a partial or full-thickness tear [72].

Ultrasonography: Ultrasonography was more accurate than MRI in confirming clinically diagnosed patellar tendinopathy [132]. Ultrasonographic examination gives a detailed image of the structures involved in the tennis elbow syndrome, confirms the diagnosis, and may be useful in monitoring treatment [187]. Elastography-ultrasound can be used as the initial modality to screen any tendon pathology in athletes and non-athletes prior to advanced imaging such as MRI [145].

Computed Tomography Arthrography: Computed tomography arthrography was a reliable and accurate diagnostic modality compared with MRI to detect the capsular tear in patients with chronic tennis elbow [181].

Other Imaging Modalities: Quantitative assessment of extensor carpi radialis brevis tendon degeneration using CT Hounsfield units offers an objective measure of tendon pathology that may complement current diagnostic approaches [58].

Treatment

Non-Operative

Nonsurgical treatment is the mainstay of management for lateral epicondylitis and elbow tendinopathy, with rest and activity modification serving as paramount initial steps [84, 130]. Approximately 90% of patients with untreated tennis elbow achieve symptom resolution at one year, and nonoperative management leads to symptom resolution in 90% of cases [35, 47]. Despite these high natural history rates, no single nonoperative treatment reliably achieves outstanding results, and the current literature provides no definitive recommendations regarding the efficacy of specific nonsurgical interventions [2, 84]. There is no true consensus on the most efficacious management for long-term outcomes [16].

Specific modalities show variable evidence. Prolotherapy injections are safe and effective for sports-related tendinopathies [121], while platelet-rich plasma (PRP) injections are a safe and effective conservative treatment for reducing pain and increasing functionality in lateral epicondylitis [137]. Topical glyceryl trinitrate should be included in the nonsurgical management of chronic tendinopathies [116]. Conversely, the efficacy of iontophoresis has not been proven due to methodological limitations and equivocal results [110], and the use of extracorporeal shockwave therapy (ESWT) in alternative doses or intervals warrants further research before advocacy [36]. ESWT results have been mixed for lateral epicondylitis and ineffective for noncalcific supraspinatus tendinosis [127]. Evidence on exercise therapy for hand and wrist tendinopathies is limited [20].

For other specific conditions, nonoperative management of distal biceps tendon partial tears yields good clinical and functional results [34]. Conservative treatment remains the mainstay for calcification at the long head of the biceps tendon [112]. The literature documents several nonsurgical approaches for chronic patellar tendinopathy, though study quality is limited [136]. Statin-associated tendinopathy usually occurs within the first year of use and improves after drug cessation [15].

Operative

Indications: Surgical intervention is reserved for patients with continued symptoms after at least six months of conservative treatment [84, 201]. Operative management for lateral epicondylitis is recommended only in severe, recalcitrant cases [50], while procedures for medial epicondylitis are typically reserved for patients with recalcitrant or recurrent symptoms despite nonsurgical management [167]. Arthroscopic debridement for calcification at the long head of the biceps tendon is reserved for cases where symptoms are not controlled by non-operative therapy [112].

Surgical Approach / Technique: Arthroscopic debridement for refractory lateral epicondylitis results in substantial improvement in tendinosis scores and good clinical outcomes [9, 115]. Postoperative MRI findings reflect clinical outcomes, with improvement of the tendinopathy area being 60% in recovered groups versus 16% in unrecovered groups [9]. The Nirschl procedure and arthroscopic extensor carpi radialis brevis debridement are comparable and highly effective for chronic recalcitrant lateral elbow tendinopathy [122]. Percutaneous ultrasonic tenotomy is a safe and effective treatment for chronic medial and lateral elbow tendinosis, producing statistically significant improvements in pain and function over one year [33], and is also effective for gluteal tendinopathy [138]. Minimally invasive treatment with TenJet is safe, effective, and well-tolerated for common extensor tendinopathy [46].

Adjuncts: Autologous tenocyte injection provides evidence for the midterm durability of treatment for chronic resistant lateral epicondylitis and is an encouraging novel treatment that warrants further evaluation [8, 104]. A new injectable recombinant human collagen scaffold combined with autologous platelet-rich plasma is a safe treatment that effectively induces clinically significant improvements in elbow symptoms and general well-being within six months for elbow tendinopathy recalcitrant to standard treatments [107].

Other Considerations: Failed surgical treatment of lateral epicondylitis is multifactorial, and distinguishing the cause is critical for appropriate management [30].

Complications

Lateral Elbow Tendinopathy (Tennis Elbow)

The term "lateral epicondylitis" is considered inappropriate because the pathology is degenerative rather than inflammatory, and the lesion may occur below the lateral epicondyle [37]. The natural history is generally favourable; approximately 90% of people with untreated tennis elbow achieve symptom resolution at 1 year [35]. The probability of recovery remains fairly constant over the first year regardless of prior symptom duration [76], with a 50% probability of recovery every three to four months [78]. Persistent symptoms have little prognostic value for predicting the need for surgery [35]. There is no evidence to support the superiority of surgery over continued nonoperative care or no treatment [78].

Corticosteroid Injections: Corticosteroid injections provide a short-term beneficial effect but have a negative effect in the intermediate term [61]. Compared to natural resolution, these injections worsen long-term outcomes [69]. Pooled data from randomized controlled trials indicate a lack of intermediate- to long-term clinical benefit after nonsurgical treatment compared with observation only or placebo [12]. Three or more preoperative injections is the most significant risk factor for revision surgery after operative treatment [192].

Surgical Outcomes: Surgical treatment by complete resection of the tendinosis tissue with sparing of normal tissue can lead to durable results at long-term follow-up [17]. Favorable short-term outcomes such as reduction of pain and increase in function after arthroscopic treatment are maintained over long-term follow-up [66]. In recovered patients undergoing arthroscopic debridement for refractory lateral epicondylitis, improvement of tendinopathy area on MRI was 60%, compared to 16% in unrecovered patients [9]. Ultrasound-guided percutaneous tenotomy for recalcitrant lateral elbow tendinopathy demonstrates sustained pain relief, functional recovery, and sonographic evidence of tissue healing at 7.5 years [73]. In a series of seven patients with refractory chronic lateral elbow tendinopathy treated with ultrasonic percutaneous tenotomy, ASES scores improved from 55.6 preoperatively to 94.1 at 2 years [75]. The annual incidence of lateral epicondylitis per 10,000 patients and the proportion of cases treated surgically remained constant from 2007 to 2014 [199].

Medial Elbow Tendinopathy

Medial elbow tendinopathy is less common than lateral elbow tendinopathy [6]. It has a favourable natural history with resolution in approximately 80% of cases within 1 to 3 years [6].

Patellar Tendinopathy

In patients treated nonoperatively for patellar tendinopathy, results were better in those with stage 2 tendinopathy than in those with stage 3 [7]. Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer with a high recurrence rate [207].

Hand and Wrist Tendinopathies

Enthesopathy of the extensor carpi radialis brevis origin is a benign, self-limiting disorder with a natural history of spontaneous resolution [70]. No treatments have been proven to alter the course of this condition [70].

General Pathophysiology and Systemic Factors

Chronic tendinopathy is a process of degradation involving neovessel formation, neoinnervation, and synovitis, which provides potential targets for therapeutic modification [18]. Peritendinitis and degenerative tendinopathy or tendinosis make up the majority of chronic resistant tendon problems [13]. Tendinopathy associated with statin use usually occurs within the first year of statin use and improves after the drug therapy is stopped [15]. Calcifying tendonitis is the most frequent pathologic condition associated with the onset of infraspinatus myotendinous junction tears [23].

Recovery

Natural History and Prognosis: Persistent tennis elbow symptoms have little prognostic value for long-term outcomes [35]. Poor prognosis at 1 year of follow-up for lateral epicondylitis was related to manual work and high baseline pain [227]. Pain sensitization during the early stages of lateral epicondylitis was associated with persistently increasing disability after 1 year of nonsurgical treatment [221]. Among patients with symptomatic rotator cuff tendinopathy that remained symptomatic at a minimum of 1 year, 39% progressed to a partial or full-thickness tear [72].

Non-Operative Treatment Outcomes: Corticosteroid injections for tennis elbow worsen the long-term outcomes of patients [69]. PRP and autologous whole blood injections are both effective methods to treat chronic lateral epicondylitis and their efficacy persisted during long-term follow-up [178]. Continuous tendon recovery assessed by MRI was found during a 2-year period after PRP treatment for lateral epicondylitis [74]. In the long term, acupotomy has greater efficacy and is associated with a lower rate of recurrence than corticosteroid injections in the management of lateral epicondylitis [186]. Nonoperative management for partial distal biceps tendon tears has been documented to yield good clinical and functional results [34].

Operative Treatment Outcomes: Favorable short-term outcomes such as reduction of pain and increase in function following arthroscopic treatment of lateral epicondylitis are maintained over a long-term follow-up [66]. In the recovered group after arthroscopic debridement for refractory lateral epicondylitis, improvement of tendinopathy area was 60%, indicating that postoperative MRI findings reflect clinical outcomes [9]. In the unrecovered group after arthroscopic debridement for refractory lateral epicondylitis, improvement of tendinopathy area was 16% [9]. At long-term follow-up of 7.5 years, ultrasound-guided percutaneous tenotomy demonstrates good sustainability of pain relief and functional recovery accompanied with sonographic evidence of tissue healing [73]. At the long-term follow-up of 90 months, ultrasonic percutaneous tenotomy demonstrated good durability of pain relief and functional recovery accompanied by sustained sonographic tissue healing with no significant deterioration [169]. This study provides evidence for the midterm durability of autologous tenocyte injection for treatment of lateral epicondylitis tendinopathy [8]. Improved clinical outcomes and an overall high rate of tendon healing were seen at the midterm follow-up after arthroscopic isolated subscapularis tendon repair [65]. The short-term clinical influence of biceps complications on shoulder outcome is very limited [63]. Results for arthroscopic transosseous treatment of rotator cuff tears were satisfactory in the early period, but long follow-up is needed to evaluate bone-tendon healing [71].

Key Evidence

• [L5] No single nonoperative treatment reliably achieves outstanding results for lateral elbow tendinopathy, likely due to the inclusion of heterogeneous patient groups rather than categorization by disease severity. [2] (10.1177/2325967116670635)
• [L5] The consensus statement establishes precise definitions for tendinopathy, tendinosis, and peritendinitis, and provides recommendations for clinical management and treatment based on expert agreement and current scientific data. [4] (10.1177/2325967117734127)
• [L5] The condition is a degenerative tendinopathy rather than an inflammatory process, and treatment should address the underlying pathoanatomy. [5] (10.1016/j.csm.2004.06.004)
• [L5] Medial elbow tendinopathy is less common than lateral elbow tendinopathy and has a favourable natural history with resolution in approximately 80% within 1 to 3 years. [6] (10.1111/sae.12022)
• [L3] In the group treated nonoperatively, results were better in the patients who had stage 2 tendinopathy than in those with stage 3. [7] (10.1177/03635465000280031901)
• [L4] This study provides evidence for the midterm durability of ATI for treatment of LE tendinopathy. [8] (10.1177/0363546515579185)
• [L4] In the recovered and unrecovered groups, improvement of tendinopathy area was 60% versus 16%, indicating that postoperative MRI findings reflect clinical outcomes. [9] (10.1016/j.arthro.2022.07.019)
• [L1] Surgical treatment for chronic patellar tendinopathy leads to substantial improvements in functional outcomes. [10] (10.1002/ksa.70284)
• [L5] This article is a review of recently published information on elbow tendinopathy and tendon ruptures intended to assist clinicians in diagnosis and management, noting that while numerous treatment options exist for epicondylitis, no single universally accepted protocol has emerged. [11] (10.1016/j.jhsa.2009.01.022)
• [L1] Pooled data from RCTs indicate a lack of intermediate- to long-term clinical benefit after nonsurgical treatment of lateral epicondylitis compared with observation only or placebo. [12] (10.1007/s11999-014-4022-y)
• [L5] Peritendinitis and degenerative tendinopathy or tendinosis appear to make up the majority of chronic resistant tendon problems. [13] (10.5435/00124635-199805000-00003)
• [L2] Clearly defined MIDs should be used with consistency in tendinopathy management studies in the future. [14] (10.1186/s12891-023-06261-9)
• [L4] Tendinopathy usually occurs within the first year of statin use and improves after the drug therapy is stopped. [15] (10.2106/jbjs.rvw.15.00072)
• [L1] Despite a wealth of research, there is no true consensus on the most efficacious management of tennis elbow especially for effective long-term outcomes. [16] (10.2147/oajsm.s10310)
• [L4] Surgical treatment for lateral epicondylitis by complete resection of the tendinosis tissue with the sparing of normal tissue can lead to durable results at long-term follow-up. [17] (10.1177/0363546507308932)
• [Paper] [18] (10.1136/bjsports-2012-091957)
• [L1] Evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited. [20] (10.1016/j.jht.2023.08.016)
• [L3] Those diagnosed with painful supraspinatus tendinopathy demonstrated increased thickening with delayed return to baseline following loading. [22] (10.1136/bmjsem-2017-000279)
• [L4] Calcifying tendonitis appeared to be the most frequent pathologic condition associated with the lesion onset. [23] (10.1016/j.jse.2022.01.092)
• [L4] Nonoperative treatment is the initial strategy for tendinopathy and/or low-demand patients with partial tears. [24] (10.1016/j.xrrt.2026.100770)
• [L4] The natural history of lateral epicondylitis is favorable, with 70% to 80% of patients having resolution of symptoms within 1 year in the absence of any treatment. [25] (10.3810/psm.2012.05.1963)
• [L5] Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years. [26] (10.1302/0301-620x.95b9.29285)
• [L4] [27] (10.1177/17585732221146731)
• [L3] Clearly, tendinopathy is a common problem in this sport but it is not a common cause of injury. [28] (10.1177/2325967117s00008)
• [L5] Failed surgical treatment of lateral epicondylitis is multifactorial, and distinguishing the cause is critical for appropriate management. [30] (10.1016/j.xrrt.2023.07.006)
• [L1] The article provides a guidance summary for the management of lateral elbow tendinopathy using the GRADE system, establishing recommendations based on the quality of available evidence and the balance between desirable and undesirable consequences of alternative management options. [32] (10.1177/17585732231170793)
• [L4] Percutaneous ultrasonic tenotomy is a safe and effective treatment for chronic medial and lateral elbow tendinosis, producing statistically significant improvements in pain and function over a 1-year follow-up period. [33] (10.1016/j.jse.2014.07.017)
• [L5] They note that nonoperative management has been documented to yield good clinical and functional results, consistent with the natural course of other self-limited enthesopathies. [34] (10.1016/j.jhsa.2026.03.017)
• [L1] Based on the placebo or no-treatment control arms of randomized trials, about 90% of people with untreated tennis elbow achieve symptom resolution at 1 year. [35] (10.1097/corr.0000000000002058)
• [L1] The use of ESWT in alternative doses and/or different dosage intervals in the management of tendinopathies warrants further research before it can be advocated for such conditions. [36] (10.1016/s0736-0266(02)00013-x)
• [L5] [37] (10.1177/1558944716643280)
• [L5] [38] (10.1186/ar2723)
• [L5] [41] (10.1177/1758573215576456)
• [L3] Almost half of the patients (46.5%) were diagnosed with a diagnosis other than lateral epicondylitis. [43] (10.1016/j.jseint.2024.08.047)
• [L4] MIT with TenJet is a safe, effective, and well-tolerated treatment for common extensor tendinopathy. [46] (10.1016/j.jseint.2023.05.003)
• [L4] Nonoperative management of lateral epicondylitis leads to resolution of symptoms in 90% of cases. [47] (10.1016/j.bpa.2020.08.004)
• [L4] Sonography of the common extensor origin can confirm the clinical suspicion of lateral epicondylitis and exclude other causes of lateral elbow pain. [48] (10.2214/ajr.176.3.1760777)
• [L1] Rotator cuff tendinopathy is a common problem but uncertainty remains regarding the true extent and risk factors associated with onset. [49] (10.1111/sae.12028)
• [L5] Lateral epicondylitis is a self-limiting condition, with operative management only recommended in severe, recalcitrant cases. [50] (10.1007/s00590-021-03181-z)
• [L5] [51] (10.1177/17585732231172166)
• [L5] Patellar tendinopathy is a degenerative disorder (tendinosis) rather than an inflammatory one. [55] (10.5435/jaaos-d-15-00703)
• [L2] Lateral epicondylitis is a condition that is usually self-limited, resolving over a 12- to 18-month period without treatment. [57] (10.1007/s11552-014-9642-x)
• [L3] This technique offers an objective measure of tendon pathology that may complement the current diagnostic approaches. [58] (10.1186/s12891-025-08346-z)
• [L4] The proposed MRI classification has emerged as one of the most reliable methods to define stages of chronic lateral epicondylitis. [59] (10.1186/s12891-022-05758-z)
• [L3] The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair. [60] (10.1007/s11999-008-0585-9)
• [L1] Corticosteroid injections have a shortterm beneficial effect on lateral epicondylitis, but a negative effect in the intermediate term. [61] (10.1136/bmjopen-2013-003564)
• [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. [62] (10.1177/0363546517753385)
• [L3] Nevertheless, the short-term clinical influence of biceps complications on shoulder outcome is very limited. [63] (10.1177/2325967121s00362)
• [L4] The type and extent of pathologic changes within the common extensor tendon can be evaluated using a dedicated low-field MR system. [64] (10.1007/s003300050851)
• [L4] Improved clinical outcomes and an overall high rate of tendon healing were seen at the midterm follow-up after AISR. [65] (10.1177/23259671241229429)
• [L4] Favorable short-term outcomes such as reduction of pain and increase in function are maintained over a long-term follow-up. [66] (10.1197/j.jht.2008.04.007)
• [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. [67] (10.1016/j.jse.2009.12.016)
• [L3] MRI defined patellar tendinopathy is common in community-based adults and is associated with current and past history of obesity assessed by BMI or body weight, but not fat mass. [68] (10.1186/1471-2474-15-266)
• [Paper] Corticosteroid injections for tennis elbow worsen the long term outcomes of patients. [69] (10.1016/j.jsams.2009.09.009)
• [L5] Enthesopathy of the extensor carpi radialis brevis origin is a benign, self-limiting disorder with a natural history of spontaneous resolution, for which no treatments have been proven to alter the course. [70] (10.5435/jaaos-d-15-00233)
• [L4] Results were satisfactory in the early period, but long follow-up is needed to evaluate bone-tendon healing. [71] (10.1177/2325967117s00060)
• [L3] Among patients with symptomatic rotator cuff tendinopathy that remained symptomatic at a minimum of 1 year and obtained a follow-up MRI, 39% progressed to a partial or full-thickness tear. [72] (10.1016/j.asmr.2022.05.004)
• [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. [73] (10.1177/2325967120s00420)
• [L4] Continuous tendon recovery assessed by MRI was found during a 2-year period after PRP treatment. [74] (10.1016/j.jse.2022.01.147)
• [L4] In this series of seven patients with refractory chronic lateral elbow tendinopathy, ASES scores significantly improved from 55.6 preoperatively to 94.1 at 2 years (P < 0.001). [75] (10.1097/bth.0000000000000178)
• [L1] Approximately 90% of people with untreated tennis elbow achieved symptom resolution by 1 year, and the probability of recovery remained fairly constant over that timespan regardless of prior symptom duration, undermining the concept that surgery is indicated if symptoms persist for an arbitrary duration. [76] (10.1097/corr.0000000000002149)
• [L4] [77] (10.1016/j.jse.2025.01.052)
• [L4] [78] (10.1302/0301-620x.105b2.bjj-2022-0883.r1)
• [L5] [79] (10.1177/1558944718794008)
• [L4] A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further. [82] (10.1302/2058-5241.1.160005)
• [L1] [92] (10.1016/j.jht.2021.02.002)
• [L3] Nearly half (46.5%) of patients presenting with lateral elbow pain receive a diagnosis other than lateral elbow tendinopathy (LET). [97] (10.1016/j.jse.2025.10.006)
• [L2] [100] (10.1016/j.otsr.2014.01.006)
• [L1] [103] (10.1177/0095399703258714)
• [L4] This novel treatment is encouraging for the treatment of tendinopathy and warrants further evaluation. [104] (10.1177/0363546513504285)
• [L4] STR/PRP is a safe treatment that effectively induces clinically significant improvements in elbow symptoms and general well-being as well as objective measures of strength and imaging of the common extensor tendon within 6 months of treatment of elbow tendinopathy recalcitrant to standard treatments. [107] (10.1016/j.jse.2018.09.007)
• [L1] [109] (10.1177/0363546513518416)
• [Commentary] The efficacy of iontophoresis in the management of lateral epicondylitis has not been proven due to methodological limitations, lack of a control group, and equivocal results from other trials. [110] (10.1016/j.jhsa.2011.10.029)
• [L4] Conservative treatment remains the mainstay, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy. [112] (10.1177/1758573214567559)
• [L4] Surgical treatment through arthroscopy for recalcitrant lateral epicondylitis is effective and safe, presenting positive outcomes in the studied patients. [115] (10.1590/1413-785220192703216249)
• [L1] Topical glyceryl trinitrate should be included as part of nonsurgical management of chronic tendinopathies. [116] (10.1177/0363546504270998)
• [L1] This study presents a reproducible MRI-based assessment technique for lateral tendinopathy, enhancing diagnostic precision and treatment evaluation. [120] (10.1016/j.jse.2026.03.020)
• [L1] This systematic review summarized high quality RCTs and found PrT injections to be overall safe and effective in the treatment of sports‐related tendinopathies. [121] (10.1177/2325967123s00324)
• [L3] Both techniques are comparable and highly effective for treating chronic recalcitrant lateral elbow tendinopathy. [122] (10.1016/j.jse.2016.09.022)
• [L2] The results of this meta-analysis strongly support the hypothesis of an association between biomechanical exposure involving wrist and/or elbow at work and incidence of lateral epicondylitis. [126] (10.1002/acr.22874)
• [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. [127] (10.5435/00124635-200604000-00001)
• [L5] Nonsurgical treatment is the mainstay of management for lateral epicondylitis, involving options such as rest, physical therapy, and injections. [130] (10.5435/00124635-200801000-00004)
• [L2] Ultrasonography was more accurate than MRI in confirming clinically diagnosed patellar tendinopathy. [132] (10.1177/0363546506294858)
• [L3] The clinical use of MRI in the management of patients with enthesopathy of the ECRB origin merits further study. [135] (10.1016/j.jhsa.2009.02.023)
• [L1] The literature documents several nonsurgical approaches for the treatment of chronic patellar tendinopathy with important limitations in terms of study quality. [136] (10.1177/0363546518759674)
• [L4] PRP injections are a safe and effective conservative treatment method for reducing pain symptoms and increasing functionality in patients with lateral epicondylitis. [137] (10.1177/2325967125s00169)
• [L4] PUT is an effective treatment, with good results for patients with gluteal tendinopathy. [138] (10.1177/2325967120907868)
• [L3] Although there is variation in the use of MRI for lateral epicondylitis and its use is associated with downstream effects, the routine use of MRI for the diagnosis of lateral epicondylitis is low. [141] (10.1016/j.jhsa.2023.03.025)
• [L4] MRI in patients with chronic lateral epicondylitis can help to differentiate the disease and may be of use in clinical management, preoperative planning, and in the evaluation of the degree of degeneration at the common extensor tendon insertion. [142] (10.1007/s004020050330)
• [L4] The arthroscopic identification of the 3 types of Baker lesions helps the surgeon to confirm the presence of pathology commonly seen intra-articularly in patients with lateral epicondylitis. [143] (10.1016/j.eats.2024.103142)
• [L2] Magnetic resonance imaging is a reliable tool in determining radiological severity of lateral epicondylitis. [144] (10.1016/j.jhsa.2010.11.040)
• [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). [145] (10.1177/2325967119s00483)
• [L2] The Snyder classification system is reproducible and can be used in future research studies in analyzing the treatment options of partial rotator cuff tears. [147] (10.1177/2325967116667058)
• [L4] The use of MR imaging in patients with recalcitrant lateral epicondylitis assists in surgical planning. [149] (10.1148/radiology.196.1.7784585)
• [L2] [151] (10.1136/bmj.d2687)
• [L2] Persistent tennis elbow symptoms are a poor indication for surgery as the majority of patients experience symptom resolution without it, and surgeons are unable to reliably predict who will or will not improve with nonoperative treatment. [152] (10.1097/corr.0000000000003425)
• [L4] This study emphasizes the strength of the associations between combined physical exertion and elbow movements and lateral epicondylitis. [156] (10.1002/ajim.22140)
• [L2] It is not recommended for use as an outcome measure in studies evaluating interventions for lateral epicondylitis until further development and validation are performed. [158] (10.1258/ht.2010.010014)
• [L2] Compensation guidance, management and prevention should incorporate these new findings and practitioners from primary to secondary care should note strenuous biomechanical hand and elbow exposures for patients with lateral epicondylalgia. [160] (10.1016/j.jbspin.2014.10.013)
• [L5] This review outlines the role of low-grade inflammation in the pathogenesis of tendinopathy, stressing the role of proinflammatory cytokines, proteolytic enzymes and growth factors, and explores how inflammation exerts a negative influence on the process of tendon healing. [161] (10.1186/s13018-021-02811-w)
• [L5] [162] (10.2106/00004623-199902000-00014)
• [L4] A large percentage of patients who fail conservative treatment for medial humeral epicondylitis (tendinosis) can obtain pain relief and return to activities with the described operative technique. [165] (10.1177/036354659502300215)
• [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. [166] (10.1177/0363546515612758)
• [L5] [167] (10.5435/JAAOS-D-14-00145)
• [L4] At the long-term follow-up of 90 months, ultrasonic percutaneous tenotomy demonstrated good durability of pain relief and functional recovery that was previously achieved, accompanied by sustained sonographic tissue healing with no significant deterioration. [169] (10.1177/03635465211010158)
• [L4] MRI is an important decision-making tool in the surgical treatment of refractory tennis elbow. [174] (10.1016/j.jse.2004.07.011)
• [L2] PRP and autologous whole blood injections are both effective methods to treat chronic lateral epicondylitis and their efficacy persisted during long term follow up. [178] (10.1186/2052-1847-6-12)
• [L4] [180] (10.2106/jbjs.rvw.15.00079)
• [L2] CTA was a reliable and accurate diagnostic modality compared with MRI to detect the capsular tear in patients with chronic tennis elbow. [181] (10.1016/j.jse.2010.12.002)
• [L4] Increased MRI signal in the ECRB origin is common in symptomatic and in asymptomatic elbows. [184] (10.1016/j.jse.2016.01.033)
• [L1] In the long term, acupotomy has greater efficacy and is associated with a lower rate of recurrence than corticosteroid injections in the management of lateral epicondylitis. [186] (10.1186/s13018-022-03323-x)
• [L4] Ultrasonographic examination gives a detailed image of the structures involved in the tennis elbow syndrome, confirms the diagnosis, and may be useful in monitoring treatment. [187] (10.1136/bjsm.24.3.151)
• [L3] This study presents novel evidence of an adaptive motor pattern in lateral elbow tendinopathy, characterized by increased relative activation and coactivation of the anconeus muscle depending on grip force. [188] (10.1016/j.jse.2024.11.001)
• [L3] Despite MRI evidence of a partial ECRB tear, nonsurgical treatment may be a viable option for some patients with recalcitrant lateral epicondylitis. [190] (10.1016/j.jseint.2021.11.017)
• [L2] [191] (10.1186/s12891-026-09558-7)
• [L4] [192] (10.1016/j.jse.2016.10.022)
• [L3] In patients with lateral epicondylitis, the grip strength decreases as one moves from a position of flexion to a position of extension. [194] (10.1016/j.jhsa.2007.04.010)
• [L3] [197] (10.1177/03635465030310031401)
• [L4] The annual incidence of lateral epicondylitis per 10,000 patients and the proportion of cases treated surgically remained constant from 2007 to 2014. [199] (10.1007/s11420-017-9559-3)
• [L4] Decreased muscular performance in these patients is associated with both elbow pain and physical damage to the ECRB muscle. [200] (10.1054/jhsb.1998.0178)
• [L4] [201] (10.1016/j.xrrt.2024.08.008)
• [L4] [205] (10.1186/s12891-022-05651-9)
• [L2] Although mainly mild in nature, patellar tendinopathy is a fairly common condition in elite soccer and the recurrence rate is high. [207] (10.1177/0363546511408877)
• [L4] [208] (10.1007/s00167-014-2855-2)
• [Paper] Tennis biomechanics, player characteristics and equipment are important in preventing the condition. [218] (10.1136/bjsm.2007.036723)
• [L3] Lower string-tensions transmit less force to the elbow in backhand strokes. [219] (10.1177/1758573216640201)
• [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. [221] (10.1016/j.jhsa.2018.06.013)
• [L5] Muscle strain on the ECRL and ECRB was greatest during elbow extension with forearm pronation and wrist flexion–ulnar deviation. [222] (10.1016/j.jse.2007.03.022)
• [L2] Poor prognosis at 1yr of follow-up for lateral epicondylitis was related to manual work and high baseline pain, whilst no relation was found between the type of medical treatment given/chosen and prognosis. [227] (10.1093/rheumatology/keg360)

See Also

• Tennis Elbow

References

[1] Chapter 32 Tendon Injuries and Tendinopathies of the Hand and Wrist. 2020.

[2] Lateral Elbow Tendinopathy. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116670635

[4] Spanish Consensus Statement: Clinical Management and Treatment of Tendinopathies in Sport. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117734127

[5] Lateral epicondylitis. Clinics in Sports Medicine. 2004. DOI: 10.1016/j.csm.2004.06.004

[6] Tendinopathies Around the Elbow Part 2: Medial Elbow, Distal Biceps and Triceps Tendinopathies. Shoulder & Elbow. 2014. DOI: 10.1111/sae.12022

[7] Patellar Tendinopathy in Athletes. The American Journal of Sports Medicine. 2000. DOI: 10.1177/03635465000280031901

[8] Evidence for the Durability of Autologous Tenocyte Injection for Treatment of Chronic Resistant Lateral Epicondylitis. The American Journal of Sports Medicine. 2015. DOI: 10.1177/0363546515579185

[9] Arthroscopic Debridement for Refractory Lateral Epicondylitis Results for Substantial Improvement in Tendinosis Scores and Good Clinical Outcomes: Qualitative and Quantitative Magnetic Resonance Imaging Analysis. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.07.019

[10] Fat pad debridement prolongs return‐to‐sport: A meta‐analysis and meta‐regression of surgical interventions for chronic patellar tendinopathy. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70284

[11] Elbow Tendinopathy and Tendon Ruptures: Epicondylitis, Biceps and Triceps Ruptures. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.01.022

[12] Does Nonsurgical Treatment Improve Longitudinal Outcomes of Lateral Epicondylitis Over No Treatment? A Meta-analysis. Clinical Orthopaedics & Related Research. 2015. DOI: 10.1007/s11999-014-4022-y

[13] Tendinitis and Other Chronic Tendinopathies. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199805000-00003

[14] Determining minimal important differences for patient-reported outcome measures in shoulder, lateral elbow, patellar and Achilles tendinopathies using distribution-based methods. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06261-9

[15] Tendinopathy and Tendon Rupture Associated with Statins. JBJS Reviews. 2016. DOI: 10.2106/jbjs.rvw.15.00072

[16] Management of tennis elbow. Open Access Journal of Sports Medicine. 2011. DOI: 10.2147/oajsm.s10310

[17] Ten- to 14-Year Follow-up of the Nirschl Surgical Technique for Lateral Epicondylitis. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507308932

[18] Tendons – time to revisit inflammation. British Journal of Sports Medicine. 2013. DOI: 10.1136/bjsports-2012-091957

[19] Lateral Epicondylitis. 2021.

[20] Evidence for exercise therapy in patients with hand and wrist tendinopathy is limited: A systematic review. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2023.08.016

[22] Increased supraspinatus tendon thickness following fatigue loading in rotator cuff tendinopathy: potential implications for exercise therapy. BMJ Open Sport & Exercise Medicine. 2017. DOI: 10.1136/bmjsem-2017-000279

[23] Infraspinatus Myotendinous Junction Tears: Analysis Of A Consecutive Series And Their Relationship With Calcifying Tendonitis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.092

[24] Clinical outcomes following treatment of distal biceps tendon partial tears and tendinopathy: a systematic review. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2026.100770

[25] A Review of Modern Management of Lateral Epicondylitis. The Physician and Sportsmedicine. 2012. DOI: 10.3810/psm.2012.05.1963

[26] Lateral epicondylitis. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b9.29285

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