Lateral Epicondylitis

■ Review Article

SPOTLIGHT ON softtissue cme ARTICLE Lateral Epicondylitis

DANIELLE L SCHER, MD; JENNIFER MORIATIS WOLF, MD; BRETT D. OWENS, MD, MAJ, MC, USA

educational objectives As a result of reading this article, physicians should be able to: carpi radialis brevis origin is most commonly implicated as the specifi c site of 1. Identify the typical presentation of lateral epicondylitis based on history pathology.6,12 Lateral epicondylitis is bet- and physical examination. ter described as a process of tendinosis rather than tendinitis, seen histologically 2. Review the pathophysiology underlying the development of lateral epi- as initial fi broblastic hyperplasia, fol- condylitis and resulting histology. lowed by vascular hyperplasia and the 3. Describe the fi rst-line conservative therapy options for lateral epicondyli- production of abnormal collagen. In con- tis and the supporting data in the literature. trast, an infl ammatory process would be distinguished by an increased number of 4. Discuss the indications for initiating operative therapy and detail the op- lymphocytes and neutrophils.13 The accu- erative options for lateral epicondylitis. mulation of internal microtears leads to a cellular response characterized by a non- ateral epicondylitis is the most PATHOANATOMY infl ammatory, degenerative and avascular common cause of lateral elbow While many etiologies have been pro- process that Nirschl termed angiofi bro- Lpain presenting to the orthopedic posed, the most accepted theory holds that blastic tendinosis.5 surgeon, with an estimated occurrence in 4 lateral epicondylitis is a result of cumula- Bunata et al14 studied the bony and per 1000 patients.1,2 Every year 1% to 3% tive microtrauma resulting from repetitive tendinous anatomy of the elbow joint in of adults are affected by lateral epicondyli- wrist extension and alternating forearm cadavers, and showed that the origin of tis, with an equal prevalence between men supination and pronation.11 The extensor the extensor carpi radialis brevis tendon and women.3,4 Patients typically present in the fourth to fi fth decade of life with symptoms more commonly in their dominant Drs Scher and Owens are from William Beaumont Army Medical Center, El Paso, Texas; and Dr Wolf is from University of Colorado – Denver, Aurora, Colorado. arm. While commonly called “tennis el- Drs Scher, Wolf, and Owens have no relevant fi nancial relationships to disclose. Dr Morgan, CME bow,” this condition affects many individu- Editor, has disclosed the following relevant fi nancial relationships: Stryker, speakers bureau; Smith & als who never pick up a tennis racket. Lat- Nephew, speakers bureau, research grant recipient; AO International, speakers bureau, research grant eral epicondylitis is generally a self-limited recipient; Synthes, institutional support. Dr D’Ambrosia, Editor-in-Chief, has no relevant fi nancial relationships to disclose. The staff of ORTHOPEDICS have no relevant fi nancial relationships to disclose. condition with most patients having symp- The material presented in any Vindico Medical Education continuing education activity does not tomatic relief within 1 year through non- necessarily refl ect the views and opinions of Vindico Medical Education or ORTHOPEDICS. Neither surgical management and modifi cation of Vindico Medical Education or ORTHOPEDICS nor the authors endorse or recommend any techniques, activities. Five to 10% of patients are re- commercial products, or manufacturers. The authors may discuss the use of materials and/or products that have not yet been approved by the US Food and Drug Administration. All readers and continuing calcitrant to conservative therapy and may education participants should verify all information before treating patients or using any product. eventually require surgical intervention to Correspondence should be addressed to: Danielle L. Scher, MD, William Beaumont Army Medical relieve lifestyle-limiting symptoms.5 -10 Center, Department of Orthopedic Surgery and Rehabilition, 5005 N Piedras St, El Paso, TX 79920.

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impinges on the lateral edge of the capitel- lum during elbow extension and fl exion. Table 1 Cellular changes have been noted in pa- Provocative Tests for Lateral Epicondylitis tients with lateral epicondylitis, however, these changes may be more reactionary Test Name Performance of Test than the inciting event.15-17 Thomson19 Flex patient’s shoulder to 60Њ with elbow extended, forearm pronated, and wrist extended 30Њ. Apply pressure to the dorsum of the second and third metacarpals in the direction of fl exion and ulnar deviation. CLINICAL PRESENTATION Chair19 Have patient lift a light chair by the chair back with the elbow Patients frequently describe an insidi- extended and forearm pronated. ous onset of pain with no history of a par- Bowden19 Have patient squeeze a blood pressure cuff to maintain a particular ticular traumatic event. On examination, pressure. pain is typically located anterior or just Cozen’s19 Have patient fl ex elbow and extend wrist against resistance. distal to the lateral epicondyle. Patients Mill’s20 Have patient extend elbow and fl ex wrist against resistance. will often report a sharp pain exacerbated when carrying items in their hand, par- ticularly with the arm in neutral rotation. It is important to evaluate the integrity normal fi ndings, with the most common On physical examination, patients report of the lateral collateral ligament on initial fi nding (in 7%) being faint calcifi cations tenderness to palpation distal to the in- examination. Insuffi ciency of the lateral along the lateral epicondyle. He conclud- volved epicondyle, in particular over the collateral ligament with progression to ed that routine use of elbow radiographs origin of the extensor carpi radialis brevis. posterolateral rotatory instability should were not cost-effective, as only 2 of the Practitioners can reproduce the patient’s be considered in patients with either per- 294 studied radiographs altered his clini- pain with resisted extension of the wrist sistent or recurrent symptoms of tennis cal management. or third fi nger. elbow who have undergone treatment for Ultrasonography is most helpful for The Thomson test18 (Table 1) is a pro- lateral epicondylitis. Incompetence of the evaluating for joint fl uid, guidance for vocative test performed with the patient’s lateral collateral ligament has been attrib- aspiration, and assessing the integrity of shoulder fl exed to 60Њ, elbow extended, uted to both iatrogenic injury during later- supporting ligaments and tendons. The forearm pronated, and the wrist extended al epicondylitis surgery22,23 and repeated normal common extensor origin is seen as 30Њ. The examiner will then apply pres- corticosteroid injections.24 Kalainov and longitudinal bands of tendon fi brils run- sure to the dorsum of the send and third Cohen24 suggested that a lateral pivot-shift ning in close parallel without disruption. metacarpals to stress the extensor carpi test should be performed during every lat- The most common sonographic appear- radialis brevis and extensor carpi radialis eral epicondylitis surgery. ance in patients with lateral epicondylitis longus. Several other provocative tests aid Lateral elbow pain may also indicate is a focal hypoechoic area on a normal in the diagnosis of lateral epicondylitis; intra-articular pathology such as an osteo- background or one showing a loss of the including the Chair Test,19 Bowden test,19 chondral lesion or a posterolateral plica in normal fi brillar pattern. Visualization of a Cozen’s test,19 and Mill’s test.20 Grip the radiocapitellar joint. In their series of complete tear of the common extensor ori- strength can be tested and compared with posterolateral plicas, Ruch et al25 showed gin may lead the surgeon to consider ear- the contralateral side as patients often re- the site of maximal tenderness to be poste- lier surgical options.27 Ultrasonography is port weakness when gripping items.19 rior to the lateral epicondyle and centered highly operator-dependent and it is impor- at the posterior radiocapitellar joint. Pa- tant to correlate preoperative fi ndings with DIFFERENTIAL DIAGNOSIS tients may report painful locking or snap- those seen during surgery. Radial tunnel syndrome is caused by en- ping, which can be reproduced with termi- Magnetic resonance imaging (MRI) can trapment of the posterior interosseous nerve, nal extension and full supination. help to quantify the degree of tendon dis- usually as it passes between the superfi cial ease, look for alternative diagnoses and for and deep parts of the supinator muscle. On IMAGING preoperative planning. The visualization of physical examination these patients will Although lateral epicondylitis is a clin- intra-articular lesions on MRI might lead display pain with resisted supination with ical diagnosis, various imaging modalities the surgeon to consider elbow arthros- the elbow fl exed 20Њ (when the nerve is may be useful to rule out other etiologies copy before a planned open procedure. In trapped in the supinator) or pain with resist- of elbow pain. Pomerance26 reviewed the early stages of lateral epicondylitis, 90% ed middle fi nger extension with the elbow radiographs of lateral epicondylitis pa- of symptomatic patients may show edema fully extended (Maudsley’s test).21 tients and found that only 16% had ab- and thickening of the common extensor

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The authors concluded that steroids were roid was favored by all studied outcomes good for short-term relief and physical at 6 weeks, therapy was favored at both therapy was more benefi cial for long-term 26 and 52 weeks. The authors hypoth- follow-up. Korthals et al35 looked at the esized that these results may be second- total costs of steroid, physical therapy, ary to the fact that patients may misjudge and wait-and-see and found none superior their initial pain relief after steroid injec- with regards to cost effectiveness. tion and resume aggravating activities too Iontophoresis uses low electrical cur- soon after treatment or the possibility of rents to deliver transdermal medications the corticosteroid causing direct damage 1 such as NSAIDs and corticosteroids. In a to the tendon. A high rate of good results Figure 1: Corticosteroid injection into the extensor multicenter randomized controlled trial, was seen with the wait-and-see group, and carpi radialis brevis origin. Nirschl et al36 compared dexamethasone therefore it was suggested that physicians versus saline iontophoresis, showing thoroughly explain all advantages and origin.28-30 Because of the high sensitivity dexamethasone to have short-term signifi - disadvantages of the different therapeutic of MRI, it is important to reserve its use for cant improvements in visual analog scores modalities. recalcitrant lateral epicondylitis, as signal and investigators’ global evaluation of the Recent in vitro studies39,40 have shown intensity changes of the common extensor patient’s improvement. that dexamethasone has direct deleteri- origin may be a common fi nding in patients ous effects on human tenocyte cell num- older than 40 years.30 Injections ber, proliferation, and collagen synthesis. Corticosteroid is the most commonly These investigations also showed that CONSERVATIVE MANAGEMENT injected substance for patients with lateral dexamethasone suppresses proteoglycan Therapy Modalities epicondylitis (Figure 1). Based on an ul- synthesis, an important factor in tendon The mainstay of lateral epicondylitis trasound diagnosis of early lateral epicon- healing and repair. Although tendon rup- treatment is physical therapy and bracing. dylitis, Torp-Pederson et al37 reported on a ture has not been reported in the lateral Bracing treatment is thought to inhibit the decrease in hyperemia after corticosteroid epicondylitis literature,37 there are case maximum contraction of the wrist and injection into the common extensor origin, reports of Achilles tendon rupture after fi nger fl exors and extensors leading to de- suggesting that there is an initial infl am- corticosteroid injection.41-43 It has been creased tension in the common extensor matory component in this disease that is suggested that an early return to sports af- origin.31 In a randomized controlled trial affected by corticosteroid treatment. The ter the steroid injection exposes the weak- comparing brace-only treatment, physi- standard injection for lateral epicondylitis ened tendon to excessive stress and there- cal therapy and a combination of the two, combines 20 mg triamcinolone with 1.5 fore may lead to a spontaneous tear.41 Struijs et al32 showed that a decrease in cc 1% lidocaine for a total volume up to In 2003 Edwards and Calandruccio44 pain as the patient’s main outcome mea- 2 mL, with most randomized controlled fi rst reported use of autologous blood in- sure was statistically better for physical trials showing a treatment regime of up to jection for the treatment of refractory lat- therapy than brace-only, but these results three corticosteroid injections.38 A meta- eral epicondylitis. In their study, 50% of did not hold out at 1 year. Another study33 analysis by Assendelft et al38 reported on the 28 patients with chronic lateral epicon- used a custom-made dynamic wrist exten- 10 trials, 6 of which showed that steroid dylitis had complete relief of pain after 1 sion orthotic and showed signifi cant im- was a more effective short-term therapeu- autologous blood injection and 6 of the re- provement in functionality, pain-free grip tic agent (up to 6 weeks) compared with maining 14 had a similar response after 2 strength and a reduction in VAS score. the reference therapy. The two most com- injections. The pain relief seen with blood Comparing wait-and-see (ergonomic mon adverse effects were worsening pain injection is hypothesized to be secondary advice and nonsteroidal anti-infl ammatory 24 to 48 hours after injection and skin at- to transforming growth factor-␤ and basic drug [NSAID] use) with corticosteroid in- rophy at the injection site. fi broblast growth factor acting as humoral jections and physical therapy, Smidt et al34 In a randomized controlled trial com- mediators to induce a healing cascade.45 showed that all modalities had signifi cant paring steroid injection, therapy, and ob- On a macroscopic level, Taylor et increases in studied outcome measures. servation in 183 patients, success rates at al46 showed no abnormality or structural Physical therapy showed signifi cant im- 6 weeks were 92% for corticosteroid, 47% changes in the arrangement of collagen provements over injection therapy, but no for physical therapy, and 32% for wait- after direct injection of autologous blood signifi cant difference was found between and-see and 69%, 91% and 83%, respec- into rabbit patellar tendons. Clinical stud- physical therapy and wait-and-see policy. tively at 52 weeks.34 Although corticoste- ies have also shown low complication

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rates for autologous injections, with no infections or tendon ruptures seen.47,48 Re- searchers have also begun to use platelet- rich plasma, containing platelet-derived growth factor, epidermal growth factor and transforming growth factor beta, which have been shown to have a role in tendon healing and collagen production.49,50 Injection of botulinum toxin Type A 2A 2B causes a paralytic effect in muscles by irreversibly inhibiting acetylcholine re- Figure 2: Open surgical resection of the extensor carpi radialis brevis origin before (A) and after (B) resection. lease at the neuromuscular junction. In a multicenter, randomized controlled trial, trate patches to deliver nitric oxide to the operative treatment for lateral epicondy- Placzek et al51 found a mean clinical pain site of maximal tenderness in lateral epi- litis (Figure 2). Care must be taken not to score of 2.88 versus 4.29 (Pϭ.009) in condylitis patients. Paoloni et al56 showed dissect too far posteriorly on the lateral those treated with botulinum toxin com- that 81% of patients receiving this treat- epicondyle, risking injury to the lateral col- pared with placebo at 18 weeks following ment reported excellent improvement at lateral ligament. All fi brous and granula- injection. Table 2 lists a summary of the 24 weeks compared with 60% of placebo tion tissue, which appears grey, shiny, and most common injectates. patients (Pϭ.005). abnormal, is excised at the extensor carpi Low-level laser therapy is a treatment radialis brevis origin, often encompassing Other Treatments with local dose-response effects that at low 75% of the origin of the extensor carpi ra- The Cochrane Database review by levels displays anti-infl ammatory activity dialis brevis.5 Any abnormalities in the ex- Green et al52 showed a trend toward short- and fi broblast stimulation and can inhibit tensor carpi ulnaris, extensor carpi radialis term pain relief using acupuncture to treat fi broblasts at higher levels.57 A systematic longus, or extensor digitorum communis lateral epicondylitis. With the addition of review by Bjordal et al58 reported on 7 tri- should be identifi ed and excised. To stimu- newer studies, a systemic review showed als that used 904 nm wavelength applied late blood fl ow to the surgical site and pro- that acupuncture is an effective short-term to the tendon pathology that demonstrated vide a raw bleeding surface for the tendon pain reliever, although again these authors positive results. The authors found that repair, the exposed lateral epicondyle is de- were limited by the heterogeneity of the more rapid recovery was seen in patients corticated with an osteotome or rongeur or studies defi nitions of pain relief, types of who had low-level laser therapy combined with the drilling of multiple small holes. acupuncture used, and defi nitions of lat- with an exercise regime. Nirschl reported short-term follow-up eral epicondylitis. results showing a 97.7% subjective im- The use of extracorporeal shock wave SURGICAL MANAGEMENT provement from patient perceived preop- therapy53 has remained a controversial Numerous surgical options are avail- erative pain level.5 Eighty-fi ve percent of addition to the treatment regime of lat- able to the surgeon treating patients with the patients returned to full activity, with eral epicondylitis. Rompe et al18 showed recalcitrant lateral epicondylitis, usually 84% of the tennis players in his cohort signifi cant improvement in VAS and 60% considered after 6 to 12 months of failed returning to competitive play at an aver- good or excellent results on the Roles and nonoperative management. Most options age of 6.1 months. In 2008, Dunn et al59 Maudsley score at 12-month follow-up. A involve debridement of the pathologic tis- reviewed 92 patients with a 10- to 14- Cochrane database analysis reported that sue within the extensor carpi radialis bre- year follow-up after a Nirschl procedure. shock wave therapy provides little or no vis origin or extensor carpi radialis brevis Only 3 elbows had to be revised and no benefi t in terms of improving pain and release. The optimal surgical treatment is operative complications were described. function in tennis elbow.54 debatable as most options are associated Patients had an increase in mean strength Murrell et al55 used a rat Achilles ten- with a high proportion of successful pa- with 93% returning to sports at their pre- don model to demonstrate that nitric oxide tient outcomes. vious level. Continued symptoms of el- is induced during tendon healing and the bow pain after surgical excision may be inhibition of nitric oxide synthase results Open Debridement secondary to an inadequate excision of the in a decrease in tendon cross-sectional Described by Nirschl and Pettrone5 in damaged tissue or iatrogenic lateral col- area and failure load. This discovery led 1979, open debridement of the common lateral ligament injury leading to postero- to the use of transdermal glyceryl trini- extensor origin has been the mainstay of lateral instability.60

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Table 2 Injectables for Lateral Epicondylitis

Age No. of Range Follow-up Study/Type Injectant/Control Patients (y) (mo) Outcomes Data Smidt et al34/RCT Triamcinoloneacetonide 185 41-54 12 Mean difference in improvement (95% CI) in pain (10 mg/mL) during the day: at 3 weeks, injectiion vs wait and see, 30 (23-36); injections vs physiotherapy, 30 (23-37). At 52 weeks, Ϫ4 (Ϫ13 to 6), Ϫ11(20 to Ϫ2) Lindenhovius et Dexamethasone (4 mg/ 64 35-70 6 Average DASHa score: At 1 month, 24 for dexametha- al69/RCT mL) Lidocaine 1% sone and 27 for control. At 6 months, 18 and 13 respectively. Connell et al48/CS Autologous blood (2 mL) 35 26-62 6 Median VAS# pre-injection 9, 6 at 4 weeks and 0 at 6 months (zϭ5.16, PϽ.001)

Mishra et al70/ Platelet-rich plasma (2-3 140 45.2a 25.6a Mean improvement in VAS at 4 weeks 46% platelet- Cohort mL)/Bupivacaine with rich plasma vs 17% control; at 8 weeks 60% vs 16%; epinephrine (2-3 mL) at ﬁ nal follow-up 93% Placzek et al51/ Botulinum toxin Type A 130 47.2a 3.5 VAS for continuous pain at 2 weeks 3.6 botulinum RCT (60 mouse units of vs 4.25 control (Pϭ.147); at 18 weeks 1.82 vs 2.68 Dysport)/NaCI 0.9% (Pϭ.035) Scarpone et al71/ Dextrose and sodium 24 19-62 12 Resting elbow pain on the Likert scale at baseline 5.1 RCT morrhuateb/NaCl 0.9% dextrise vs 3.3 control; at 8 weeks 0.5 vs 4.5; at 16 weeks 3.6 vs 3.5, respectively (PϽ.001). At the 52- week follw-up, 60% of dextrose group reported “no elbow pain or impact on activities of daily living vs 10% of the control group.

Abbreviations: CS, case series; DASH, disabilities of the arm, shoulder, and hand questionnaire; RCT, randomized controlled trial, VAS, visual analog pain score. aMean. bAn extract of cod liver oil.

Percutaneous Release a study reported 27 of 30 patients return- lateral epicondyle and distal portion of Percutaneous release of the common ing to their former job or activities that the lateral condylar ridge are decorticated. extensor origin is an offi ce-based proce- had previously caused their symptoms.63 Arthroscopic procedures also allow for the dure performed using local anesthetic to Reported complications are a palpable re- evaluation of concomitant intra-articular lengthen the extensor carpi radialis brevis sidual band, inadequate release, synovial pathology within the joint. Active range- tendon.61 The blade is kept in contact with fi stula or cyst formation and superfi cial of motion is usually begun within 24 hours the lateral epicondyle and the entire thick- infection.61,62 In a prospective randomized and Baker et al65 showed an average return ness of the extensor origin is cut through controlled trial comparing open versus to work of 2.2 weeks. The most common from the proximal to the distal portion of percutaneous surgery for lateral epicon- complications of arthroscopic treatment the epicondyle. An approximately one-half dylitis, Dunkow et al64 found that percuta- of lateral epicondylitis are transient low inch defect will be palpable overlying the neous treatment has a signifi cantly higher radial or median nerve palsies, exces- anterior aspect of the lateral epicondyle. level of patient satisfaction as well as a sive drainage or swelling, loss of motion Yerger and Turner62 described the gradual shorter median return to work. postoperatively, and superfi cial wound relief of pain within 3 months for 70% of infections.66 In a retrospective review of the patients, with up to 20% of the patients Arthroscopic Debridement a single surgeon’s open and arthroscopic having pain for up to 6 months after the Arthroscopic debridement involves re- releases,67 one report showed no statistical procedure. In their 1- to 11-year follow- secting the damaged area of the extensor difference between the 2 procedures with up, they reported on 109 cases with 93.5% carpi radialis brevis tendon while preserv- regards to mean time to return to work. good or excellent results. More recently, ing the common extensor origin, and the There was no statistically signifi cant dif-

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ference between the 2 groups in good or 5. Nirschl RP, Pettrone FA. Tennis elbow: The treatment for lateral epicondylitis. Clin Or- surgical treatment of lateral epicondylitis. J thop Relat Res. 2002; (398):127-130. excellent results or the amount of postop Bone Joint Surg Am. 1979; 61(6):832-839. 21. Whaley AL, Baker CL. Lateral epicondylitis. physical therapy required after the opera- 6. Cyriax JH. The pathology and treatment of Clin Sports Med. 2004; 23(4):677-691. tennis elbow. J Bone Joint Surg Am. 1936; tive procedure, although the study may 22. Nestor BJ, O’Driscoll SW, Morrey BF. Liga- 18(4):921-940. have been underpowered. mentous reconstruction for posterolateral ro- Szabo et al68 retrospectively reviewed 7. Boyd HB, McLeod AC. Tennis elbow. J Bone tatory instability of the elbow. J Bone Joint Joint Surg Am. 1973; 55(6):1183-1187. Surg Am. 1992; 74(8):1235-1241. the clinical results of a single surgeon’s 8. Calvert PT, Allum RL, Macpherson IS, Bentley 23. Morrey BF. 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Ruch DS, Papadonikolakis A, Campolattaro open cases and 1 of the arthroscopic cases, release for lateral epicondylitis: A cadaveric RM. The posterolateral plica: A cause of re- model. Arthroscopy. 1999; 15(3):259-264. fractory lateral elbow pain. J Shoulder Elbow overuse was the cause of recurrence. They Surg. 11. Goldie I. Epicondylitis lateralis humeri (epi- 2006; 15(3):367-370. concluded that the benefi t of arthroscopy condylalgia or tennis elbow): A pathologi- 26. Pomerance J. Radiographic analysis of lateral was the ability to address concomitant in- cal study. Acta Chir Scand. 1964; 57:(Suppl epicondylitis. J Shoulder Elbow Surg. 2002; 339:1+. 11(2):156-157. traarticular pathology avoiding violating 12. Nirschl RP. Prevention and treatment of el- 27. Connell D, Burke F, Coombes P, et al. Sono- the extensor aponeurosis. bow and shoulder injuries in the tennis play- graphic examination of lateral epicondylitis. er. Clin Sports Med. 1988; 7(2):289-308. AJR Am J Roentgenol. 2001; 176(3):777-782. SUMMARY 13. Kraushaar BS, Nirschl RP. Tendinosis of the 28. Mackay D, Rangan A, Hide G, Hughes T, Lateral epicondylitis is the most com- elbow (tennis elbow). Clinical features and Latimer J. The objective diagnosis of early fi ndings of histological, immunohistochemi- tennis elbow by magnetic resonance imaging. mon cause of elbow pain in patients pre- cal, and electron microscopy studies. J Bone Occup Med (Lond). 2003; 53(5):309-312. Joint Surg Am. 1999; 81(2):259-278. senting to orthopaedic surgeons. While 29. Potter HG, Hannafi n JA, Morwessel RM, Di- physical therapy, NSAIDs, and activity 14. Bunata RE, Brown DS, Capelo R. Anatomic Carlo EF, O’Brien SJ, Altchek DW. Lateral modifi cation are the mainstay of treat- factors related to the cause of tennis elbow. J epicondylitis: Correlation of MR imaging, Bone Joint Surg Am. 2007; 89(9):1955-1963. surgical, and histopathologic fi ndings. Radi- ment, other modalities have been used ology. 15. Alfredson H, Ljung BO, Thorsen K, Lorent- 1995; 196(1):43-46. successfully, including many injectable zon R. In vivo investigation of ECRB tendons 30. Steinborn M, Heuck A, Jessel C, Bonel H, substances. While surgery is reserved for with microdialysis technique: No signs of in- Reiser M. Magnetic resonance imaging of patients with refractory symptoms after fl ammation but high amounts of glutamate lateral epicondylitis of the elbow with a in tennis elbow. Acta Orthop Scand. 2000; 0.2-T dedicated system. Eur Radiol. 1999; failed nonoperative management, good re- 71(5):475-479. 9(7):1376-1380. sults can be anticipated with most of the 16. Dickenson AH, Chapman V, Green GM. 31. Froimson AI. Treatment of tennis elbow with reported techniques, including open de- The pharmacology of excitatory and in- forearm support band. 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