Laurence Laudicina and Thomas Noonan

Tennis Elbow Secrets Revealed

Tennis Elbow Secrets Revealed

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Lateral tendonosis (tennis elbow) Medial tendonosis (golfer's elbow) Olecranon bursitis Olecranon stress fracture Valgus extension overload Nerve compression syndromes

LATERAL TENDONOSIS/EPICONDYLITIS (TENNIS ELBOW)

Clinical Features and Evaluation

Lateral epicondylitis or tendonosis is usually an overuse injury, although it may be precipitated by minor elbow trauma. The condition is typically due to repetitive flexion/extension or pronation/supination with the elbow near extension. It generally presents as lateral-side elbow pain and tenderness directly over the lateral epicondyle (at the extensor origin), and just distal to it. Pain is elicited at the lateral epicondyle extensor insertion with passive wrist flexion and with resisted wrist and digital extension. The elbow is extended for both provocative maneuvers.1

Relevant Anatomy

Lateral epicondylitis (tennis elbow) occurs secondary to repetitive microtrauma involving extensor carpi radialis brevis, sometimes also involving the extensor carpi radialis longus and extensor carpi ulnaris (Fig. 35-1). Microscopic changes in the extensor carpi radialis brevis have been described as angiofi-broblastic hyperplasia and hyaline degeneration (Fig. 35-2).2

Treatment Options

The mainstay of treatment is nonoperative and can include activity modification, nonsteroidal anti-inflammatory drugs, counter-force brace, physical therapy with stretching and strengthening, ultrasound therapy, ionto-/phonophoresis3,4 as well as activity modification and sport technique refinement such as modifying racquet grip size and string tension. Limited corticosteroid injections may also be considered. Trephination of tissue and bone in conjunction with percutaneous injection has provided anecdotal relief. Laser therapy and extracorporeal shock wave therapy have recently been suggested as treatments, although significant benefit has yet to be demonstrated.5-7 Corticosteroid injections have demonstrated short-term benefit, while physical therapy has demonstrated long-term benefit.8

Surgery

Surgery is generally reserved for cases not relieved by conservative means and persisting for longer than 6 months. Several techniques have been described (Figs. 35-3 and 35-4). Generally, open excision of the torn abnormal origin and granulation tissue with repair of the extensor carpi radialis and extensor digitorum communis is performed. Decortication of the lateral epicondyle with a rongeur, bur, or pick is typically preferable to lateral epicondylectomy.9,10

Arthroscopy has been recently described to delineate concurrent intra-articular pathology. The undersurface of the lateral pathology is debrided via an anterolateral portal and visualized through an anteromedial portal.11 Percutaneous release has also been described.12

Complications of surgical treatment can include residual pain, posterolateral instability, and posterior interosseous nerve injury.

Postoperative Rehabilitation

A postoperative posterior splint at 90 degrees of elbow flexion and neutral rotation is removed within 2 weeks. Progressive range-of-motion exercises are followed by progressive resistance exercises once full range of motion is achieved. Residual or recurrent pain is treated with decreased activities, anti-inflammatory drugs, scar massage, ultrasound therapy, and cryotherapy.

Criteria for Return to Sports

Little or no residual pain, full range of motion, full strength, and ability to tolerate activities in a progressive manner are appropriate return to activity criteria. Initially, a counterforce brace should be used during activities.

INTRODUCTION

• Overuse injuries of the elbow are best diagnosed by a thorough history and physical examination.

• Most overuse injuries of the elbow can be treated with conservative means.

• Some conditions may prove recalcitrant to such treatment.

• Less invasive surgical techniques have evolved.

• Avoidance of iatrogenic injury caused by surgical intervention, especially for nerve compression disorders, remains paramount.

Extensor carpi radialis longus muscle

Extensor carpi radialis brevis muscle r

Supracondylar ridge

Site of common extensor origin tear

Lateral epicondyle r

Site of common extensor origin tear

Lateral epicondyle

Figure 35-1 Lateral elbow anatomy with common extensor origin. (From Froimson A: Tennis elbow. In Green DP Hotchkiss RN, Pederson WC [eds]: Green's Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, p 684.)

Figure 35-2 A, Angiofibroblastic hyperplasia demonstrating vascular proliferation. B, Focal hyaline degeneration. (From Morrey B, Regan W: Elbow and forearm: Section B: Tendinopathies about the elbow. In DeLee J, Drez D, Miller, MD [eds]: DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, WB Saunders, 2003, p 1222.)

Lateral Epicondyle Debridement

Extensor carpi "radialis brevis

Extensor carpi "radialis brevis

Lateral epicondyle

Figure 35-3 Lateral elbow extensor tendon debridement and repair. A, Longitudinal incision directly over extensor insertion at the lateral epicondyle. B, Common extensor tendon longitudinally incised. C, Necrotic, degenerative tendon and granulation tissue excised. D, Lateral epicondyle decorticated with osteotome, rongeur, bur, or pick. E, Common extensor tendon reapproximated over lateral epicondyle. (From Froimson A: Tennis elbow. In Green DP Hotchkiss RN, Pederson WC [eds]: Green's Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, p 686.)

Figure 35-3 Lateral elbow extensor tendon debridement and repair. A, Longitudinal incision directly over extensor insertion at the lateral epicondyle. B, Common extensor tendon longitudinally incised. C, Necrotic, degenerative tendon and granulation tissue excised. D, Lateral epicondyle decorticated with osteotome, rongeur, bur, or pick. E, Common extensor tendon reapproximated over lateral epicondyle. (From Froimson A: Tennis elbow. In Green DP Hotchkiss RN, Pederson WC [eds]: Green's Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, p 686.)

Lateral Epicondylitis Surgery Not

Figure 35-4 A, Proximal lateral (1) and direct lateral (2) portals. B, An arthroscopic shaver is used to débride the extensor carpi radialis brevis (ECRB) tendon at the insertion. C, Fatty degenerative changes (arrow) in the extensor carpi radialis brevis tendon overlying the extensor carpi radialis longus (ECRL). D, A hooded bur is used to decorticate the lateral epicondyle. (From Murphy K, Lehman R: Arthroscopic management of lateral epicondylitis. In Miller M, Cole B [eds]: Textbook of Arthroscopy. Philadelphia, WB Saunders, 2004, pp 355-357.)

Figure 35-4 A, Proximal lateral (1) and direct lateral (2) portals. B, An arthroscopic shaver is used to débride the extensor carpi radialis brevis (ECRB) tendon at the insertion. C, Fatty degenerative changes (arrow) in the extensor carpi radialis brevis tendon overlying the extensor carpi radialis longus (ECRL). D, A hooded bur is used to decorticate the lateral epicondyle. (From Murphy K, Lehman R: Arthroscopic management of lateral epicondylitis. In Miller M, Cole B [eds]: Textbook of Arthroscopy. Philadelphia, WB Saunders, 2004, pp 355-357.)

MEDIAL EPICONDYLITIS/TENDONOSIS (GOLFER'S ELBOW)

Clinical Features and Evaluation

Medial epicondylitis is usually an overuse injury, although it may be precipitated by minor elbow trauma. Repetitive pronation and valgus with the elbow near extension is the typical mechanism. It presents with medial elbow pain, pain with active wrist flexion, and weakness of grip with tenderness over the medial epicondyle at the flexor-pronator origin. Provocative maneuvers include pain with passive wrist extension and elbow extension and pain with resisted wrist and digital flexion and forearm pronation.

Relevant Anatomy

The flexor-pronator mass inserts at the medial epicondyle (Fig. 35-5). Ulnar collateral ligament injury is differentiated by valgus stress testing with pain localized to the ligament. Mild ulnar neuropathy may also be concurrent with medial epicondylitis.

Treatment Options

The mainstay of treatment is nonoperative and involves non-steroidal anti-inflammatory drugs, counterforce brace, physical therapy with stretching and strengthening, ultrasound therapy, ionto-/phonophoresis, and activity modification and sport technique refinement. Injections may be considered; however, care should be taken and multiple injections are to be avoided due to the proximity of the ulnar nerve and ulnar collateral ligament. Injections should remain anterior to the medial epicondyle to avoid the ulnar nerve.1

Surgery

Surgical intervention is reserved for refractory cases with symptoms persisting longer than 6 months to 1 year despite persistent conservative management. Precise localization of the maximal point of tenderness preoperatively is important (Fig. 35-6). The origin of the pronator teres and flexor carpi radialis are exposed. Torn, scarred, and abnormal tissue is excised. Normal tissue is left intact to avoid iatrogenic injury to the ulnar collateral ligament. Care must be taken to protect the medial antebrachial cutaneous nerve branches. Avoid medial epi-condylectomy and consider nerve transposition if significant preoperative neuropathy exists.9

Postoperative Rehabilitation

Postoperative care is slower than that of lateral epicondylitis and may require as long as 6 months. A posterior elbow splint is placed in 90 degrees of elbow flexion and neutral forearm rotation for 3 weeks. Range of motion is progressively increased followed by progressive strength and endurance exercises at approximately 6 weeks.

Criteria for Return to Sport

Little or no residual pain, full range of motion, full strength (within 85% of the contralateral side), and ability to tolerate activities in a progressive manner are appropriate return to activity criteria. A counterforce brace should be used during initial sporting activities.

Complications

Persistent ulnar neuropathy, ulnar nerve injury, iatrogenic medial instability, and elbow stiffness are recognized complications. All are fortunately rare.13

OLECRANON BURSITIS (MINER'S OR STUDENT'S ELBOW)

Clinical Features and Evaluation

Olecranon bursitis involves inflammation of the superficial olecranon bursa and may be considered acute, chronic, or septic. It has been termed miner's or student's elbow. Nonseptic bur-sitis is most commonly seen in football and hockey and other contact sports that may involve a direct fall onto a partially flexed elbow. Painless swelling of the bursa after a direct blow is the most common presentation. Recurrent episodes may be the result of less trauma than the initial insult. Septic bursitis is more commonly seen in mat sports such as wrestling or gymnastics, and clinical suspicion should leave a low threshold for aspiration and analysis of warm, erythematous or painful bursitis. The most common organism is Staphylococcus aureus. Chronic cases may replace the bursa with fibrous tissue and

Figure 35-5 Medial elbow anatomy demonstrating the common flexor insertion and ulnar nerve. (From Froimson A: Tennis elbow. In Green DP Hotchkiss RN, Pederson WC [eds]: Green's Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, p 685.)

Laurence Laudicina
Medial collateral ligament

Figure 35-5 Medial elbow anatomy demonstrating the common flexor insertion and ulnar nerve. (From Froimson A: Tennis elbow. In Green DP Hotchkiss RN, Pederson WC [eds]: Green's Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, p 685.)

Olecranon Bursitis UssLaurence LaudicinaFeather Drawings

can prove difficult to resolve by conservative means (Fig. 35-7).

Relevant Anatomy

The subcutaneous bursa is most often involved in olecranon bursitis. Intratendinous and subtendinous bursae have been described but are rarely involved. With recurrent episodes, tra-beculae and villiform and fibrous masses may be palpable in the subcutaneous bursa. An olecranon bone spur may be present in chronic recurrent cases.

Treatment Options

Compression and cryotherapy can help minimize swelling following traumatic acute olecranon bursitis. Protective covering and doughnut padding are important to prevent recurrent trauma and subsequent swelling, fibrous tissue formation, and progression to chronic bursitis. Aspiration may be considered for severe bursa distension interfering with elbow function and is recommended if there is suspicion of infection. Cell count, crystal analysis, and Gram stain should be performed. A purulent aspiration may be lavaged and injected with 0.5 g methicillin in 10 mL saline. Aspiration is performed with sterile technique and followed by compressive dressing for 36 to 48 hours.1

Figure 35-6 Medial epicondylitis operative debridement. A, Excision of the frayed, degenerative common flexor origin. B, Normal tissue of the flexor pronator origin left intact. C, Reapproximation of the flexor pronator origin following decortication. (From Dlabach JA, Baker CL: Lateral and medial epicondylitis in the overhead athlete. Op Tech Orthop 2001;11:52.)

Figure 35-7 Olecranon bursitis clinical appearance. (From Baker CL, Cummings PD: Arthroscopic management of miscellaneous elbow disorders. Op Tech Sports Med 1998;6:16-21.)

Figure 35-8 The thickened, scarred olecranon bursa is excised through an incision centered lateral to the midline. (From Morrey B, Regan W: Elbow and forearm: Section B: Tendinopathies about the elbow. In DeLee J, Drez D, Miller, MD [eds]: DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, WB Saunders, 2003, p 1234.)

Figure 35-8 The thickened, scarred olecranon bursa is excised through an incision centered lateral to the midline. (From Morrey B, Regan W: Elbow and forearm: Section B: Tendinopathies about the elbow. In DeLee J, Drez D, Miller, MD [eds]: DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, WB Saunders, 2003, p 1234.)

Surgery

Surgical intervention is considered for cases that do not respond to nonoperative therapy or prevent function and performance (Fig. 35-8). Septic bursitis that does not respond to aspiration and antibiotics should undergo open incision and drainage. A longitudinal incision directly over the midline or slightly lateral (to avoid the ulnar nerve) is performed, carefully dissecting the bursa in its entirety (Fig. 35-9). Meticulous skin handling and closure followed by compressive dressing and 7 to 10 days of elbow splinting help prevent wound-healing problems and recurrence. Protective padding should be used for return to activities. Endoscopic debridement has also been described.

OLECRANON STRESS FRACTURE

Clinical Features and Evaluation

The insidious onset of posterior elbow pain during the acceleration phase of throwing and point tenderness over the olecranon or pain with valgus stress should raise suspicion for an olecranon stress fracture (Fig. 35-10). Repetitive impaction of the olecranon against the olecranon fossa as in valgus extension overload or triceps traction during the deceleration phase of throwing may cause stress reaction. Plain radiographs may show the stress fracture, but computed tomography, bone scan, and magnetic resonance imaging may be more definitive studies.

Relevant Anatomy

Transverse olecranon stress fractures are due to triceps traction and extension forces, while oblique fractures are due to olecra-non impaction on the medial wall of the olecranon fossa due to valgus extension overload. Ulnar collateral ligament injury, often

Valgus Extension Overload Symptoms
Figure 35-9 Portal placement for olecranon bursectomy. The arthroscope is in the proximal central portal; the shaver is in the lateral portal. (From Baker CL, Cummings PD: Arthroscopic management of miscellaneous elbow disorders. Op Tech Sports Med 1998;6:16-21.)

partial, may be concurrent with olecranon stress fracture. Epiphyseal injury should also be considered in the skeletally immature gymnast, wrestler, or weight lifter.14

Treatment Options

Initial nonoperative treatment involves rest from throwing with lifting restrictions and may require as long as 6 months. Once point tenderness resolves and radiographic union is present, reconditioning may commence. Gradual progression through rotator cuff, scapulothoracic, biceps, and triceps exercises; plyometrics; and eventually an interval throwing program is appropriate.

Surgery

Should symptoms fail to resolve with nonoperative means or if lengthy healing times cannot be tolerated, operative intervention is indicated. A single large cannulated screw across the fracture site placed percutaneously through the triceps tendon is most appropriate (Fig. 35-11). The screw only needs to be removed if local soft-tissue irritation persists after the fracture is well healed. A titanium screw may cause less artifact should magnetic resonance imaging be required at some point in the postoperative course.15,16

Figure 35-10 Radiographic appearance of olecranon stress fracture. A, Plain film lateral view. B, Bone scan. C, Computed tomography scan. D, Magnetic resonance imaging. (From Jones R, Miller R: Bony overuse injuries about the elbow. Op Tech Orthop 2001;11:58.)

Flexion Contracture Osteophyte

Figure 35-10 Radiographic appearance of olecranon stress fracture. A, Plain film lateral view. B, Bone scan. C, Computed tomography scan. D, Magnetic resonance imaging. (From Jones R, Miller R: Bony overuse injuries about the elbow. Op Tech Orthop 2001;11:58.)

VALGUS EXTENSION OVERLOAD/POSTERIOR MEDIAL OSTEOPHYTE

Valgus extension overload can occur during the acceleration phase of throwing (Fig. 35-12). Posterior elbow pain during acceleration is characteristic. Flexion contracture, pain with forced extension, and tenderness of the posterior joint line is typical. A posterior medial osteophyte results from repetitive stress to this area. The osteophyte can be excised through open or arthroscopic techniques (Figs. 35-13 and 35-14). Evaluation for medial instability is also important clinically, under anesthesia and arthroscopically, as posteromedial bone resection may unmask underlying medial instability. Care should be taken not to create iatrogenic medial instability by overzealous resection of the posteromedial olecranon.17

NERVE COMPRESSION SYNDROMES

Ulnar Nerve Compression Clinical Features and Evaluation

The ulnar nerve is most commonly compressed at the elbow. Medial elbow pain with radiating paresthesias to the small and ring fingers is a common presentation in these patients. Examination may reveal decreased ulnar sensation, a positive Tinel's sign at the cubital tunnel, reproduction of symptoms with prolonged elbow flexion, and, in severe cases, weakness of the ulnar intrinsics (flexor carpi ulnaris, interossei, adductor). Subluxation of the ulnar nerve can also occur.1 Segmental nerve conduction velocity may prove more sensitive than standard motor conduction velocity testing.18

Olecranon Fracture Screw Fixation

Figure 35-11 Percutaneous screw fixation of an olecranon stress fracture. (From Morrey B, Regan W: Elbow and forearm: Section B: Tendinopathies about the elbow. In DeLee J, Drez D, Miller, MD [eds]: DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, WB Saunders, 2003, p 1246.)

Figure 35-11 Percutaneous screw fixation of an olecranon stress fracture. (From Morrey B, Regan W: Elbow and forearm: Section B: Tendinopathies about the elbow. In DeLee J, Drez D, Miller, MD [eds]: DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, WB Saunders, 2003, p 1246.)

Relevant Anatomy

The ulnar nerve passes through the cubital tunnel at the medial elbow. Several potential sites of compression include the aponeurosis of the flexor carpi ulnaris, arcade of Struthers, or cubital tunnel retinaculum (Fig. 35-15). Ulnar neuropathy may be the result of mechanical irritation due to medial collateral ligament deficiency in an athlete.

Treatment Options

Nonsurgical Typical nonoperative treatment involves cessation of aggravating activities, elbow padding, elbow extension splints at night, and evaluation for valgus overload.

Traction

Compression

Figure 35-13 Osteophytes are excised from the olecranon with two osteotomies: transverse (A) and oblique (B). (From Miller M, Howard R, Plancher K: Surgical Atlas of Sports Medicine, Saunders 2003, p 439.)

Surgery Surgical techniques for ulnar nerve compression include decompression as well as submuscular, subcutaneous, and intramuscular transposition techniques. Submuscular techniques have generally achieved better results.19,20

Figure 35-12 Biomechanical forces on the elbow during throwing. Traction on the medial collateral ligament (A); posteromedial olecranon stress (B); olecranon fossa stress (C); compression stress on the radiocapitellar joint (D). (From Morrey B, Regan W: Elbow and forearm: Section B: Tendinopathies about the elbow. In DeLee J, Drez D, Miller, MD [eds]: DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, WB Saunders, 2003, p 1272.)

Posterior Interosseous and Radial Nerve Clinical Features and Evaluation

Posterior interosseous compression syndrome can present with vague elbow pain, weakness of the wrist and finger extensors, and lack of sensory changes.

Radial tunnel syndrome presents with dorsal lateral forearm pain at night. Passive pronation with wrist flexion and resisted

Laurence Laudicina
Figure 35-14 Osteophytes are debrided from the olecranon fossa. (From Miller M, Howard R, Plancher K: Surgical Atlas of Sports Medicine. Philadelphia, WB Saunders, 2003, p 439.)

Rights were not granted to include this figure in electronic media Please refer to the printed publication.

Figure 35-15 Potential ulnar nerve compression sites. (From Posner M: Compressive ulnar neuropathies at the elbow. I. Etiology and diagnosis. J Am Acad Orthop Surg 1998;6:283.)

Radial nerve

Posterior interosseous ner

Arcade of Frohse

Radial nerve

Posterior

Arcade Frohse

Arcade of Frohse

Extensor digitorum communis

Extensor digitorum communis

Figure 35-16 Potential radial nerve compression sites. ecrb, extensor carpi radialis brevis; ecrl, extensor carpi radialis longus. (From Spinner M: Injuries to the Major Branches of the Forearm, 2nd ed. Philadelphia, WB Saunders, 1978.)

forearm supination with wrist extension aggravate symptoms. Pain with resisted middle finger extension during elbow extension (Maudsley's test) can distinguish radial tunnel syndrome from lateral epicondylitis.21

Relevant Anatomy

The radial nerve divides proximal to the elbow joint into the posterior interosseous nerve and superficial radial nerve. The supinator muscle's two heads can compress the posterior interosseous nerve as it passes distally (Fig. 35-16). Nerve conduction velocity studies are generally diagnostic.

Treatment Options

For posterior interosseous nerve compression, cessation of aggravating activities and conservative means should provide relief. Surgical decompression may be considered for recalcitrant cases.

For radial tunnel syndrome, injection of the radial tunnel should eliminate pain and produce a temporary wrist drop. If rest and nonsteroidal anti-inflammatory drugs do not relieve symptoms, surgical decompression may be considered.22

Median Nerve (Pronator Syndrome) Clinical Features and Evaluation

Repetitive pronation/supination activities can aggravate symptoms. Symptoms are similar to carpal tunnel syndrome with paresthesias of the radial digits and weakness or atrophy of the thenar muscles. However, Phalen's test is negative and percussion at the volar elbow and forearm reproduces symptoms. Anterior interosseous nerve compression can result in vague anterior forearm pain and the loss of thumb to finger pinch. Bilateral anterior interosseous nerve compression present for at least 3 months is known as Parsonage-Andrew-Turner syndrome.

Relevant Anatomy

Pronator syndrome involves compression of the median nerve at the elbow by the bicipital aponeurosis, pronator teres, flexor dig-itorum superficialis, medial supracondylar process, and/or ligament of Struthers (Fig. 35-17).

Treatment Options

If rest and nonsteroidal anti-inflammatory drugs do not relieve symptoms, surgical decompression may be considered if debilitating symptoms persist despite extended conservative management.14

Bicipital aponeurosis

Pronator teres insertion

Reflected ulnar head pronator teres

Ulnar Head Pronator Teres

Reflected FDS arch

Anterior interosseous nerve

Reflected ulnar head pronator teres

Reflected humeral head, pronator teres

Median nerve

Radial artery

Reflected FDS arch

Anterior interosseous nerve

Median nerve Reflected humeral head, pronator teres

Bicipital aponeurosis

Bicipital Aponeurosis Funktion

Median nerve Reflected humeral head, pronator teres

Radial artery

Ulnar head, pronator teres

Pronator teres insertion

Radial artery

Ulnar head, pronator teres

Figure 35-17 Potential sites of median nerve compression. A, The bicipital aponeurosis may compress the flexor muscle in pronation and is divided. B, The reflected humeral head of pronator teres exposes the flexor digitorum superficialis (FDS) arch and ulnar head of the pronator teres. C, The radial origin of the FDS is elevated to expose the deep volar compartment and anterior interosseous nerve. (From Szabo R: Entrapment and compression neuropathies. In Green's Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, p 1420.)

REFERENCES

1. Morrey B, Regan W: Elbow and forearm: Section B: Tendinopathies about the elbow. In DeLee J, Drez D, Miller, MD (eds): DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, WB Saunders, 2003, pp 1221-1235.

2. Kraushaar B, Nirschl R: Current concepts review—tendonosis of the elbow. Clinical features and findings of histological immunohisto-chemical and electron microscopy studies. J Bone Joint Surg (Am) 1999;81:259-278.

3. Nirschl R, Rodin D, Ochiai D, et al: Iontophoretic administration of sodium dexamethasone phosphate for acute epicondylitis: A randomized, double-blind, placebo controlled study. Am J Sports Med 2003;31:189-195.

4. Runeson L, Haker E: Iontophoresis with cortisone in the treatment of lateral epicondylalgia (tennis elbow): A double-blind study. Scand J Med Sci Sports 2002;12:136-142.

5. Simunovic Z, Trobonjaca T, Trobonjaca Z: Treatment of medial and lateral epicondylitis—tennis and golfer's elbow—with low level laser therapy: A multicenter double-blind, placebo-controlled clinical study on 324 patients. J Clin Laser Med Surg 1998;16:145-151.

6. Haake M, Konig I, Decker T, et al: Extracorporeal shock wave therapy in the treatment of lateral epicondylitis: A randomized multicenter trial. J Bone Joint Surg Am 2002;84:1982-1991.

7. Speed C, Nichols D, Richards C, et al: Extracorporeal shock wave therapy for lateral epicondylitis: A double blind randomized controlled trial. J Orthop Res 2002;20:895-898.

8. Smidt N, van der Windt D, Assendelft W et al: Corticosteroid injections, physiotherapy, or a wait and see policy for lateral epicondylitis: A randomized controlled trial. Lancet 2002;359:657-662.

9. Teitz C, Garrett W Miniaci A, et al: Tendon problems in athletic individuals. Instructional course lecture. J Bone Joint Surg Am 1997; 79:138-152.

10. Jobe F, Ciccotti M: Lateral and medial epicondylitis of the elbow. J Am Acad Orthop Surg 1994;2:1-8.

11. Baker C, Murphy K, Gottlob C, et al: Arthroscopic classification and treatment of lateral epicondylitis: Two-year clinical results. J Shoulder Elbow Surg 2000;9:475-482.

12. Grundberg A, Dobson J: Percutaneous release of the common extensor origin for tennis elbow. Clin Orthop 2000;376:137-140.

13. Dlabach JA, Baker CL: Lateral and medial epicondylitis in the overhead athlete. Op Tech Orthop 2001;11:46-54.

14. Garrick J: Sports Medicine 3 Orthopaedic Knowledge Update. Rose-mont, IL, American Academy of Orthopaedic Surgeons, 2004.

15. Nuber G, Diment M: Olecranon stress fractures in throwers: A report of two cases and review of the literature. Clin Orthop 1992;278:58-61.

16. Schickendantz M, Ho C, Koh J: Stress injury of the proximal ulna in professional baseball players. Am J Sports Med 2002;30:737-741.

17. Azar F, Andrews J, Wilke K, et al: Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000;28:16-23.

18. Azreili Y, Weimer L, Lovelace R, et al: The utility of segmental nerve conduction studies in ulnar mono-neuropathy at the elbow. Muscle Nerve 2003;27:46-50.

19. Posner M: Compressive ulnar neuropathies at the elbow. I. Etiology and diagnosis. J Am Acad Orthop Surg 1998;6:289-297.

20. Nikitins M, Ch'ng S, Rice N: A dynamic anatomical study of ulnar nerve motion after anterior transposition for cubital tunnel syndrome. Hand Surg 2002;7:177-182.

21. Fairbank S, Corelett R: The role of the extensor digitorum communis muscle in lateral epicondylitis. J Hand Surg (Br) 2002;27:405-409.

22. Lorei M, Hershman E: Peripheral nerve injuries in athletes: Treatment and prevention. Sports Med 1993;16:130-147.

SUGGESTED READING

Gabel G: Acute and chronic tendinopathies at the elbow. Curr Opin

Rheumatol 1999;11:138-143. Miller M, Cole B: Textbook of Arthroscopy. Philadelphia, WB Saunders, 2004.

Miller M, Cooper D, Warner J: Review of Sports Medicine and Arthroscopy, 2nd ed. Philadelphia, WB Saunders, 2002.

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Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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