Romeo discusses diagnosis, treatment of lateral, medial epicondylitis
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KOLOA, Hawaii — Although the elbow is not the most common area where surgeons see problems, when these problems occur, the lateral epicondylitis is the most common diagnosis, according to a presenter here.
In his presentation at Orthopedics Today Hawaii, Anthony A. Romeo, MD, said that when diagnosing a patient with lateral epicondylitis, it is important that surgeons make sure the patient’s pain is not being caused by another issue. He said if the pain is coming from somewhere other than the extensor carpi radialis brevis (ECRB), it is not lateral epicondylitis.
“A lot of people just say, ‘Well, it is a lateral elbow. It has to be lateral epicondylitis,’” Romeo, who is Chief Medical Editor of Orthopedics Today, said. “You can be a bit more sophisticated about that if you think carefully about the anatomy.”
Although surgeons may not see much on plain radiographs, Romeo noted MRI can be valuable if the problem involves more than lateral epicondylitis.
Treatment of lateral epicondylitis
When it comes to treatment, most patients will do well with nonoperative treatment, such as exercise and a counterforce brace, according to Romeo. He noted previously published research has shown that physical therapy (PT) results in more symptomatic improvement vs. a corticosteroid injection at 1 year after initiating treatment in patients with lateral epicondylitis.
“I know that we all say it’s all the same, you are going to get better, but ... PT does make a difference better than corticosteroid injection. [It is] not much better than placebo, though,” Romeo said.
He added that research has shown that patients who get corticosteroid injections have a lower recovery rate 1 year after initiating treatment with less improvement and a higher recurrence rate compared with patients who receive placebo. Patients with lateral epicondylitis who receive three or more corticosteroid injections preoperatively may have a higher risk of revision surgery, as well, Romeo noted. Although some surgeons hold that platelet-rich plasma injections show promise for treatment of lateral epicondylitis, Romeo said studies with an adequate placebo or control groups are lacking.
“When the patient won’t get better despite everything you do, there’s an open incision treatment, which has been the standard of care for many years,” he said. “It’s important when you do this you take your time going through the various layers. Right under that fascia layer of the [extensor digitorum communis] EDC is where the ECRB is. So, you don’t want to make a deep cut and then be so into the middle of that bad tissue, you can’t separate that out.”
Medial epicondylitis
Less common than lateral epicondylitis, medial epicondylitis can be more persistent, is more common in men than women and generally resolves in up to 1 year, according to Romeo.
“The risk factors [for medial epicondylitis] are sports that [patients] play and a number of other things related to work,” he said. “Anything that requires strong grip strength can bother this, and it may present up to 20% of the time with ulnar neuropathy symptoms.”
The problem is identified as tenderness around the medial epicondyle slightly anterior to the ulnar collateral ligament and worsened with resistant pronation. Romeo noted surgeons can order an MRI if they are unsure if the patient has another problem and to evaluate the integrity of the attachment of the flexor pronator and the UCL.
Unlike lateral epicondylitis, Romeo said treatment with corticosteroid injection may be valuable at least once for medial epicondylitis.
“[There are the] same issues with multiple nonoperative treatment modalities, including the use of PRP, with poor evidence that that’s the best answer. But we are using [PRP] more often in our patients because we think it’s a better biological solution than corticosteroids that we hope will work,” Romeo said.
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Romeo AA. Five most common problems of the elbow. Presented at: Orthopedics Today Hawaii; Jan. 8-12, 2023; Koloa, Hawaii.
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