Current concept| Volume 34, ISSUE 3, P566-576, March 2009

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Elbow Tendinopathy and Tendon Ruptures: Epicondylitis, Biceps and Triceps Ruptures

      Lateral and medial epicondylitis are common causes of elbow pain in the general population, with the lateral variety being more common than the medial by a ratio reportedly ranging from 4:1 to 7:1. Initially thought to be an inflammatory condition, epicondylitis has ultimately been shown to result from tendinous microtearing followed by an incomplete reparative response. Numerous nonoperative and operative treatment options have been employed in the treatment of epicondylitis, without the emergence of a single, consistent, universally accepted treatment protocol.
      Tendon ruptures about the elbow are much less frequent, but result in more significant disability and loss of function. Distal biceps tendon ruptures typically occur in middle-aged males as a result of an event that causes a sudden, eccentric contraction of the biceps. Triceps tendon ruptures are exceedingly rare but usually have a similar etiology with a forceful eccentric contraction of the triceps that causes avulsion of the tendon from the olecranon. The diagnosis of these injuries is not always readily made. Complete ruptures of the biceps or triceps tendons have traditionally been treated surgically with good results. With regard to biceps ruptures, there continues to be debate about the best surgical approach, as well as the best method of fixation of tendon to bone.
      This article is not meant to be an exhaustive review of the broad topics of elbow tendinopathy and tendon ruptures, but rather is a review of recently published information on the topics that will assist the clinician in diagnosis and management of these conditions.

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        • Whaley A.L.
        • Baker C.L.
        Lateral epicondylitis.
        Clin Sports Med. 2004; 23: 677-691
        • Dorf E.R.
        • Chhabra A.B.
        • Golish S.R.
        • McGinty J.L.
        • Pannunzio M.E.
        Effect of elbow position on grip strength in the evaluation of lateral epicondylitis.
        J Hand Surg. 2007; 32A: 882-886
        • Mackay D.
        • Rangan A.
        • Hide G.
        • Hughes T.
        • Latimer J.
        The objective diagnosis of early tennis elbow by magnetic resonance imaging.
        Occup Med (Lond). 2003; 53: 309-312
        • Savnik A.
        • Jensen B.
        • Nørregaard J.
        • Egund N.
        • Danneskiold-Samsøe B.
        • Bliddal H.
        Magnetic resonance imaging in the evaluation of treatment response of lateral epicondylitis of the elbow.
        Eur Radiol. 2004; 14: 964-969
        • Levin D.
        • Nazarian L.N.
        • Miller T.T.
        • O'Kane P.L.
        • Feld R.I.
        • Parker L.
        • et al.
        Lateral epicondylitis of the elbow: US findings.
        Radiology. 2005; 237: 230-234
        • Struijs P.A.A.
        • Kerkhoffs G.M.M.J.
        • Assendelft W.J.J.
        • Dijk van C.N.
        Conservative treatment of lateral epicondylitis: brace versus physical therapy or a combination of both—a randomized clinical trial.
        Am J Sports Med. 2004; 32: 462-469
        • Altan L.
        • Kanat E.
        Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices.
        Clin Rheumatol. 2008; 27: 1015-1019
        • Struijs P.A.A.
        • Smidt N.
        • Arola H.
        • Dijk van C.N.
        • Buchbinder R.
        • Assendelft W.J.J.
        Orthotic devices for the treatment of tennis elbow.
        Cochrane Database of Systematic Reviews. 2002; 1 (CD001821): 1-23
        • Smidt N.
        • van der Windt D.A.W.M.
        • Assendelft W.J.J.
        • Devillé W.L.J.M.
        • Korthals-de Bos I.B.C.
        • Bouter L.M.
        Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial.
        Lancet. 2002; 359: 657-662
        • Altay T.
        • Günal I.
        • Öztürk H.
        Local injection treatment for lateral epicondylitis.
        Clin Orthop Relat Res. 2002; 398: 127-130
        • Hayton M.J.
        • Santini A.J.A.
        • Hughes P.J.
        • Frostick S.P.
        • Trail I.A.
        • Stanley J.K.
        Botulinum toxin injection in the treatment of tennis elbow: a double-blind, randomized, controlled, pilot study.
        J Bone Joint Surg. 2005; 87A: 503-507
        • Wong S.M.
        • Hui A.C.F.
        • Tong P.-Y.
        • Poon D.W.F.
        • Yu E.
        • Wong L.K.S.
        Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial.
        Ann Intern Med. 2005; 143: 793-797
        • Placzek R.
        • Drescher W.
        • Deuretzbacher G.
        • Hempfing A.
        • Meiss A.L.
        Treatment of chronic radial epicondylitis with botulinum toxin A: a double-blind, placebo-controlled, randomized multicenter study.
        J Bone Joint Surg. 2007; 89A: 255-260
        • Edwards S.G.
        • Calandruccio J.H.
        Autologous blood injections for refractory lateral epicondylitis.
        J Hand Surg. 2003; 28A: 272-278
        • Connell D.A.
        • Ali K.E.
        • Ahmad M.
        • Lambert S.
        • Corbett S.
        • Curtis M.
        Ultrasound-guided autologous blood injection for tennis elbow.
        Skeletal Radiol. 2006; 35: 371-377
        • Suresh S.P.S.
        • Ali K.E.
        • Jones H.
        • Connell D.A.
        Medial epicondylitis: is ultrasound guided autologous blood injection an effective treatment?.
        Br J Sports Med. 2006; 40: 935-939
        • Buchbinder R.
        • Green S.E.
        • Youd J.M.
        • Assendelft W.J.J.
        • Barnsley L.
        • Smidt N.
        Shock wave therapy for lateral elbow pain.
        Cochrane Database of Systematic Reviews. 2005; 4 (CD003524): 1-51
        • Staples M.P.
        • Forbes A.
        • Ptasznik R.
        • Gordon J.
        • Buchbinder R.
        A randomized controlled trial of extracorporeal shock wave therapy for lateral epicondylitis (tennis elbow).
        J Rheumatol. 2008; 35: 2038-2046
        • Nirschl R.P.
        • Rodin D.M.
        • Ochiai D.H.
        • Maartmann-Moe C.
        Iontophoretic administration of dexamethasone sodium phosphate for acute epicondylitis: a randomized, double-blinded, placebo-controlled study.
        Am J Sports Med. 2003; 31: 189-195
        • D'Vaz A.P.
        • Ostor A.J.K.
        • Speed C.A.
        • Jenner J.R.
        • Bradley M.
        • Prevost A.T.
        • et al.
        Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial.
        Rheumatology. 2006; 45: 566-570
        • Uzunca K.
        • Birtane M.
        • Taçtekin N.
        Effectiveness of pulsed electromagnetic field therapy in lateral epicondylitis.
        Clin Rheumatol. 2007; 26: 69-74
        • Nourbakhsh M.R.
        • Fearon F.J.
        An alternative approach to treating lateral epicondylitis: a randomized, placebo-controlled, double-blinded study.
        Clinical Rehabilitation. 2008; 22: 601-609
        • Paoloni J.A.
        • Appleyard R.C.
        • Nelson J.
        • Murrell G.A.C.
        Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial.
        Am J Sports Med. 2003; 31: 915-920
        • Trinh K.V.
        • Phillips S.D.
        • Ho E.
        • Damsma K.
        Acupuncture for the alleviation of lateral epicondyle pain: a systematic review.
        Rheumatology. 2004; 43: 1085-1090
        • Buchbinder R.
        • Green S.
        • Bell S.
        • Barnsley L.
        • Smidt N.
        • Assendelft W.J.J.
        Surgery for lateral elbow pain.
        Cochrane Database of Systematic Reviews. 2002; 1 (CD003525): 1-8
        • Lo M.Y.
        • Safran M.R.
        Surgical treatment of lateral epicondylitis: a systematic review.
        Clin Orthop Relat Res. 2007; 463: 98-106
        • Szabo S.J.
        • Savoie F.H.
        • Field L.D.
        • Ramsey J.R.
        • Hosemann C.D.
        Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment.
        J Shoulder Elbow Surg. 2006; 15: 721-727
        • Dunkow P.D.
        • Jatti M.
        • Muddu B.N.
        A comparison of open and percutaneous techniques in the surgical treatment of tennis elbow.
        J Bone Joint Surg. 2004; 86B: 701-704
        • Cummins C.A.
        Lateral epicondylitis: in vivo assessment of arthroscopic debridement and correlation with patient outcomes.
        Am J Sports Med. 2006; 34: 1486-1491
        • Tasto J.P.
        • Cummings J.
        • Medlock V.
        • Hardesty R.
        • Amiel D.
        Microtenotomy using a radiofrequency probe to treat lateral epicondylitis.
        Arthroscopy. 2005; 21: 851-860
        • Meknas K.
        • Odden-Miland Å
        • Mercer J.B.
        • Castillejo M.
        • Johansen O.
        Radiofrequency microtenotomy: a promising method for treatment of recalcitrant lateral epicondylitis.
        Am J Sports Med. 2008; 36: 1960-1965
        • Ruland R.T.
        • Dunbar R.P.
        • Bowen J.D.
        The biceps squeeze test for diagnosis of distal biceps tendon ruptures.
        Clin Orthop Relat Res. 2005; 437: 128-131
        • O'Driscoll S.W.
        • Goncalves L.B.J.
        • Dietz P.
        The hook test for distal biceps tendon avulsion.
        Am J Sports Med. 2007; 35: 1865-1869
        • Chillemi C.
        • Marinelli M.
        • De Cupis V.
        Rupture of the distal biceps brachii tendon: conservative treatment versus anatomic reinsertion—clinical and radiological evaluation after 2 years.
        Arch Orthop Trauma Surg. 2007; 127: 705-708
        • Hetsroni I.
        • Pilz-Burstein R.
        • Nyska M.
        • Back Z.
        • Barchilon V.
        • Mann G.
        Avulsion of the distal biceps brachii tendon in middle-aged population: is surgical repair advisable?.
        Injury. 2008; 39: 753-760
        • McKee M.D.
        • Hirji R.
        • Schemitsch E.H.
        • Wild L.M.
        • Waddell J.P.
        Patient-oriented functional outcome after repair of distal biceps tendon ruptures using a single-incision technique.
        J Shoulder Elbow Surg. 2005; 14: 302-306
        • Khan A.D.
        • Penna S.
        • Yin Q.
        • Sinopidis C.
        • Brownson P.
        • Frostick S.P.
        Repair of distal biceps tendon ruptures using suture anchors through a single anterior incision.
        Arthroscopy. 2008; 24: 39-45
        • John C.K.
        • Field L.D.
        • Weiss K.S.
        • Savoie F.H.
        Single-incision repair of acute distal biceps ruptures by use of suture anchors.
        J Shoulder Elbow Surg. 2007; 16: 78-83
        • Hartman M.W.
        • Merten S.M.
        • Steinmann S.P.
        Mini-open 2-incision technique for repair of distal biceps tendon ruptures.
        J Shoulder Elbow Surg. 2007; 16: 616-620
        • Weinstein D.M.
        • Ciccone W.J.
        • Buckler M.C.
        • Balthrop P.M.
        • Busey T.D.
        • Elias J.J.
        Elbow function after repair of the distal biceps brachii tendon with a two-incision approach.
        J Shoulder Elbow Surg. 2008; 17: 82S-86S
        • Chavan P.R.
        • Duquin T.R.
        • Bisson L.J.
        Repair of the ruptured distal biceps tendon: a systematic review.
        Am J Sports Med. 2008; 36: 1618-1624
        • Henry J.
        • Feinblatt J.
        • Kaeding C.C.
        • Latshaw J.
        • Litsky A.
        • Sibel R.
        • et al.
        Biomechanical analysis of distal biceps tendon repair methods.
        Am J Sports Med. 2007; 35: 1950-1954
        • Sharma S.
        • MacKay G.
        Endoscopic repair of distal biceps tendon using an EndoButton.
        Arthroscopy. 2005; 21: 897
        • Kelly E.W.
        • Steinmann S.
        • O'Driscoll S.W.
        Surgical treatment of partial distal biceps tendon ruptures through a single posterior incision.
        J Shoulder Elbow Surg. 2003; 12: 456-461
        • Lemos S.E.
        • Ebramzedeh E.
        • Kvitne R.S.
        A new technique: in vitro suture anchor fixation has superior yield strength to bone tunnel fixation for distal biceps tendon repair.
        Am J Sports Med. 2004; 32: 406-410
        • Idler C.S.
        • Montgomery W.H.
        • Lindsey D.P.
        • Badua P.A.
        • Wynne G.F.
        • Yerby S.A.
        Distal biceps tendon repair: a biomechanical comparison of intact tendon and 2 repair techniques.
        Am J Sports Med. 2006; 34: 968-974
        • Spang J.T.
        • Weinhold P.S.
        • Karas S.G.
        A biomechanical comparison of EndoButton versus suture anchor repair of distal biceps tendon injuries.
        J Shoulder Elbow Surg. 2006; 15: 509-514
        • Mazzocca A.D.
        • Burton K.J.
        • Romeo A.A.
        • Santangelo S.
        • Adams D.A.
        • Arciero R.A.
        Biomechanical evaluation of 4 techniques of distal biceps brachii tendon repair.
        Am J Sports Med. 2007; 35: 252-258
        • Kettler M.
        • Lunger J.
        • Kuhn V.
        • Mutschler W.
        • Tingart M.J.
        Failure strengths in distal biceps tendon repair.
        Am J Sports Med. 2007; 35: 1544-1548
        • Kettler M.
        • Tingart M.J.
        • Lunger J.
        • Kuhn V.
        Reattachment of the distal tendon of biceps: factors affecting the failure strength of the repair.
        J Bone Joint Surg. 2008; 90B: 103-106
        • Hallam P.
        • Bain G.I.
        Repair of chronic distal biceps tendon ruptures using autologous hamstring graft and the Endobutton.
        J Shoulder Elbow Surg. 2004; 13: 648-651
        • Darlis N.A.
        • Sotereanos D.G.
        Distal biceps tendon reconstruction in chronic ruptures.
        J Shoulder Elbow Surg. 2006; 15: 614-619
        • Vastamäki M.
        • Vastamäki H.
        A simple grafting method to repair irreparable distal biceps tendon.
        Clin Orthop Relat Res. 2008; 466: 2475-2481
        • Wiley W.B.
        • Noble J.S.
        • Dulaney T.D.
        • Bell R.H.
        • Noble D.D.
        Late reconstruction of chronic distal biceps tendon ruptures with a semitendinosus autograft technique.
        J Shoulder Elbow Surg. 2006; 15: 440-444
        • Bisson L.
        • Moyer M.
        • Lanighan K.
        • Marzo J.
        Complications associated with repair of a distal biceps rupture using the modified two-incision technique.
        J Shoulder Elbow Surg. 2008; 17: 67S-71S
        • Sotereanos D.G.
        • Sarris I.
        • Chou K.H.
        Radioulnar synostosis after the two-incision biceps repair: a standardized treatment protocol.
        J Shoulder Elbow Surg. 2004; 13: 448-453
        • Wysocki R.W.
        • Cohen M.S.
        Radioulnar heterotopic ossification after distal biceps tendon repair: results following surgical resection.
        J Hand Surg. 2007; 32A: 1230-1236
        • Cheung E.V.
        • Lazarus M.
        • Taranta M.
        Immediate range of motion after distal biceps tendon repair.
        J Shoulder Elbow Surg. 2005; 14: 516-518
        • Cil A.
        • Merten S.
        • Steinmann S.P.
        Immediate active range of motion after modified 2-incision repair in acute distal biceps tendon rupture.
        Am J Sports Med. 2009; 37: 130-135
        • van Riet R.P.
        • Morrey B.F.
        • Ho E.
        • O'Driscoll S.W.
        Surgical treatment of distal triceps ruptures.
        J Bone Joint Surg. 2003; 85A: 1961-1967
        • Kijowski R.
        • Tuite M.
        • Sanford M.
        Magnetic resonance imaging of the elbow—part II: abnormalities of the ligaments, tendons, and nerves.
        Skeletal Radiol. 2005; 34: 1-18
        • Vidal A.F.
        • Drakos M.C.
        • Allen A.A.
        Biceps tendon and triceps tendon injuries.
        Clin Sports Med. 2004; 23: 707-722
        • Kibuule L.K.
        • Fehringer E.V.
        Distal triceps tendon rupture and repair in an otherwise healthy pediatric patient: a case report and review of the literature.
        J Shoulder Elbow Surg. 2007; 16: e1-e3
        • Mair S.D.
        • Isbell W.M.
        • Gill T.J.
        • Schlegel T.F.
        • Hawkins R.J.
        Triceps tendon ruptures in professional football players.
        Am J Sports Med. 2004; 32: 431-434