What is the management of lateral epicondylitis with an intrasubstance tear?

Management of Lateral Epicondylitis with Intrasubstance Tear

The management of lateral epicondylitis with an intrasubstance tear should begin with conservative treatment for at least 3-6 months, including rest, activity modification, NSAIDs, eccentric strengthening exercises, and bracing, before considering surgical intervention for persistent cases.

Initial Conservative Management (0-6 weeks)

Rest and Activity Modification

• Relative rest rather than complete immobilization
• Modification of activities that exacerbate symptoms
• Avoidance of repetitive wrist extension and gripping activities

Pain Management

• Ice application for 15-20 minutes several times daily
• Acetaminophen or NSAIDs for pain control 1
• Counterforce bracing/orthotics to reduce stress on the extensor tendon origin 1

Rehabilitation

• Begin eccentric strengthening exercises of the wrist extensors
• Gradual progression of exercises as tolerated
• Manual therapy combined with exercise therapy has shown better outcomes than exercise therapy alone 2

Intermediate Management (6-12 weeks)

Injection Therapy

• Consider corticosteroid injection if symptoms persist (limit to 1-2 injections to avoid potential tendon weakening) 1
• Alternative injection options include:
  • Platelet-rich plasma (PRP) or autologous blood injections
  • Prolotherapy
  • Note: Evidence is mixed regarding superiority of these injections compared to corticosteroids 3

Continued Rehabilitation

• Progress eccentric strengthening program
• Consider ultrasound therapy or extracorporeal shock wave therapy (ESWT)
• Functional supports (braces) have shown better outcomes compared to compression bandages 2

Advanced Management (>3 months)

Reassessment

• If symptoms persist beyond 3 months, reassess with imaging:
  • MRI is the gold standard for evaluating tendinous injuries 1
  • MRI can help determine the extent of the intrasubstance tear and guide further management

Surgical Consideration

• Surgery is typically reserved for cases that fail 6+ months of conservative management 1
• Surgical options include:
  • Open debridement
  • Percutaneous techniques
  • Arthroscopic procedures
• No single surgical technique has demonstrated clear superiority over others 4

Prognosis and Expectations

• Lateral epicondylitis is largely self-limiting, with approximately 80% of patients recovering completely within 3-6 months with conservative treatment 1
• However, the presence of an intrasubstance tear may affect outcomes:
  • Only about 27% of patients with recalcitrant lateral epicondylitis and ECRB tear have symptom relief with nonsurgical treatment 5
  • Interestingly, the size of the ECRB tendon defect on MRI does not predict success or failure of nonsurgical treatment 5

Prevention of Recurrence

• Technique modification for athletes and manual laborers to minimize repetitive stress 1
• Equipment adjustments (e.g., larger grips for racquet sports)
• Continued strength and flexibility program focusing on forearm extensors 1

Key Considerations

• The presence of an intrasubstance tear does not necessarily warrant immediate surgical intervention
• A structured, progressive approach to management is recommended
• MRI is valuable for assessing the extent of the tear but should not be the sole determinant for surgical intervention
• Patient education regarding the typically self-limiting nature of the condition is important
• Functional treatment with bracing and exercise therapy is preferred over immobilization 2