What is the appropriate treatment for intra-articular versus extra-articular tennis elbow?

Treatment of Intra-articular versus Extra-articular Tennis Elbow

For tennis elbow, treatment should focus on conservative measures first for both intra-articular and extra-articular variants, with intra-articular cases potentially requiring earlier consideration of advanced imaging and surgical intervention if symptoms persist beyond 3 months.

Diagnosis and Classification

• Tennis elbow (lateral epicondylitis) is primarily classified as:

  • Extra-articular: Involves the tendinous attachment of the extensor carpi radialis brevis at the lateral epicondyle (most common)
  • Intra-articular: Involves loose bodies, osteochondral lesions, or synovial abnormalities within the joint

• Initial radiographs are the most appropriate first imaging step for all elbow pain 1

• Advanced imaging is indicated when symptoms persist beyond 3 months:

  • MRI: Gold standard for evaluating tendinous injuries (extra-articular) 1, 2
  • MR arthrography: Superior for suspected collateral ligament injuries 2
  • CT or CT arthrography: Better for visualizing loose bodies and osteophytes (intra-articular) 2

Treatment Algorithm

1. Initial Management (0-6 weeks) - Both Types

• Rest and activity modification 2
• Ice application for pain relief 2
• NSAIDs (oral or topical) at lowest effective dose for shortest duration 2
• Eccentric strengthening exercises of wrist extensors 2
• Functional bracing/orthotics for symptom relief 2

2. Intermediate Management (6-12 weeks)

Extra-articular Tennis Elbow

• Continue eccentric exercises for at least 12 weeks 2
• Consider corticosteroid injection (limit to 1-2 injections) 2
• Manual therapy combined with exercise therapy 2

Intra-articular Tennis Elbow

• Consider intra-articular corticosteroid injection using aseptic technique 1
• Arthroscopic evaluation may be considered as an option to improve diagnostic accuracy for intra-articular pathology 1
• Avoid overuse of injected joints for 24 hours following intra-articular therapy 1

3. Persistent Symptoms (>3 months)

Extra-articular Tennis Elbow

• Reassess diagnosis with advanced imaging (MRI without contrast) 1, 2
• Consider surgical referral if symptoms persist despite 6+ months of conservative management 2
• Surgical options include open debridement, percutaneous techniques, and arthroscopic procedures 2

Intra-articular Tennis Elbow

• MR arthrography or CT arthrography to evaluate for intra-articular pathology 1
• Arthroscopic evaluation and treatment of associated ligament injuries is an option 1
• Surgical treatment of intra-articular pathology (loose bodies, osteochondral lesions) may be necessary 1

Special Considerations

• Diabetic patients should be informed about risk of transient hyperglycemia (1-3 days) following intra-articular glucocorticoid injections 1
• Intra-articular therapy may be performed at least 3 months prior to joint replacement surgery 1
• Aseptic technique should always be used when performing intra-articular injections 1
• Local anesthetic may be offered with intra-articular injections, explaining pros and cons 1

Prevention of Recurrence

• Technique modification for athletes and manual laborers to minimize repetitive stress 2
• Equipment adjustments (larger grips, graphite shafts) to reduce stress on the elbow 2
• Strength and flexibility program focusing on forearm muscles 2

Key Differences in Management

• Extra-articular tennis elbow responds well to conservative measures targeting the tendinous attachment
• Intra-articular tennis elbow may require earlier consideration of advanced imaging and arthroscopic intervention to address mechanical symptoms and intra-articular pathology
• Arthroscopic evaluation is particularly valuable for intra-articular pathology to improve diagnostic accuracy and allow simultaneous treatment 1