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Tendinopathies

Lateral & medial epicondylitis: pathophysiology, conservative management, and indications for surgical intervention (debridement, release).

145 citationsUpdated Oct 2026

Overview

Tendinopathies encompass a spectrum of degenerative and inflammatory conditions affecting tendons, with precise distinctions between tendinopathy, tendinosis, and peritendinitis established by the Spanish Consensus Statement [4]. While most cases of lateral epicondylitis respond to appropriate nonoperative treatment protocols, no single universally accepted protocol has emerged for epicondylitis management [11, 179]. The heterogeneity of patient groups and disease severity complicates the identification of reliable nonoperative treatments, as pooled data from randomized controlled trials indicate a lack of intermediate- to long-term clinical benefit after nonsurgical treatment of lateral epicondylitis compared with observation only or placebo [2, 12]. Consequently, there is no true consensus on the most efficacious management of tennis elbow, particularly regarding effective long-term outcomes [14].

Surgical intervention is reserved for refractory cases where nonoperative measures fail. For chronic patellar tendinopathy, surgical treatment leads to substantial improvements in functional outcomes [10], and a large percentage of patients who fail conservative treatment for medial humeral epicondylitis can obtain pain relief and return to activities with operative techniques [172]. In lateral epicondylitis, complete resection of the tendinosis tissue with sparing of normal tissue can lead to durable results at long-term follow-up [15]. However, persistent symptoms are a poor indication for surgery, as the majority of patients experience symptom resolution without it and surgeons cannot reliably predict who will improve with nonoperative treatment [157]. A prospective, randomized, double-blinded, placebo-controlled trial failed to show additional benefit of surgical excision of the degenerative portion of the extensor carpi radialis brevis over placebo surgery for chronic tennis elbow [163].

Minimally invasive and regenerative options offer alternatives for recalcitrant cases. Ultrasonic percutaneous tenotomy is an attractive alternative to open surgical intervention, demonstrating positive sonographic evidence of tissue-healing response [173]. In a series of seven patients with refractory chronic lateral elbow tendinopathy treated with ultrasonic percutaneous tenotomy, American Shoulder and Elbow Surgeons scores significantly improved from 55.6 preoperatively to 94.1 at 2 years (P < 0.001) [76]. Ultrasound-guided tenotomy with TenJet is a safe, effective, and well-tolerated treatment for common extensor tendinopathy [47]. Autologous tenocyte injection provides evidence for the midterm durability of treatment for lateral epicondylitis tendinopathy [7]. Postoperative MRI findings reflect clinical outcomes, with improvement of the tendinopathy area observed in 60% of recovered groups versus 16% in unrecovered groups following arthroscopic debridement [8].

Management guidance is supported by the BESS patient care pathway, which uses the GRADE system to establish recommendations based on evidence quality and the balance between desirable and undesirable consequences [31]. The use of extracorporeal shock wave therapy in alternative doses or different dosage intervals warrants further research before advocacy [36]. Evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited [16]. Nonoperative treatment remains the initial strategy for tendinopathy and low-demand patients with partial tears of the distal biceps tendon [20]. Future studies should use clearly defined minimal important differences with consistency [29], and the Patient-Rated Tennis Elbow Evaluation is not recommended as an outcome measure until further development and validation are performed [164].

Anatomy & Pathophysiology

Bony Anatomy

The elbow is a trocho-ginglymoid joint comprising medial and lateral articulations that provide bony stability [87]. The ulnohumeral joint forms where the trochlea articulates with the ulna within the greater sigmoid notch, providing highly congruent anatomy through almost 180° of articular contact, except for a bare area on the greater sigmoid notch devoid of cartilage [87]. The radiocapitellar joint is formed by the articulation of the capitellum and the radial head, which is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [87]. The distal humeral articular surface is angled 30° from the longitudinal axis of the humerus [87] and 30 degrees anterior to the humeral shaft axis [95]. The axis of rotation is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side more distal than the lateral side [87]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [95]. The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [95].

The distal humerus consists of medial and lateral columns, with the medial column diverging from the humeral shaft at a 45-degree angle and the lateral column diverging at a 20-degree angle [97]. The trochlea has a 300-degree arc of cartilage [97]. The distal humeral articular surface is aligned in 4 degrees to 8 degrees of valgus relative to the shaft and is angulated 35 to 40 degrees anteriorly in the sagittal plane [102]. The trochlea is covered by articular cartilage anteriorly, inferiorly, and posteriorly, creating an arc of almost 270 degrees [102]. The olecranon fossa and coronoid fossa are separated by a thin bony septum which is occasionally absent [102].

Ligamentous Anatomy

The medial ulnar collateral ligament (MUCL) is the primary restraint to valgus stress within functional elbow range of motion [95]. It originates on the posterior medial epicondyle and inserts on the sublime tubercle of the medial coronoid process [95]. The posterior bundle of the MUCL is the primary restraint to valgus stress with the elbow in maximal flexion [95]. The lateral collateral ligament complex consists of the radial collateral ligament, the lateral ulnar collateral ligament (LUCL), and the annular ligament [102]. The LUCL arises from an isometric point on the lateral epicondyle and attaches to the crista supinatoris of the proximal ulna [102]. The radial collateral ligament originates from an isometric point on the lateral epicondyle and fans out to attach to the annular ligament [102]. The LCL complex functions as an important restraint to varus and posterolateral rotatory instability [102]. Tensile forces are present at the medial elbow, while compressive forces are present at the lateral elbow [88].

Muscular Anatomy

The medial epicondyle forms the attachment site for the origins of the flexor pronator mass [87], while the lateral epicondyle is the origin of the lateral extensor musculature [87]. The triceps has a broad tendinous insertion into the olecranon posteriorly [97]. The brachialis inserts on the coronoid process and the tuberosity of the ulna [97]. The supinator-extensor muscle group attaches to the lateral epicondyle [97]. The mobile wad consists of the brachioradialis, extensor carpi radialis longus (ECRL), and extensor carpi radialis brevis (ECRB) [88]. The flexor-pronator mass consists of the pronator teres, flexor carpi radialis (FCR), palmaris longus, flexor carpi ulnaris (FCU), and flexor digitorum superficialis (FDS) [88]. The areas of elbow abnormality in tendinopathy include the ECRB-EDC complex laterally, the pronator teres and flexor carpi radialis medially, and the triceps posteriorly [30].

Pathophysiology

Chronic tendinopathy is a process of degradation involving neovessel formation, neoinnervation, and synovitis [37]. Overuse is considered the initial disease factor in tendinopathy, leading to microruptures of tendon fibers and the expression of molecules that act as disease mediators [39]. Histopathological studies of chronic overuse tendons show a lack of large numbers of macrophages, lymphocytes, or neutrophils [168]. Tendinosis is characterized by dense populations of fibroblasts, vascular hyperplasia, and disorganized collagen, a constellation termed angiofibroblastic hyperplasia [168]. Tendinopathy exists on a continuum that accounts for heterogeneity in presentation, progressing from initial reactive tendinopathy to tendon disrepair to degenerative tendinopathy based on the duration of the tendon's inability to cope with increased load [156]. Healthy tendons can strengthen in response to gradual increases in load but can fail if the loading increase is too sudden or too great [156].

Lateral tennis elbow is most commonly an idiopathic or work-related condition, with a distinct pathoetiology not definitively identified [79]. Fewer than 5% to 10% of patients with lateral tennis elbow syndrome are tennis players [79]. Most cases of lateral tennis elbow seen by orthopaedic surgeons are the result of a work-related repetitive strain injury [79]. Medial elbow tendinopathy has a favourable natural history with resolution in approximately 80% within 1 to 3 years [5]. Biomechanical exposure involving the wrist and/or elbow at work is associated with the incidence of lateral epicondylitis [129]. There is a strong association between combined physical exertion and elbow movements and lateral epicondylitis [161]. Strenuous biomechanical hand and elbow exposures are relevant to the management and prevention of lateral epicondylalgia [166].

Classification

Pathophysiological Classification: Lateral epicondylitis is classified as a degenerative tendinopathy rather than an inflammatory process [9]. The condition is more accurately described as a tendinopathy (or tendinosis) of the extensor carpi radialis brevis rather than a tendinitis [51]. Similarly, patellar tendinopathy is classified as a degenerative disorder (tendinosis) rather than an inflammatory one [56], and chronic Achilles tendinopathy is classified as a chronic, degenerative process [188]. Chronic tendinopathy is regarded as a process of degradation involving neovessel formation, neoinnervation, and synovitis [37]. The intrinsic pathogenetic mechanisms of tendinopathies are largely unknown, with debate remaining over whether inflammation or degeneration has the prominent role [39]. Overuse is considered the initial disease factor in tendinopathy, leading to microruptures of tendon fibers and expression of molecules that act as disease mediators [39]. Low-grade inflammation plays a role in the pathogenesis of tendinopathy, involving proinflammatory cytokines, proteolytic enzymes, and growth factors [167]. Inflammation exerts a negative influence on the process of tendon healing [167]. The pathophysiology of lateral epicondylitis is suggested to begin with overuse injury leading to microtearing and subsequent tendinosis or angiofibroblastic dysplasia [73]. The specific pathophysiology of lateral epicondylitis remains to be defined clearly [73].

Modified Steinborn Classification: This system grades lateral epicondylitis from 0 (dark tendon, no signal intensity changes) to 3 (area of increased signal intensity involving > 50% of tendon cross section with tendon thickening) [216].

Rabago Classification: This system grades lateral epicondylitis from 0 (normal tendon with uniform low signal intensity) to 3 (severe tendinopathy which is thinned and shows focal areas of intense fluid-like signal intensity which comprise more than 50% of the tendon thickness) [216].

Walz Classification: This system grades lateral epicondylitis from 0 (complete homogenous low intensity) to higher grades characterized by tendon thickening [216].

MRI Severity-Focused Score: This assessment uses enhanced magnetic resonance imaging to evaluate signal changes in the common extensor tendon origin, radial collateral ligament, lateral ulnar collateral ligament, and plica [78]. The MRI classification for common extensor tendon injuries grades from 0 (complete homogenous low signal intensity without tendon thickening) to 1 (isointense signal intensity relative to muscle; tendinosis or low-grade partial tear) [78]. The MRI classification for ligament injuries grades from 0 (complete homogenous low signal intensity without ligament thickening) to 1 (ligament thickening or thinning with increased signal intensity) [78].

Snyder Classification System: This system is reproducible and can be used in future research studies in analyzing the treatment options of partial rotator cuff tears [151]. A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further [83].

Blazina Classification: This system categorizes symptomatic patellar tendinopathy patients into phase I (pain only after activity), phase II (discomfort during activity), phase III (pain during activity that interferes with participation), and phase IV (complete tendon disruption) [219].

Other Considerations: The severity of symptoms in patellar tendinopathy can be classified as grade I, grade II, or grade IIIa [208]. The arthroscopic identification of the 3 types of Baker lesions helps the surgeon to confirm the presence of pathology commonly seen intra-articularly in patients with lateral epicondylitis [146]. The areas of elbow abnormality in tendinopathy are specific, including the ECRB-EDC complex laterally, the pronator teres and flexor carpi radialis medially, and triceps posteriorly [30]. Medial elbow tendinopathy is less common than lateral elbow tendinopathy [5]. In the group treated nonoperatively for patellar tendinopathy, results were better in the patients who had stage 2 tendinopathy than in those with stage 3 [6]. The BESS patient care pathway provides a guidance summary for the management of lateral elbow tendinopathy using the GRADE system [31]. Clearly defined minimal important differences (MIDs) should be used with consistency in tendinopathy management studies in the future [29]. The type and extent of pathologic changes within the common extensor tendon can be evaluated using a dedicated low-field MR system [63]. Calcifying tendonitis appeared to be the most frequent pathologic condition associated with the onset of infraspinatus myotendinous junction tears [19]. Tendinopathy is a common problem in volleyball but it is not a common cause of injury [24]. Failed surgical treatment of lateral epicondylitis is multifactorial, and distinguishing the cause is critical for appropriate management [26]. The use of ESWT in alternative doses and/or different dosage intervals in the management of tendinopathies warrants further research before it can be advocated for such conditions [36]. Treatment of gluteus medius and minimus lesions is based on the knowledge of pathomechanics involved and the extent of injury to the tendon and muscle tissue [159]. The poor regenerative capability of the Achilles tendon makes treatment difficult for both acute ruptures and chronic tendinopathy [188]. PRP had no significant benefit in comparison with the injection of saline solution with regard to clinical outcome scores or tendon appearance on ultrasound for chronic Achilles tendinopathy [188]. Neither study demonstrated that PRP provided any beneficial effect for the treatment of acute Achilles tendon rupture [188].

Clinical Presentation

General Characteristics and Pathophysiology

Tendinopathies of the hand and wrist are common conditions diagnosed by history and examination [1]. The condition is a degenerative tendinopathy rather than an inflammatory process [9]. Lateral epicondylitis is a degenerative tendinopathy rather than an inflammatory tendinitis [40]. The condition is more accurately described as a tendinopathy (or tendinosis) of the extensor carpi radialis brevis rather than a tendinitis [51]. Patellar tendinopathy is a degenerative disorder (tendinosis) rather than an inflammatory one [56]. Peritendinitis and degenerative tendinopathy or tendinosis appear to make up the majority of chronic resistant tendon problems [28]. Despite the absence of inflammation, patients with tennis elbow still present with pain [104]. The multifactorial etiology of lateral elbow tendinopathy makes finding one effective treatment intervention elusive [118].

Epidemiology and Demographics

Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years [22]. Lateral epicondylar tendinopathy has an estimated prevalence of 3% and most frequently afflicts those between the ages of 35 and 65 years [23]. Rotator cuff tendinopathy prevalence in the general population ranges from 2.4% to 14% [53]. Rotator cuff tendinopathy prevalence can go up to 45% in manual repetitive workers [53]. Lower limb tendinopathy is a common clinical presentation in physically active individuals, with the Achilles, posterior tibial, patellar, adductor, and upper hamstring tendons being most commonly affected [92]. Rotator cuff tendinopathy is a common problem but uncertainty remains regarding the true extent and risk factors associated with onset [50].

Natural History and Prognosis

The natural history of lateral epicondylitis is favorable, with 70% to 80% of patients having resolution of symptoms within 1 year in the absence of any treatment [21]. Lateral epicondylitis is a condition that is usually self-limited, resolving over a 12- to 18-month period without treatment [57]. Lateral epicondylitis is often self-limited but with high recurrence rates [40]. Lateral epicondylitis is a self-limiting condition [52]. Overall, the available data suggest that lateral epicondylitis often resolves spontaneously [116]. Most patients with lateral epicondylitis resolve spontaneously or with standard conservative management [54]. Nonoperative management of lateral epicondylitis leads to resolution of symptoms in 90% of cases [48]. Tendinopathy usually occurs within the first year of statin use and improves after the drug therapy is stopped [13].

Diagnostic Methods and Accuracy

Lateral epicondylitis is traditionally a clinical diagnosis based on history and examination [23]. Diagnosis of lateral epicondylitis is primarily clinical, while imaging serves mainly to exclude other pathologies [40]. Diagnosis of rotator cuff tendinopathy is based on history and examination [99]. The algorithm for diagnosing rotator cuff tendinopathy emphasizes the importance of passive external rotation [99]. Features of importance in the diagnosis of rotator cuff tendinopathy include patient expectation, hand dominance, occupation and level of activity or sports, location, radiation and onset of pain, duration of symptoms, exacerbating and relieving factors, history of trauma, involvement of other joints, systemic illnesses and comorbidities, and red flags [99]. Sonography of the common extensor origin can confirm the clinical suspicion of lateral epicondylitis and exclude other causes of lateral elbow pain [49]. Cozen’s test reported high sensitivity (91%) for the diagnosis of lateral elbow tendinopathy [94]. A grip strength difference of 5%-10% between elbow flexion and extension showed high sensitivity (78%-83%) and specificity (80%-90%) for the diagnosis of lateral elbow tendinopathy [94]. Sonoelastography showed the highest sensitivity (75-100%) and specificity (85-96%) for the diagnosis of lateral elbow tendinopathy [94]. MRI performed better in the diagnosis of tendon thickening and enthesopathy with sensitivity and specificity of 81%-100% for lateral elbow tendinopathy [94]. Almost half of the patients (46.5%) presenting with lateral elbow pain were diagnosed with a diagnosis other than lateral epicondylitis [44]. Nearly half (46.5%) of patients presenting with lateral elbow pain receive a diagnosis other than lateral elbow tendinopathy [100]. The diagnostic and prognostic value of MRI findings in lateral epicondylar tendinopathy has been repeatedly challenged due to a lack of evidence on the prevalence of these imaging findings in an asymptomatic population [23]. Defining a clear correlation between the degree of change on MRI and clinical symptoms in lateral epicondylar tendinopathy has not been possible [23]. Changes in the common extensor tendon such as high signal intensity, oedema, thinning, thickening and tears can be reliably identified on MRI [23]. These MRI changes are identified in nearly all cases of symptomatic lateral epicondylar tendinopathy [23]. MRI changes in lateral epicondylar tendinopathy have been shown to be associated with both surgical and histopathological findings [23]. Clinical assessment is the most commonly used method of diagnosis for lateral epicondylitis [103]. Open or arthroscopic surgery is still considered the gold standard reference test for the diagnosis of lateral epicondylitis pathology [103]. The diagnosis of patellar tendinopathy was made by clinical examination and confirmed by MRI [113]. Clinical examination features indicative of patellar tendinopathy included tenderness to palpation at the inferior pole of the patella with the knee fully extended and the quadriceps relaxed [113]. MRI features consistent with patellar tendinopathy included enhanced signal intensity in the proximal patellar tendon, increased tendon size in the anteroposterior direction, and poor definition of the posterior tendon border [113]. Those diagnosed with painful supraspinatus tendinopathy demonstrated increased thickening with delayed return to baseline following loading [18]. A quantitative assessment of ECRB tendon degeneration using CT hounsfield units offers an objective measure of tendon pathology that may complement current diagnostic approaches [58].

Investigations

Clinical Diagnosis: The diagnosis of lateral epicondylitis is primarily clinical, traditionally based on history and physical examination [40, 23]. However, differential diagnosis is critical, as almost half of patients (46.5%) presenting with lateral-sided elbow pain receive a diagnosis other than lateral epicondylitis [44].

MRI: Magnetic resonance imaging is increasingly utilised to gauge the severity of lateral epicondylar tendinopathy and justify treatment decisions, including surgical intervention [23]. MRI changes in the common extensor tendon are identified in nearly all cases of symptomatic lateral epicondylar tendinopathy [23]. Despite this, a clear correlation between the degree of change on MRI and clinical symptoms has not been established [23]. The reliability and validity of MRI in assessing chronic lateral epicondylitis have been established, making it a reliable tool for determining radiological severity [147]. In patients with chronic lateral epicondylitis, MRI can help differentiate the disease and is useful for clinical management, preoperative planning, and evaluating the degree of degeneration at the common extensor tendon insertion [145]. For recalcitrant cases, MR imaging assists in surgical planning [153] and serves as an important decision-making tool in the surgical treatment of refractory tennis elbow [181].

MRI Limitations and Variability: The routine use of MRI for the diagnosis of lateral epicondylitis is low, with variation in its use associated with downstream effects [144]. Increased MRI signal in the extensor carpi radialis brevis origin is common in both symptomatic and asymptomatic elbows [192]. Consequently, the clinical use of MRI in managing patients with enthesopathy of the extensor carpi radialis brevis origin merits further study [137]. A reproducible MRI-based assessment technique for lateral tendinopathy enhances diagnostic precision and treatment evaluation [124].

MRI Outcomes and Monitoring: Continuous tendon recovery assessed by MRI was found during a 2-year period after platelet-rich plasma treatment for lateral epicondylitis [75]. In recovered versus unrecovered groups, improvement of tendinopathy area was 60% versus 16%, indicating that postoperative MRI findings reflect clinical outcomes [8].

Ultrasonography: Ultrasonographic examination provides detailed images of structures involved in tennis elbow syndrome, confirms the diagnosis, and may be useful in monitoring treatment [195]. Elastography-ultrasound can be used as the initial modality to screen for tendon pathology in both athletes and non-athletes prior to advanced imaging such as MRI [148]. In the context of patellar tendinopathy, ultrasonography was more accurate than MRI in confirming clinically diagnosed cases [135].

CT and Radiography: Obtaining radiographs for patients with lateral epicondylitis does not appear to be warranted [155]. Computed tomography arthrography was a reliable and accurate diagnostic modality compared with MRI for detecting capsular tears in patients with chronic tennis elbow [189]. Quantitative assessment of extensor carpi radialis brevis tendon degeneration using CT Hounsfield units offers an objective measure of tendon pathology that may complement current diagnostic approaches [58].

Other Considerations: MRI can be used to evaluate ligaments and tendons but is rarely indicated for elbow stiffness [109]. Radiographs should always be obtained for the evaluation of elbow stiffness [109]. CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies in elbow stiffness, but it is not necessary when the stiffness is entirely soft-tissue related [109]. MRI-defined patellar tendinopathy is common in community-based adults and is associated with current and past history of obesity assessed by BMI or body weight, but not fat mass [66]. Among patients with symptomatic rotator cuff tendinopathy that remained symptomatic at a minimum of 1 year and obtained a follow-up MRI, 39% progressed to a partial or full-thickness tear [70].

Treatment

Non-Operative

Tendinopathies of the hand and wrist are common conditions diagnosed by history and examination, with treatment protocols similar for most entities [1]. Lateral epicondylitis is a self-limiting condition with a course of 12 to 18 months, where approximately 90% of patients achieve symptom resolution at one year without intervention [119, 34]. Nonsurgical treatment remains the mainstay of management, prioritizing rest and activity modification [133, 85]. The UK National Institute of Health and Care Excellence recommends initial management with activity modification and oral nonsteroidal anti-inflammatory (NSAID) medication [209]. For persistent symptoms, the NICE advises corticosteroid injection, physiotherapy, and orthotics before specialist referral if disability remains after 6 to 12 months [209]. However, randomized clinical trial evidence indicates that corticosteroid injections prolong pain and disability in the medium and long term compared to no treatment or NSAIDs [209]. Consequently, corticosteroid injections are not cost-effective, negate the benefits of physiotherapy, and should be avoided; physiotherapy should be the mainstay of conservative treatment [209].

Other nonsurgical modalities include topical glyceryl trinitrate for chronic tendinopathies [121], prolotherapy injections for sports-related tendinopathies [125], and PRP injections for lateral epicondylitis, which are safe and effective for reducing pain and increasing functionality [139]. Conversely, one author recommends against using platelet-rich plasma or autologous blood injections in lateral epicondylitis [141]. STR/PRP is a safe treatment that induces clinically significant improvements in elbow symptoms, well-being, strength, and imaging within 6 months for recalcitrant cases [111]. Autologous tenocyte injection is an encouraging novel treatment warranting further evaluation [108]. The efficacy of iontophoresis has not been proven due to methodological limitations and equivocal results [114]. Results for extracorporeal shock wave therapy are mixed for lateral epicondylitis and ineffective for noncalcific supraspinatus tendinosis [130]. Future studies are needed to support the efficacy of oscillating-energy manual therapy [35]. Nonoperative management yields good results for distal biceps tendon partial tears [33] and remains the mainstay for spontaneous resorption of calcification at the long head of the biceps tendon [117]. The literature documents several nonsurgical approaches for chronic patellar tendinopathy, though study quality is limited [138]. Statin-associated tendinopathy usually occurs within the first year of use and improves after drug cessation [13].

Operative

Indications: Surgical intervention for elbow tendinopathy is reserved for patients with continued symptoms after 6 months or more of treatment [85]. Operative management for lateral epicondylitis is recommended only in severe, recalcitrant cases [52], with refractory cases potentially benefiting from interventional therapies or surgical approaches [54]. Surgical procedures for medial epicondylitis are typically reserved for patients with recalcitrant or recurrent symptoms despite nonsurgical management [174]. In a cohort of litigants' epicondylitis, no patient was operated on unless they had undergone three steroid injections, physiotherapy, and NSAID treatment [224]. The median time of minimum conservative management before surgery for lateral epicondylitis was six months [213].

Surgical Approach / Technique: Arthroscopic debridement for refractory lateral epicondylitis results in substantial improvement in tendinosis scores and good clinical outcomes [8]. Postoperative MRI findings reflect clinical outcomes, with improvement of tendinopathy area at 60% in recovered groups versus 16% in unrecovered groups [8]. Arthroscopic treatment is effective and safe for recalcitrant lateral epicondylitis [120]. The Nirschl procedure and arthroscopic extensor carpi radialis brevis debridement are comparable and highly effective for chronic recalcitrant lateral elbow tendinopathy [126]. Semicircumferential detachment of the extensor enthes is recommended for lateral epicondylitis nonresponsive to conservative treatment [150]. Percutaneous ultrasonic tenotomy is a safe and effective minimally invasive treatment for chronic medial and lateral elbow tendinosis, producing statistically significant improvements in pain and function over 1 year [32, 143]. Ultrasound-guided tenotomy for lateral epicondylitis with TenJet is a safe, effective, and well-tolerated treatment for common extensor tendinopathy [47]. Ultrasound-guided percutaneous tenotomy is an effective treatment with good results for gluteal tendinopathy [140]. Arthroscopic debridement is reserved for cases of long head of the biceps tendon calcification where symptoms are not controlled by non-operative therapy [117].

Other Considerations: In a cohort of litigants' epicondylitis, symptoms persisted for an average of 4.6 years despite treatment with physiotherapy, NSAIDs, and steroid injections [224]. Postoperative immobilization for lateral epicondylitis surgery involves a sling for 10 days followed by a gradual passive and active assisted movements program up to 6 weeks postoperatively [225]. In a study of surgical treatment for resistant lateral epicondylitis, pain disappearance occurred on average 3 months after surgery, and satisfactory subjective strength in the forearm and hand was regained on average 4 months postoperatively [225]. One patient in this study had no improvement in symptoms for 24 months after the operation and was considered a failure [225].

Complications

Lateral Elbow Tendinopathy

Persistent Pain: Continued and similar pain following lateral epicondylitis surgery indicates improper patient selection, an incorrect initial diagnosis, or persistence of the original disease not corrected by the procedure [74]. In a series of 88 surgical patients, 3% noted no relief of symptoms [218].

Surgical Failure: Failure of lateral epicondylitis surgery may be associated with incomplete resection of pathologic tissue, additional pathologic processes such as intraarticular problems, or inadequate tendon-healing potential [218]. Three or more preoperative injections is the most significant risk factor for revision surgery after operative treatment of lateral epicondylitis [202].

Functional Outcomes: Postoperative morbidity, residual weakness, and the percentage return to high-level activities are not defined in historical reports of EDC release operative techniques [218].

Patellar Tendinopathy

Nonoperative Outcomes: In the group treated nonoperatively for patellar tendinopathy, results were better in patients with stage 2 tendinopathy than in those with stage 3 [6].

Recovery

Natural History and Prognosis: Approximately 90% of people with untreated tennis elbow achieve symptom resolution by 1 year, with the probability of recovery remaining fairly constant over that timespan regardless of prior symptom duration [77]. Enthesopathy of the extensor carpi radialis brevis origin is a benign, self-limiting disorder with a natural history of spontaneous resolution [68]. Nonoperative management of partial distal biceps tendon tears yields good clinical and functional results, consistent with the natural course of other self-limited enthesopathies [33]. In contrast, distal biceps short head tears have a poor natural history akin to complete tears [236]. Poor prognosis at 1 year of follow-up for lateral epicondylitis is related to manual work and high baseline pain [234]. Furthermore, pain sensitization during the early stages of lateral epicondylitis is associated with persistently increasing disability after 1 year of nonsurgical treatment [233].

Non-Operative Recovery and Outcomes: Corticosteroid injections provide a short-term beneficial effect on lateral epicondylitis but exert a negative effect in the intermediate term [61]. These injections worsen the long-term outcomes of patients with tennis elbow [67]. PRP and autologous whole blood injections are both effective methods to treat chronic lateral epicondylitis, and their efficacy persists during long-term follow-up [185]. Continuous tendon recovery assessed by MRI was found during a 2-year period after PRP treatment for lateral epicondylitis [75]. In the long term, acupotomy has greater efficacy and is associated with a lower rate of recurrence than corticosteroid injections in the management of lateral epicondylitis [194].

Operative Recovery and Outcomes: Favorable short-term outcomes such as reduction of pain and increase in function after arthroscopic treatment of lateral epicondylitis are maintained over a long-term follow-up [65]. In the recovered and unrecovered groups after arthroscopic debridement for refractory lateral epicondylitis, improvement of tendinopathy area was 60% versus 16%, indicating that postoperative MRI findings reflect clinical outcomes [8]. At long-term follow-up, ultrasound-guided percutaneous tenotomy demonstrates good sustainability of pain relief and functional recovery that was previously achieved, accompanied with sonographic evidence of tissue healing at 7.5 years [71]. At the long-term follow-up of 90 months, ultrasonic percutaneous tenotomy demonstrated good durability of pain relief and functional recovery that was previously achieved, accompanied by sustained sonographic tissue healing with no significant deterioration [176]. Improved clinical outcomes and an overall high rate of tendon healing were seen at the midterm follow-up after arthroscopic isolated subscapularis tendon repair [64]. Results were satisfactory in the early period after arthroscopic transosseous treatment of rotator cuff tears, but long follow-up is needed to evaluate bone-tendon healing [69]. The short-term clinical influence of biceps complications on shoulder outcome following tenotomy associated with arthroscopic rotator cuff repair is very limited [62].

Key Evidence

• [L5] No single nonoperative treatment reliably achieves outstanding results for lateral elbow tendinopathy, likely due to the inclusion of heterogeneous patient groups rather than categorization by disease severity. [2] (10.1177/2325967116670635)
• [L5] The consensus statement establishes precise definitions for tendinopathy, tendinosis, and peritendinitis, and provides recommendations for clinical management and treatment based on expert agreement and current scientific data. [4] (10.1177/2325967117734127)
• [L5] Medial elbow tendinopathy is less common than lateral elbow tendinopathy and has a favourable natural history with resolution in approximately 80% within 1 to 3 years. [5] (10.1111/sae.12022)
• [L3] In the group treated nonoperatively, results were better in the patients who had stage 2 tendinopathy than in those with stage 3. [6] (10.1177/03635465000280031901)
• [L4] This study provides evidence for the midterm durability of ATI for treatment of LE tendinopathy. [7] (10.1177/0363546515579185)
• [L4] In the recovered and unrecovered groups, improvement of tendinopathy area was 60% versus 16%, indicating that postoperative MRI findings reflect clinical outcomes. [8] (10.1016/j.arthro.2022.07.019)
• [L5] The condition is a degenerative tendinopathy rather than an inflammatory process, and treatment should address the underlying pathoanatomy. [9] (10.1016/j.csm.2004.06.004)
• [L1] Surgical treatment for chronic patellar tendinopathy leads to substantial improvements in functional outcomes. [10] (10.1002/ksa.70284)
• [L5] This article is a review of recently published information on elbow tendinopathy and tendon ruptures intended to assist clinicians in diagnosis and management, noting that while numerous treatment options exist for epicondylitis, no single universally accepted protocol has emerged. [11] (10.1016/j.jhsa.2009.01.022)
• [L1] Pooled data from RCTs indicate a lack of intermediate- to long-term clinical benefit after nonsurgical treatment of lateral epicondylitis compared with observation only or placebo. [12] (10.1007/s11999-014-4022-y)
• [L4] Tendinopathy usually occurs within the first year of statin use and improves after the drug therapy is stopped. [13] (10.2106/jbjs.rvw.15.00072)
• [L1] Despite a wealth of research, there is no true consensus on the most efficacious management of tennis elbow especially for effective long-term outcomes. [14] (10.2147/oajsm.s10310)
• [L4] Surgical treatment for lateral epicondylitis by complete resection of the tendinosis tissue with the sparing of normal tissue can lead to durable results at long-term follow-up. [15] (10.1177/0363546507308932)
• [L1] Evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited. [16] (10.1016/j.jht.2023.08.016)
• [L3] Those diagnosed with painful supraspinatus tendinopathy demonstrated increased thickening with delayed return to baseline following loading. [18] (10.1136/bmjsem-2017-000279)
• [L4] Calcifying tendonitis appeared to be the most frequent pathologic condition associated with the lesion onset. [19] (10.1016/j.jse.2022.01.092)
• [L4] Nonoperative treatment is the initial strategy for tendinopathy and/or low-demand patients with partial tears. [20] (10.1016/j.xrrt.2026.100770)
• [L4] The natural history of lateral epicondylitis is favorable, with 70% to 80% of patients having resolution of symptoms within 1 year in the absence of any treatment. [21] (10.3810/psm.2012.05.1963)
• [L5] Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years. [22] (10.1302/0301-620x.95b9.29285)
• [L4] [23] (10.1177/17585732221146731)
• [L3] Clearly, tendinopathy is a common problem in this sport but it is not a common cause of injury. [24] (10.1177/2325967117s00008)
• [L5] Failed surgical treatment of lateral epicondylitis is multifactorial, and distinguishing the cause is critical for appropriate management. [26] (10.1016/j.xrrt.2023.07.006)
• [L5] Peritendinitis and degenerative tendinopathy or tendinosis appear to make up the majority of chronic resistant tendon problems. [28] (10.5435/00124635-199805000-00003)
• [L2] Clearly defined MIDs should be used with consistency in tendinopathy management studies in the future. [29] (10.1186/s12891-023-06261-9)
• [L4] The areas of elbow abnormality are specific, including the ECRB-EDC complex laterally, the pronator teres, flexor carpi radialis medially, and triceps posteriorly. [30] (10.1016/s0278-5919(03)00051-6)
• [L1] The article provides a guidance summary for the management of lateral elbow tendinopathy using the GRADE system, establishing recommendations based on the quality of available evidence and the balance between desirable and undesirable consequences of alternative management options. [31] (10.1177/17585732231170793)
• [L4] Percutaneous ultrasonic tenotomy is a safe and effective treatment for chronic medial and lateral elbow tendinosis, producing statistically significant improvements in pain and function over a 1-year follow-up period. [32] (10.1016/j.jse.2014.07.017)
• [L5] They note that nonoperative management has been documented to yield good clinical and functional results, consistent with the natural course of other self-limited enthesopathies. [33] (10.1016/j.jhsa.2026.03.017)
• [L1] Based on the placebo or no-treatment control arms of randomized trials, about 90% of people with untreated tennis elbow achieve symptom resolution at 1 year. [34] (10.1097/corr.0000000000002058)
• [L5] Future studies with larger patient populations, larger treatment effects for short- and long-term follow-up, and validated outcome measures specific to lateral epicondylosis are needed to support the efficacy of OEMT for treatment of lateral epicondylosis. [35] (10.1197/j.jht.2007.10.004)
• [L1] The use of ESWT in alternative doses and/or different dosage intervals in the management of tendinopathies warrants further research before it can be advocated for such conditions. [36] (10.1016/s0736-0266(02)00013-x)
• [Paper] [37] (10.1136/bjsports-2012-091957)
• [L5] [39] (10.1186/ar2723)
• [L3] Almost half of the patients (46.5%) were diagnosed with a diagnosis other than lateral epicondylitis. [44] (10.1016/j.jseint.2024.08.047)
• [L4] MIT with TenJet is a safe, effective, and well-tolerated treatment for common extensor tendinopathy. [47] (10.1016/j.jseint.2023.05.003)
• [L4] Nonoperative management of lateral epicondylitis leads to resolution of symptoms in 90% of cases. [48] (10.1016/j.bpa.2020.08.004)
• [L4] Sonography of the common extensor origin can confirm the clinical suspicion of lateral epicondylitis and exclude other causes of lateral elbow pain. [49] (10.2214/ajr.176.3.1760777)
• [L1] Rotator cuff tendinopathy is a common problem but uncertainty remains regarding the true extent and risk factors associated with onset. [50] (10.1111/sae.12028)
• [L5] Lateral epicondylitis is a self-limiting condition, with operative management only recommended in severe, recalcitrant cases. [52] (10.1007/s00590-021-03181-z)
• [L5] [53] (10.1177/17585732231172166)
• [L4] Most patients with lateral epicondylitis resolve spontaneously or with standard conservative management, but refractory cases may benefit from interventional therapies or surgical approaches. [54] (10.5397/cise.2019.22.4.227)
• [L5] Patellar tendinopathy is a degenerative disorder (tendinosis) rather than an inflammatory one. [56] (10.5435/jaaos-d-15-00703)
• [L2] Lateral epicondylitis is a condition that is usually self-limited, resolving over a 12- to 18-month period without treatment. [57] (10.1007/s11552-014-9642-x)
• [L3] This technique offers an objective measure of tendon pathology that may complement the current diagnostic approaches. [58] (10.1186/s12891-025-08346-z)
• [L4] The proposed MRI classification has emerged as one of the most reliable methods to define stages of chronic lateral epicondylitis. [59] (10.1186/s12891-022-05758-z)
• [L1] Corticosteroid injections have a shortterm beneficial effect on lateral epicondylitis, but a negative effect in the intermediate term. [61] (10.1136/bmjopen-2013-003564)
• [L3] Nevertheless, the short-term clinical influence of biceps complications on shoulder outcome is very limited. [62] (10.1177/2325967121s00362)
• [L4] The type and extent of pathologic changes within the common extensor tendon can be evaluated using a dedicated low-field MR system. [63] (10.1007/s003300050851)
• [L4] Improved clinical outcomes and an overall high rate of tendon healing were seen at the midterm follow-up after AISR. [64] (10.1177/23259671241229429)
• [L4] Favorable short-term outcomes such as reduction of pain and increase in function are maintained over a long-term follow-up. [65] (10.1197/j.jht.2008.04.007)
• [L3] MRI defined patellar tendinopathy is common in community-based adults and is associated with current and past history of obesity assessed by BMI or body weight, but not fat mass. [66] (10.1186/1471-2474-15-266)
• [Paper] Corticosteroid injections for tennis elbow worsen the long term outcomes of patients. [67] (10.1016/j.jsams.2009.09.009)
• [L5] Enthesopathy of the extensor carpi radialis brevis origin is a benign, self-limiting disorder with a natural history of spontaneous resolution, for which no treatments have been proven to alter the course. [68] (10.5435/jaaos-d-15-00233)
• [L4] Results were satisfactory in the early period, but long follow-up is needed to evaluate bone-tendon healing. [69] (10.1177/2325967117s00060)
• [L3] Among patients with symptomatic rotator cuff tendinopathy that remained symptomatic at a minimum of 1 year and obtained a follow-up MRI, 39% progressed to a partial or full-thickness tear. [70] (10.1016/j.asmr.2022.05.004)
• [L4] At long term follow up, ultrasound-guided percutaneous tenotomy demonstrates good sustainability of pain relief and functional recovery that was previously achieved, accompanied with sonographic evidence of tissue healing at 7.5 years. [71] (10.1177/2325967120s00420)
• [L5] The specific pathophysiology remains to be defined clearly, with current thinking suggesting the process begins with overuse injury leading to microtearing and subsequent tendinosis or angiofibroblastic dysplasia. [73] (10.1016/s0278-5919(05)70269-6)
• [L4] Continued and similar pain after lateral epicondylitis surgery represents improper patient selection, an incorrect initial diagnosis, or persistence of the original disease, not corrected by surgery. [74] (10.1016/s1058-2746(09)80016-5)
• [L4] Continuous tendon recovery assessed by MRI was found during a 2-year period after PRP treatment. [75] (10.1016/j.jse.2022.01.147)
• [L4] In this series of seven patients with refractory chronic lateral elbow tendinopathy, ASES scores significantly improved from 55.6 preoperatively to 94.1 at 2 years (P < 0.001). [76] (10.1097/bth.0000000000000178)
• [L1] Approximately 90% of people with untreated tennis elbow achieved symptom resolution by 1 year, and the probability of recovery remained fairly constant over that timespan regardless of prior symptom duration, undermining the concept that surgery is indicated if symptoms persist for an arbitrary duration. [77] (10.1097/corr.0000000000002149)
• [L4] [78] (10.1016/j.jse.2025.01.052)
• [L5] [79] (10.1016/s1058-2746(99)90081-2)
• [L4] A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further. [83] (10.1302/2058-5241.1.160005)
• [Paper] Lower limb tendinopathy is a common clinical presentation in physically active individuals, with the Achilles, posterior tibial, patellar, adductor, and upper hamstring tendons being most commonly affected. [92] (10.1016/s0278-5919(03)00007-3)
• [L1] [94] (10.1016/j.jht.2021.02.002)
• [L5] [99] (10.1177/1758573215576456)
• [L3] Nearly half (46.5%) of patients presenting with lateral elbow pain receive a diagnosis other than lateral elbow tendinopathy (LET). [100] (10.1016/j.jse.2025.10.006)
• [L2] [103] (10.1016/j.otsr.2014.01.006)
• [Paper] Despite the absence of inflammation, patients with tennis elbow still present with pain. [104] (10.1197/j.jht.2006.02.016)
• [L4] This novel treatment is encouraging for the treatment of tendinopathy and warrants further evaluation. [108] (10.1177/0363546513504285)
• [L4] STR/PRP is a safe treatment that effectively induces clinically significant improvements in elbow symptoms and general well-being as well as objective measures of strength and imaging of the common extensor tendon within 6 months of treatment of elbow tendinopathy recalcitrant to standard treatments. [111] (10.1016/j.jse.2018.09.007)
• [L1] [113] (10.1177/0363546513518416)
• [Commentary] The efficacy of iontophoresis in the management of lateral epicondylitis has not been proven due to methodological limitations, lack of a control group, and equivocal results from other trials. [114] (10.1016/j.jhsa.2011.10.029)
• [L4] Overall, the available data suggest that lateral epicondylitis often resolves spontaneously, warranting considerable circumspection before embarking on treatment. [116] (10.1016/j.otsr.2019.09.004)
• [L4] Conservative treatment remains the mainstay, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy. [117] (10.1177/1758573214567559)
• [L5] The multifactorial etiology of lateral elbow tendinopathy makes finding one effective treatment intervention elusive; a multifaceted treatment method addressing tendon pathology, the pain system, and proprioception may be the answer to resolving symptoms and eliminating recurrence. [118] (10.1016/j.jht.2018.04.002)
• [L5] Lateral epicondylitis is a common condition with a self-limiting course of 12 to 18 months, and most patients are well-managed with non-operative treatment and activity modification, though many surgical techniques exist for refractory symptoms. [119] (10.1302/2058-5241.1.000049)
• [L4] Surgical treatment through arthroscopy for recalcitrant lateral epicondylitis is effective and safe, presenting positive outcomes in the studied patients. [120] (10.1590/1413-785220192703216249)
• [L1] Topical glyceryl trinitrate should be included as part of nonsurgical management of chronic tendinopathies. [121] (10.1177/0363546504270998)
• [L1] This study presents a reproducible MRI-based assessment technique for lateral tendinopathy, enhancing diagnostic precision and treatment evaluation. [124] (10.1016/j.jse.2026.03.020)
• [L1] This systematic review summarized high quality RCTs and found PrT injections to be overall safe and effective in the treatment of sports‐related tendinopathies. [125] (10.1177/2325967123s00324)
• [L3] Both techniques are comparable and highly effective for treating chronic recalcitrant lateral elbow tendinopathy. [126] (10.1016/j.jse.2016.09.022)
• [L2] The results of this meta-analysis strongly support the hypothesis of an association between biomechanical exposure involving wrist and/or elbow at work and incidence of lateral epicondylitis. [129] (10.1002/acr.22874)
• [L5] Results have been mixed in the management of lateral epicondylitis, and this therapy has not been effective in managing noncalcific tendinosis of the supraspinatus. [130] (10.5435/00124635-200604000-00001)
• [L5] Nonsurgical treatment is the mainstay of management for lateral epicondylitis, involving options such as rest, physical therapy, and injections. [133] (10.5435/00124635-200801000-00004)
• [L2] Ultrasonography was more accurate than MRI in confirming clinically diagnosed patellar tendinopathy. [135] (10.1177/0363546506294858)
• [L3] The clinical use of MRI in the management of patients with enthesopathy of the ECRB origin merits further study. [137] (10.1016/j.jhsa.2009.02.023)
• [L1] The literature documents several nonsurgical approaches for the treatment of chronic patellar tendinopathy with important limitations in terms of study quality. [138] (10.1177/0363546518759674)
• [L4] PRP injections are a safe and effective conservative treatment method for reducing pain symptoms and increasing functionality in patients with lateral epicondylitis. [139] (10.1177/2325967125s00169)
• [L4] PUT is an effective treatment, with good results for patients with gluteal tendinopathy. [140] (10.1177/2325967120907868)
• [L5] The author recommends against using these injections in patients with lateral epicondylitis. [141] (10.1097/corr.0000000000001249)
• [L4] PUT is a minimally invasive treatment technique that can be considered in patients with tendinopathy refractory to conservative treatment measures. [143] (10.1177/1941738120951764)
• [L3] Although there is variation in the use of MRI for lateral epicondylitis and its use is associated with downstream effects, the routine use of MRI for the diagnosis of lateral epicondylitis is low. [144] (10.1016/j.jhsa.2023.03.025)
• [L4] MRI in patients with chronic lateral epicondylitis can help to differentiate the disease and may be of use in clinical management, preoperative planning, and in the evaluation of the degree of degeneration at the common extensor tendon insertion. [145] (10.1007/s004020050330)
• [L4] The arthroscopic identification of the 3 types of Baker lesions helps the surgeon to confirm the presence of pathology commonly seen intra-articularly in patients with lateral epicondylitis. [146] (10.1016/j.eats.2024.103142)
• [L2] Magnetic resonance imaging is a reliable tool in determining radiological severity of lateral epicondylitis. [147] (10.1016/j.jhsa.2010.11.040)
• [L4] EUS can be used as the initial modality to screen any tendon pathology both in athlete and non-athlete, prior to advance imaging such as magnetic resonance imaging (MRI). [148] (10.1177/2325967119s00483)
• [L4] As a result, we recommend this technique in nonresponding to conservative treatment lateral epicondylitis. [150] (10.1097/bth.0000000000000243)
• [L2] The Snyder classification system is reproducible and can be used in future research studies in analyzing the treatment options of partial rotator cuff tears. [151] (10.1177/2325967116667058)
• [L4] The use of MR imaging in patients with recalcitrant lateral epicondylitis assists in surgical planning. [153] (10.1148/radiology.196.1.7784585)
• [L4] Obtaining radiographs for this segment of patients with lateral epicondylitis does not appear to be warranted. [155] (10.1067/mpn.2002.121147)
• [L2] [156] (10.1136/bmj.d2687)
• [L2] Persistent tennis elbow symptoms are a poor indication for surgery as the majority of patients experience symptom resolution without it, and surgeons are unable to reliably predict who will or will not improve with nonoperative treatment. [157] (10.1097/corr.0000000000003425)
• [L5] Treatment of these lesions is based on the knowledge of pathomechanics involved and the extent of injury to the tendon and muscle tissue. [159] (10.1016/j.asmr.2021.10.024)
• [L4] This study emphasizes the strength of the associations between combined physical exertion and elbow movements and lateral epicondylitis. [161] (10.1002/ajim.22140)
• [L2] With the number of available participants, this study failed to show additional benefit of the surgical excision of the degenerative portion of the ECRB over placebo surgery for the management of chronic tennis elbow. [163] (10.1177/0363546517753385)
• [L2] It is not recommended for use as an outcome measure in studies evaluating interventions for lateral epicondylitis until further development and validation are performed. [164] (10.1258/ht.2010.010014)
• [L2] Compensation guidance, management and prevention should incorporate these new findings and practitioners from primary to secondary care should note strenuous biomechanical hand and elbow exposures for patients with lateral epicondylalgia. [166] (10.1016/j.jbspin.2014.10.013)
• [L5] This review outlines the role of low-grade inflammation in the pathogenesis of tendinopathy, stressing the role of proinflammatory cytokines, proteolytic enzymes and growth factors, and explores how inflammation exerts a negative influence on the process of tendon healing. [167] (10.1186/s13018-021-02811-w)
• [L5] [168] (10.2106/00004623-199902000-00014)
• [L4] A large percentage of patients who fail conservative treatment for medial humeral epicondylitis (tendinosis) can obtain pain relief and return to activities with the described operative technique. [172] (10.1177/036354659502300215)
• [L4] It is one of the few procedures to demonstrate positive sonographic evidence of tissue-healing response and is an attractive alternative to surgical intervention for definitive treatment of recalcitrant elbow tendinopathy. [173] (10.1177/0363546515612758)
• [L5] [174] (10.5435/JAAOS-D-14-00145)
• [L4] At the long-term follow-up of 90 months, ultrasonic percutaneous tenotomy demonstrated good durability of pain relief and functional recovery that was previously achieved, accompanied by sustained sonographic tissue healing with no significant deterioration. [176] (10.1177/03635465211010158)
• [L4] Most cases of lateral epicondylitis respond to appropriate nonoperative treatment protocols, but when unsuccessful, surgical interventions may be performed with a high rate of success. [179] (10.1016/j.jse.2009.12.016)
• [L4] MRI is an important decision-making tool in the surgical treatment of refractory tennis elbow. [181] (10.1016/j.jse.2004.07.011)
• [L2] PRP and autologous whole blood injections are both effective methods to treat chronic lateral epicondylitis and their efficacy persisted during long term follow up. [185] (10.1186/2052-1847-6-12)
• [L4] [188] (10.2106/jbjs.rvw.15.00079)
• [L2] CTA was a reliable and accurate diagnostic modality compared with MRI to detect the capsular tear in patients with chronic tennis elbow. [189] (10.1016/j.jse.2010.12.002)
• [L4] Increased MRI signal in the ECRB origin is common in symptomatic and in asymptomatic elbows. [192] (10.1016/j.jse.2016.01.033)
• [L1] In the long term, acupotomy has greater efficacy and is associated with a lower rate of recurrence than corticosteroid injections in the management of lateral epicondylitis. [194] (10.1186/s13018-022-03323-x)
• [L4] Ultrasonographic examination gives a detailed image of the structures involved in the tennis elbow syndrome, confirms the diagnosis, and may be useful in monitoring treatment. [195] (10.1136/bjsm.24.3.151)
• [L4] [202] (10.1016/j.jse.2016.10.022)
• [L3] [208] (10.1177/03635465030310031401)
• [L4] [209] (10.1177/1758573217738199)
• [L4] [213] (10.1016/j.xrrt.2024.08.008)
• [L4] [216] (10.1186/s12891-022-05651-9)
• [L5] [218] (10.1097/00132589-200001030-00008)
• [L4] [219] (10.1007/s00167-014-2855-2)
• [L4] [224] (10.1016/s0266-7681(03)00162-1)
• [L4] [225] (10.1007/s00402-002-0421-8)
• [L3] Pain sensitization during the early stages of lateral epicondylitis correlated with initial symptom severity and duration and was associated with persistently increasing disability after 1 year of nonsurgical treatment. [233] (10.1016/j.jhsa.2018.06.013)
• [L2] Poor prognosis at 1yr of follow-up for lateral epicondylitis was related to manual work and high baseline pain, whilst no relation was found between the type of medical treatment given/chosen and prognosis. [234] (10.1093/rheumatology/keg360)
• [L4] They present acutely, have a poor natural history akin to complete tears, and have good outcomes with acute and delayed reconstruction. [236] (10.1016/j.jse.2020.04.038)

See Also

• Tennis Elbow
• Ligament Injuries

References

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