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Pain over the lateral aspect of the elbow without nerve injury or elbow instability often is diagnosed as lateral epicondylitis or, colloquially, tennis elbow. It is a common complaint, seen most frequently in women between ages 40 and 60, although it is common in men too. Typical presenting symptoms include pain with prolonged wrist extension activities, pain with resisted wrist or elbow extension, and pain at rest radiating from the elbow along the dorsum of the forearm.

Common flexor-pronator tendon injuries and medial epicondylitis can be successfully treated nonoperatively in most cases. Operative treatment is reserved for patients with continued symptoms despite adequate nonoperative treatment or in high-level athletes with complete rupture of the common flexor-pronator tendon. The physical examination and workup of patients with flexor-pronator tendon injuries should focus on related or concomitant pathologies of the medial elbow. The gold standard for surgical treatment of flexor-pronator tendon ruptures or medial epicondylitis includes tendon debridement and reattachment.

Although limited literature exists on medial epicondylitis of the elbow, this disorder is an injury affecting many athletes at every level, especially throwing athletes. Care must be taken in diagnosing medial epicondylitis to distinguish it from other possible pathologies of the medial elbow, which may exist concurrently. The large majority of patients diagnosed with medial epicondylitis will respond to a well-structured, nonsurgical program; however, patients with persistent or recurring symptoms can be treated surgically, which yields high patient satisfaction and ultimately a reliable return to preinjury levels of activity.

Medial epicondylitis and ulnar nerve problems are common in the throwing athlete, resulting from the tremendous valgus stress that occurs during the acceleration phase of pitching. They are too often ignored as a cause of medial pain in the throwing athlete in favor of the diagnosis of ulnar collateral ligament injury. The latter seems to be in vogue, and there is a virtual epidemic of reconstructive surgery to address this diagnosis. The question is whether more medial pain is caused by the former two diagnoses than the latter. We need to have a better understanding of the natural history and differential diagnosis of medial side pain, which, I hope, will come with time. Nonetheless, medial stress injuries occur in the throwing athlete, and can cause inflammation of the adjacent anterior capsule flexor pronator mass, the ulnar collateral ligament, and the ulnar nerve. This review highlights these problems, their anatomy, diagnosis, and management.

An appropriate diagnosis must be made after carefully excluding all other options in treating the patient with lateral epicondylitis. The majority of these patients will do well with nonsurgical treatment; however, if unresponsive to this regimen, a carefully selected patient will have a successful result with surgical reconstruction (85%-95% of patients). Attention to detail both pre- and postoperatively will help to create a successful result in a disease entity that plagues a large proportion of our athletic population.

Epicondylitis is a diagnostic term that describes a pattern of pain and tenderness localized to the medial or lateral epicondyles of the distal humerus. The pathoanatomy, clinical presentation, and treatment of these disorders is described. Nonoperative treatment, operative techniques, postoperative care, and the results of treatment are discussed.

MRI is a useful diagnostic method for evaluating nerve disease at the shoulder and elbow. MRI can depict the normal anatomy of the nerves, confirm and identify the cause of the neuropathy, identify the site of entrapment based on muscle denervation patterns, and detect unsuspected space-occupying lesions. MRI can also narrow down the differential diagnosis of nerve disease, such as in the case of suprascapular nerve syndrome versus Parsonage-Turner syndrome, or radial tunnel syndrome versus lateral epicondylitis. Large prospective studies with surgical correlation, however, are still necessary to better elucidate MRI's exact role in the assessment of entrapment neuropathies of the upper extremity.

In throwing activities, the elbow is sometimes stressed to its biomechanical limits. In this article, forces, torques, angular velocities, and muscle activity about the elbow are reviewed for the baseball pitch, the football pass, the javelin throw, the windmill softball pitch, the tennis serve, and the golf swing. The elbow goes through rapid extension in baseball pitching (about 2400 degrees/s) and rapid flexion in the javelin throw (about 1900 degrees/s). During baseball pitching, the elbow joint is subject to a valgus torque reaching 64 Nm, and requires proximal forces as high as 1000 N to prevent elbow distraction. The ulnar collateral ligament (UCL) rupture in baseball pitching, lateral epicondylitis in the tennis backhand, and other injury mechanisms are also discussed.

The pathoanatomy of overuse tendinopathy is noninflammatory angiofibroblastic tendinosis. The areas of elbow abnormality are specific, including the ECRB-EDC complex laterally, the pronator teres, flexor carpi radialis medially, and triceps posteriorly. The goals of nonoperative treatment are to revitalize the unhealthy pain-producing tendinosis tissue. The key to nonoperative treatment is rehabilitative resistance exercise with progression of the exercise program. If rehabilitation fails, the surgical interventions as described are highly successful.

Elbow pain in athletes who engage in contact sports and in overhand throwing is fairly common. Its cause can be myotendinous (medial or lateral epicondylitis), articular surface (loose bodies or chondromalacia), stability (ligamentous insufficiency), or apophyseal in young athletes. Posterior impingement of the elbow can arise from a repetitive microtraumatic process or a single traumatic event. Posterior impingement of the elbow is a mechanical abutment of bony and soft tissues in the posterior compartment, producing pain, locking, and crepitation, especially at the limits of elbow extension. Extension loss of varying degrees can exist. Often, pathologic changes are not limited to the posterior compartment of the elbow and can include anterior compartment loose bodies and degenerative chondromalacia of the radiocapitellar joint. Not all patients with posterior elbow pain have posterior impingement, however; for example, posterior pain can arise because of triceps tendinitis or olecranon stress fractures. 21 Posterior impingement of the elbow in athletes can be separated into two broad categories, even though this is a somewhat artificial classification. Posterior impingement can occur in stable elbows (with intact, functional collateral ligaments) owing to hyperextension forces and in unstable elbows owing to functionally lengthened collateral ligaments that, in turn, cause bony abutment of the olecranon and the humerus. Posterior impingement of the elbow can be the primary cause leading to clinical presentation or it can be a minor part of a symptom complex that should be addressed as part of a global treatment plan. 11

Epicondylitis plagues a significant proportion of athletes and can result in prolonged symptoms and suboptimal athletic performance. The diagnosis can be confused with many other pathologic entities affecting the elbow, some of which can occur concurrently. Most patients will respond favorably to a well-guided nonsurgical treatment protocol. A minority of patients will have persistent problems and will require surgical intervention that can relieve pain effectively and return patients to their preinjury level of activity.

An understanding of the anatomy and biomechanics of the elbow is essential for accurate diagnosis and treatment. In the athlete, the lateral compressive and medial traction forces account for the majority of problems. Lesions range from the valgus extension overloads to osteochondritis dissecans. Soft-tissue problems, be they "tennis elbow" or ulnar collateral ligament injuries, are frequently the greatest diagnostic and therapeutic challenge.

Tennis elbow is a common condition, with the extensor carpi radialis brevis attachment being the usual site of pain. Conservative care including decreased activity, ice, nonsteroidal anti-inflammatory medications, and muscle strengthening will help most people. The small percentage of cases that require surgery usually benefit from debridement of the damaged portion of the extensor carpi radialis brevis attachment. The postoperative course must include muscle strengthening and a gradual return to activity.