Abstract
Purpose
Lateral epicondylitis is generally considered an extra-articular condition. The role of minor instability in the aetiology of lateral elbow pain has rarely been considered. The aim of this study was to evaluate the correlation of lateral ligamentous laxity with aspects of intra-articular lateral elbow pathology and investigate the role of minor instability in lateral elbow pain.
Methods
Thirty-five consecutive patients aged between 20 and 60 years with recalcitrant lateral epicondylitis who had failed conservative therapy and had no previous trauma or overt instability, were included. The presence of three signs of lateral ligamentous patholaxity and five intra-articular findings were documented during arthroscopy. The relative incidence of each of these was calculated, and the correlation between patholaxity and intra-articular pathology was evaluated.
Results
At least one sign of lateral ligamentous laxity was observed in 48.6% of the studied cohort, and 85.7% demonstrated at least one intra-articular abnormal finding. Radial head ballottement was the most common sign of patholaxity (42.9%). Synovitis was the most common intra-articular aspect of pathology (77.1%), followed by lateral capitellar chondropathy (40.0%). A significant correlation was found between the presence of lateral ligamentous patholaxity signs and capitellar chondropathy (p = 0.0409), as well as anteromedial synovitis (p = 0.0408).
Conclusions
Almost one half of patients suffering from recalcitrant lateral epicondylitis display signs of lateral ligamentous patholaxity, and over 85% demonstrate at least one intra-articular abnormality. The most frequent intra-articular findings are synovitis and lateral capitellar chondropathy, which correlate significantly with the presence of lateral ligamentous patholaxity. The fact that several patients demonstrated multiple intra-articular findings in relation to laxity provides support to a sequence of pathologic changes that may result from a symptomatic minor instability of the lateral elbow (SMILE) condition.
Level of evidence
III.
Similar content being viewed by others
References
Ahmad CS, ElAttrache NS (2004) Valgus extension overload syndrome and stress injury of the olecranon. Clin Sports Med 23(4):665–676
Akagi M, Nakamura T (1998) Snapping elbow caused by the synovial fold in the radiohumeral joint. J Shoulder Elb Surg 7(4):427–429
Antuna SA, O’Driscoll SW (2001) Snapping plicae associated with radiocapitellar chondromalacia. Arthroscopy 17(5):491–495
Arrigoni P, Cucchi D, D’Ambrosi R, Menon A, Aliprandi A, Randelli P (2017) Arthroscopic R-LCL plication for symptomatic minor instability of the lateral elbow (SMILE). Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-017-4531-9
Arrigoni P, Fossati C, Zottarelli L, Brady PC, Cabitza P, Randelli P (2014) 70° frontal visualization of lateral compartment of the elbow allows extensor carpi radialis brevis tendon release with preservation of the radial lateral collateral ligament. Arthroscopy 30(2):29–35
Baker C, Cummings P (1998) Arthroscopic managementof miscellaneous elbow disorders. Oper Tech Sports Med 6:16–21
Baker CL, Jones GL (1999) Arthroscopy of the elbow. Am J Sports Med 27(2):251–264
Baker CL, Murphy KP, Gottlob CA, Curd DT (2000) Arthroscopic classification and treatment of lateral epicondylitis: two-year clinical results. J Shoulder Elb Surg 9(6):475–482
Baumgard SH, Schwartz DR (1982) Percutaneous release of the epicondylar muscles for humeral epicondylitis. Am J Sports Med 10(4):233–236
Boileau P, Zumstein M, Balg F, Penington S, Bicknell RT (2011) The unstable painful shoulder (UPS) as a cause of pain from unrecognized anteroinferior instability in the young athlete. J Shoulder Elb Surg 20(1):98–106
Burkhart SS, Morgan CD, Kibler WB (2003) The disabled throwing shoulder: spectrum of pathology part I: Pathoanatomy and biomechanics. Arthroscopy 19(4):404–420
Caggiano N, Matullo KS (2014) Carpal instability of the wrist. Orthop Clin North Am 45(1):129–140
Caprise PA, Sekiya JK (2006) Open and arthroscopic treatment of multidirectional instability of the shoulder. Arthroscopy 22(10):1126–1131
Carayannopoulos A, Borg-Stein J, Sokolof J, Meleger A, Rosenberg D (2011) Prolotherapy versus corticosteroid injections for the treatment of lateral epicondylosis: a randomized controlled trial. PM & R 3(8):706–715
Castagna A, Nordenson U, Garofalo R, Karlsson J (2007) Minor shoulder instability. Arthroscopy 23(2):211–215
Cerezal L, Rodriguez-Sammartino M, Canga A, Capiel C, Arnaiz J, Cruz A, Rolón A (2013) Elbow synovial fold syndrome. Am J Roentgenol 201:88–96
Ciaudo O, Guérin-Surville H (1980) Importance of damage to the medial fascia of the external lateral ligament (radial collateral ligament) in the mechanisms of luxations of the elbow. Study on the cadaver (author’s transl). J Chir (Paris) 117(4):237–239
Clarke AW, Ahmad M, Curtis M, Connell DA (2010) Lateral elbow tendinopathy: correlation of ultrasound findings with pain and functional disability. Am J Sports Med 38(6):1209–1214
Clarke RP (1988) Symptomatic, lateral synovial fringe (plica) of the elbow joint. Arthroscopy 4(2):112–116
Cohen MS, Romeo AA, Hennigan SP, Gordon M (2008) Lateral epicondylitis: anatomic relationships of the extensor tendon origins and implications for arthroscopic treatment. J Shoulder Elb Surg 17(6):954–960
Commandre FA, Taillan B, Benezis C, Follacci FM, Hammou JC (1988) Plica synovialis (synovial fold) of the elbow. Report on one case. J Sports Med Phys Fit 28(2):209–210
Creaney L, Wallace A, Curtis M, Connell D (2011) Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections. Br J Sports Med 45(12):966–971
Dewan AK, Chhabra AB, Khanna AJ, Anderson MW, Brunton LM (2013) MRI of the elbow: techniques and spectrum of disease: AAOS exhibit selection. J Bone Jt Surg Am 95(14):e99
Dines JS, Bedi A, Williams PN, Dodson CC, Ellenbecker TS, Altchek DW, Windler G, Dines DM (2015) Tennis Injuries: epidemiology, pathophysiology, and treatment. J Am Acad Orthop Surg 23(3):181–189
Dogramaci Y, Kalaci A, Savaş N, Duman IG, Yanat AN (2009) Treatment of lateral epicondilitis using three different local injection modalities: a randomized prospective clinical trial. Arch Orthop Trauma Surg 129(10):1409–1414
Dones VC, Grimmer K, Thoirs K, Suarez CG, Luker J (2014) The diagnostic validity of musculoskeletal ultrasound in lateral epicondylalgia: a systematic review. BMC Med Imaging 14:10
Dugas JR (2010) Valgus extension overload: diagnosis and treatment. Clin Sports Med 29(4):645–654
Dunkow PD, Jatti M, Muddu BN (2004) A comparison of open and percutaneous techniques in the surgical treatment of tennis elbow. J Bone Jt Surg Br 86(5):701–704
Emanet SK, Altan LI, Yurtkuran M (2010) Investigation of the effect of GaAs laser therapy on lateral epicondylitis. Photomed Laser Surg 28(3):397–403
Foster CR (1983) Multidirectional instability of the shoulder in the athlete. Clin Sports Med 2(2):355–368
Gerber C, Nyffeler RW (2002) Classification of glenohumeral joint instability. Clin Orthop Relat Res 400:65–76
Kijowski R, Tuite M, Sanford M (2005) Magnetic resonance imaging of the elbow. Part II: abnormalities of the ligaments, tendons, and nerves. Skelet Radiol 34(1):1–18
Kim DH, Gambardella RA, Elattrache NS, Yocum LA, Jobe FW (2006) Arthroscopic treatment of posterolateral elbow impingement from lateral synovial plicae in throwing athletes and golfers. Am J Sports Med 34(3):438–444
Kim S-H, Ha K-I, Yoo J-C, Noh K-C (2004) Kim’s lesion: an incomplete and concealed avulsion of the posteroinferior labrum in posterior or multidirectional posteroinferior instability of the shoulder. Arthroscopy 20(7):712–720
Kitay A, Wolfe SW (2012) Scapholunate instability: current concepts in diagnosis and management. J Hand Surg Am 37(10):2175–2196
Kniesel B, Huth J, Bauer G, Mauch F (2014) Systematic diagnosis and therapy of lateral elbow pain with emphasis on elbow instability. Arch Orthop Trauma Surg 134(12):1641–1647
Latham SK, Smith TO (2014) The diagnostic test accuracy of ultrasound for the detection of lateral epicondylitis: a systematic review and meta-analysis. Orthop Traumatol Surg Res 100(3):281–286
Levin D, Nazarian LN, Miller TT, O’Kane PL, Feld RI, Parker L, McShane JM (2005) Lateral epicondylitis of the elbow: US findings. Radiology 237(1):230–234
Lin Y-C, Tu Y-K, Chen S-S, Lin I-L, Chen S-C, Guo H-R (2010) Comparison between botulinum toxin and corticosteroid injection in the treatment of acute and subacute tennis elbow: a prospective, randomized, double-blind, active drug-controlled pilot study. Am J Phys Med Rehabil 89(8):653–659
Lindenhovius A, Henket M, Gilligan BP, Lozano-Calderon S, Jupiter JB, Ring D (2008) Injection of dexamethasone versus placebo for lateral elbow pain: a prospective, double-blind, randomized clinical trial. J Hand Surg Am 33(6):909–919
Lo MY, Safran MR (2007) Surgical treatment of lateral epicondylitis: a systematic review. Clin Orthop Relat Res 463:98–106
Magee T (2015) Accuracy of 3-T MR arthrography versus conventional 3-T MRI of elbow tendons and ligaments compared with surgery. AJR Am J Roentgenol 204:W70–W75
McAdams TR, Masters GW, Srivastava S (2005) The effect of arthroscopic sectioning of the lateral ligament complex of the elbow on posterolateral rotatory stability. J Shoulder Elb Surg 14(3):298–301
Neer CS, Foster CR (1980) Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Jt Surg Am 62(6):897–908
Nirschl RP, Pettrone FA (1979) Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Jt Surg Am 61(6A):832–839
Pappou IP, Basel J, Deal DN (2013) Scapholunate ligament injuries: a review of current concepts. Hand (N Y) 8(2):146–156
Peart RE, Strickler SS, Schweitzer KM (2004) Lateral epicondylitis: a comparative study of open and arthroscopic lateral release. Am J Orthop 33(11):565–567
Poltawski L, Ali S, Jayaram V, Watson T (2012) Reliability of sonographic assessment of tendinopathy in tennis elbow. Skelet Radiol 41(1):83–89
Rajeev A, Pooley J (2015) Arthroscopic resection of humeroradial synovial plica for persistent lateral elbow pain. J Orthop Surg (Hong Kong) 23(1):11–14
Randelli P, Cucchi D, Butt U (2016) History of shoulder instability surgery. Knee Surg Sport Traumatol Arthrosc 24(2):305–329
Safran M, Ahmad CS, Elattrache NS (2005) Ulnar collateral ligament of the elbow. Arthroscopy 21(11):1381–1395
Savoie FH, VanSice W, O’Brien MJ (2010) Arthroscopic tennis elbow release. J Shoulder Elb Surg 19(2 Suppl):31–36
Sims SEG, Miller K, Elfar JC, Hammert WC (2014) Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand (N Y) 9(4):419–446
Slutsky DJ, Trevare J (2014) Scapholunate and lunotriquetral injuries: arthroscopic and open management. Sports Med Arthrosc 22(1):12–21
Spatschil A, Landsiedl F, Anderl W, Imhoff A, Seiler H, Vassilev I, Klein W, Boszotta H, Hoffmann F, Rupp S (2006) Posttraumatic anterior-inferior instability of the shoulder: arthroscopic findings and clinical correlations. Arch Orthop Trauma Surg 126(4):217–222
Staples MP, Forbes A, Ptasznik R, Gordon J, Buchbinder R (2008) A randomized controlled trial of extracorporeal shock wave therapy for lateral epicondylitis (tennis elbow). J Rheumatol 35(10):2038–2046
Stefanou A, Marshall N, Holdan W, Siddiqui A (2012) A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis. J Hand Surg Am 37(1):104–109
Steinert AF, Goebel S, Rucker A, Barthel T (2010) Snapping elbow caused by hypertrophic synovial plica in the radiohumeral joint: a report of three cases and review of literature. Arch Orthop Trauma Surg 130(3):347–351
Szabo SJ, Savoie FH, Field LD, Ramsey JR, Hosemann CD (2006) Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment. J Shoulder Elb Surg 15(6):721–727
Taylor SA, Hannafin JA (2012) Evaluation and management of elbow tendinopathy. Sports Health 4(5):384–393
Thanasas C, Papadimitriou G, Charalambidis C, Paraskevopoulos I, Papanikolaou A (2011) Platelet-rich plasma versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis: a randomized controlled clinical trial. Am J Sports Med 39(10):2130–2134
Timmerman LA, Andrews JR (1994) Undersurface tear of the ulnar collateral ligament in baseball players. A newly recognized lesion. Am J Sports Med 22(1):33–36
Wada T, Moriya T, Iba K, Ozasa Y, Sonoda T, Aoki M, Yamashita T (2009) Functional outcomes after arthroscopic treatment of lateral epicondylitis. J Orthop Sci 14(2):167–174
Wegmann K, Burkhart KJ, Bingoel AS, Ries C, Neiss WF, Müller LP (2014) Anatomic relations between the lateral collateral ligament and the radial head: implications for arthroscopic resection of the synovial fold of the elbow. Knee Surg Sports Traumatol Arthrosc 23(11):3421–3425
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflicts of interest relevant to this study.
Funding
This study was not funded.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Video 1: Right elbow, Posterolateral viewing portal showing radial head ballottement and annular drive through (ADT) of a 4.2-mm shaver between the radial head and the annular ligament (MP4 3634 kb)
Video 2: Right elbow, Anteromedial 30° arthroscopic view over the lateral compartment showing a partial detachment with insertional elongation from the capitellum of the R-LCL. Laxity of the R-LCL that can easily be reduced to the humerus or translated more than 1 cm with a grasper or introduced via the anterolateral portal (R-LCL pull-up sign, RPS) (MP4 3894 kb)
Rights and permissions
About this article
Cite this article
Arrigoni, P., Cucchi, D., D’Ambrosi, R. et al. Intra-articular findings in symptomatic minor instability of the lateral elbow (SMILE). Knee Surg Sports Traumatol Arthrosc 25, 2255–2263 (2017). https://doi.org/10.1007/s00167-017-4530-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00167-017-4530-x