Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 25, Issue 7, pp 2255–2263 | Cite as

Intra-articular findings in symptomatic minor instability of the lateral elbow (SMILE)

  • Paolo Arrigoni
  • Davide CucchiEmail author
  • Riccardo D’Ambrosi
  • Usman Butt
  • Marc R. Safran
  • Patrick Denard
  • Pietro Randelli



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.


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.


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).


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



Elbow arthroscopy Lateral elbow pain Lateral epicondylitis Elbow instability Laxity 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest relevant to this study.


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.

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)


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2017

Authors and Affiliations

  1. 1.Dipartimento di Scienze Biomediche per la SaluteUniversità degli Studi di MilanoMilanItaly
  2. 2.U.O. Ortopedia IIIRCCS Policlinico San DonatoSan Donato Milanese, MilanItaly
  3. 3.IRCCS Policlinico San DonatoSan Donato Milanese, MilanItaly
  4. 4.Salford Royal NHS Foundation TrustSalfordUK
  5. 5.Stanford UniversityStanfordUSA
  6. 6.Southern Oregon OrthopedicsMedfordUSA
  7. 7.Department of Orthopaedics and RehabilitationOregon Health and Science UniversityPortlandUSA

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