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Tendinopathies

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

Overview

Nonoperative management for lateral elbow tendinopathy lacks a single reliable protocol to achieve outstanding results, likely due to heterogeneous patient groups rather than disease severity stratification [2]. While numerous treatment options exist for epicondylitis, no universally accepted protocol has emerged [11]. In contrast, the majority of patients with Achilles tendinopathy fully recover symptoms and function with exercise alone [4], and results for nonoperative patellar tendinopathy are superior in stage 2 cases compared to stage 3 [3]. Despite these variations, there is no clear consensus defining chronic Achilles disorders or a uniform classification and treatment scheme [6].

Surgical intervention is indicated for refractory cases, with arthroscopic debridement showing a 60% improvement in tendinopathy area for recovered patients versus 16% in unrecovered groups [15]. Postoperative MRI findings in these patients reflect clinical outcomes [15], and complete resection of tendinosis tissue while sparing normal tissue yields durable long-term results [16]. However, a prospective, randomized, double-blinded, placebo-controlled trial failed to demonstrate additional benefit of surgical excision of the degenerative ECRB portion over placebo surgery for chronic tennis elbow [64]. For chronic patellar tendinopathy, surgical treatment leads to substantial functional improvements, though fat pad debridement prolongs return-to-sport [7].

Alternative definitive treatments include autologous tenocyte injection, which evidence supports for midterm durability in lateral epicondylitis [5], and ultrasonic percutaneous tenotomy, an attractive alternative to surgery that demonstrates positive sonographic evidence of tissue-healing response [66]. While surgical outcomes for rotator cuff repair are well-documented, patients' characteristics and indications for surgery were not described in a majority of these clinical outcome studies [23].

Anatomy & Pathophysiology

Elbow disorders, including tendinopathy, ligament reconstruction, and throwing injuries, encompass distinct pathophysiological mechanisms, diagnostic criteria, and treatment strategies [13]. Elbow arthroscopy has emerged as a safe and effective intervention for these pathologies, driven by improved instrumentation, advanced surgical techniques, and a refined anatomical understanding [75]. The Discovery Elbow System demonstrated improved function, reduced pain, and high patient satisfaction with a 4-year mean follow-up [71]. In a prospective, randomized, double-blinded, placebo-controlled trial, both surgical and placebo procedures improved pain frequency, severity, stiffness, and functional difficulty over 6 months, with benefits maintained at 12 months [82].

Osseous Morphology: A high correlation exists between radial head and capitellum dimensions, as well as between left and right elbows, permitting radial head size estimation via capitellum measurements [79]. In cadaveric models of the throwing shoulder, all participant models contacted the glenoid by 150 degrees of humerothoracic elevation during standardized overhead reaching, though anatomic factors influenced the precise angle of contact [80].

Kinematics & Biomechanics: Dynamic elongation of repair tissue during scapular-plane abduction exhibits one of two distinct patterns, suggesting divergent supraspinatus mechanical and neuromuscular functions [68]. The 3D glenohumeral kinematics during early arm elevation may significantly impact shoulder function in patients with massive rotator cuff tears [69]. Reverse shoulder arthroplasty (RSA) and superior capsular reconstruction (SCR) models produce moment arms that vary between muscles, with some contributing more to abduction and others less [84]. Biomechanical analysis of distal biceps tendon repair identifies the extramedullary cortical button and two intramedullary cortical buttons as the fixation constructs with the greatest overall performance [83].

Tendinopathy & Neuromuscular Control: Lateral epicondylalgia (LE) management requires focusing on the upper segments in addition to the elbow [62]. An adaptive motor pattern in lateral elbow tendinopathy is characterized by increased relative activation and coactivation of the anconeus muscle dependent on grip force [76]. Grip strength in lateral epicondylitis patients decreases as the position shifts from flexion to extension [77]. Significant differences in biomechanical parameters and clinical scores exist between tennis elbow patients and controls across manual, physical, and sports work groups [72]. Orthoses improve elbow proprioception, pain severity, and force production in the hand for lateral elbow tendinopathy patients [70]. Following tenotomy of the long head of the biceps tendon, isometric flexion improves but does not reach the power of the contralateral healthy arm [52].

Throwing Pathology: Tears of the posterior rotator cuff cable alter glenohumeral biomechanics and kinematics in a cadaveric throwing shoulder model [61]. Posteromedial elbow impingement is the most common diagnosis for posterior elbow pain in Japanese high school baseball players [86]. All Japanese high school baseball players with posterior elbow problems returned to competitive sports activity levels within 77 ± 47 days [86].

Classification

Hand and Wrist: Tendinopathies of the hand and wrist are common conditions diagnosed by history and examination [1].

Lateral Elbow: The proposed MRI classification has emerged as one of the most reliable methods to define stages of chronic lateral epicondylitis [22]. 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].

Patellar: Patellar tendinopathy is a degenerative disorder (tendinosis) rather than an inflammatory one [21]. In patients with patellar tendinopathy treated nonoperatively, results were better in those with stage 2 tendinopathy than in those with stage 3 [3].

Achilles: The classification of midportion and insertional tendinopathy and retrocalcaneal bursitis in the Achilles tendon should strictly be used as a clinical diagnosis, as more specific pathologies may be identified during surgical evaluations [33]. There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme [6]. The exact aetiology and pathophysiology of non-insertional Achilles tendinopathy are not fully known and warrant further studies [12]. The modified, 4-graded, Öhberg score was found to be a reproducible instrument for assessment of tendon structure and neovascularisation [51].

Rotator Cuff: A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further [31]. The Snyder classification system is reproducible and can be used in future research studies in analyzing the treatment options of partial rotator cuff tears [59].

Other Considerations: Tendinopathy and acute muscle injuries are common yet difficult-to-treat conditions with large gaps in knowledge regarding etiology and management [9].

Clinical Presentation

Tendinopathies of the hand and wrist are common conditions diagnosed by history and examination [1]. Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years [19]. However, nearly half (46.5%) of patients presenting with lateral elbow pain receive a diagnosis other than lateral elbow tendinopathy [34]. Rotator cuff tendinopathy is a common problem but uncertainty remains regarding the true extent and risk factors associated with onset [39]. Tendinopathy and acute muscle injuries are common yet difficult-to-treat conditions with large gaps in knowledge regarding etiology and management [9].

Inspection and palpation reveal specific structural changes. Patients diagnosed with painful supraspinatus tendinopathy demonstrated increased tendon thickening with delayed return to baseline following loading [10]. Calcifying tendonitis appeared to be the most frequent pathologic condition associated with the onset of infraspinatus myotendinous junction tears [18]. Asymptomatic tendon structures should not be used as reference in clinical practice for patients with unilateral insertional or midportion Achilles tendinopathy or patellar tendinopathy [20]. Patellar tendinopathy is a degenerative disorder (tendinosis) rather than an inflammatory one [21].

Functional assessment and history highlight variable recovery and classification challenges. The majority of patients with Achilles tendinopathy fully recover regarding both symptoms and function when treated with exercise alone [4] [12]. There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme [6]. The exact aetiology and pathophysiology of non-insertional Achilles tendinopathy are not fully known and warrant further studies [12]. Tendinopathy associated with statins usually occurs within the first year of use and improves after the drug therapy is stopped [8].

Management protocols remain heterogeneous across sites. No single nonoperative treatment reliably achieves outstanding results for lateral elbow tendinopathy [2]. Numerous treatment options exist for epicondylitis, but no single universally accepted protocol has emerged [11]. The multifactorial etiology of lateral elbow tendinopathy makes finding one effective treatment intervention elusive [41]. Accurate detection of the painful area and stabilization of the tendon origin may lead to excellent clinical results in recalcitrant lateral epicondylitis treated with tenodesis [35]. Emerging evidence on lateral epicondylitis focuses on pathogenesis, diagnosis, and management to shed light on understandings and treatment for healthcare professionals [17]. Comprehensive overviews of elbow disorders summarize pathophysiology, diagnosis, and treatment strategies based on existing literature [13]. Current understanding regarding peroneal tendon disorders aims to summarize anatomy and diagnostic evaluation, and to present both conservative and operative management options [38].

Investigations

Plain radiography: While plain radiographs are not explicitly detailed in the provided evidence base for diagnosing specific tendon pathologies, they remain a standard initial step in the broader workup of hand and wrist complaints where diagnosis relies on history and examination [1].

MRI: Magnetic resonance imaging serves as a reliable tool for determining the radiological severity of lateral epicondylitis [56] and represents one of the most reliable methods to define stages of chronic lateral epicondylitis [22]. Postoperative MRI findings correlate with clinical outcomes, showing a 60% improvement in the tendinopathy area in recovered groups versus 16% in unrecovered groups following arthroscopic debridement for refractory lateral epicondylitis [15]. Continuous tendon recovery has been documented over a 2-year period after platelet-rich plasma (PRP) treatment for lateral epicondylitis [65], and PRP treatment permitted a return to normal tendon architecture as assessed by MRI in patients with chronic patellar tendinopathy [74]. In the context of rotator cuff pathology, 39% of patients with symptomatic tendinopathy persisting for at least one year progressed to a partial or full-thickness tear on follow-up MRI [29]. Patients with painful supraspinatus tendinopathy demonstrate increased tendon thickening with delayed return to baseline following loading [10]. 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 [26]. However, the diagnostic and prognostic value of MRI in lateral epicondylar tendinopathy is questioned, particularly in older patients [54], and the clinical use of MRI for enthesopathy of the extensor carpi radialis longus origin merits further study [49]. Routine use of MRI for diagnosing lateral epicondylitis remains low despite variation in its application and downstream effects [53].

Ultrasound: Ultrasonography was found to be more accurate than MRI in confirming clinically diagnosed patellar tendinopathy [48]. Elastography-ultrasound (EUS) can be utilized as the initial screening modality for tendon pathology in both athletes and non-athletes prior to advanced imaging such as MRI [57].

CT: Quantitative assessment of extensor carpi radialis brevis (ECRB) tendon degeneration using CT Hounsfield units offers an objective measure of tendon pathology that may complement current diagnostic approaches [73].

Other Considerations: Tendinopathies of the hand and wrist are diagnosed primarily by history and examination [1]. No single nonoperative treatment reliably achieves outstanding results for lateral elbow tendinopathy [2], though autologous tenocyte injection (ATI) provides evidence for midterm durability in its treatment [5]. Asymptomatic tendon structures should not be used as a reference in clinical practice for patients with unilateral insertional or midportion achilles tendinopathy or patellar tendinopathy [20].

Treatment

Non-Operative

Tendinopathies of the hand and wrist are common conditions diagnosed by history and examination, with treatment similar for most, advancing both nonsurgical and surgical management [1]. Nonsurgical treatment remains the mainstay for lateral epicondylitis, involving options such as rest, physical therapy, and injections [47], though 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]. While most patients with lateral epicondylosis experience relief with non-operative management, controversy remains regarding the optimal modality for quickest recovery and the role of surgical intervention for refractory cases [44]. Numerous treatment options exist for epicondylitis, but no single universally accepted protocol has emerged [11], and although many treatments have been advocated for lateral epicondylitis, there is little clear consensus on which modality works best for both conservative and operative options, indicating that the understanding of the disease process is currently incomplete [60].

Evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited [32], yet the majority of patients with Achilles tendinopathy fully recovered in regard to both symptoms and function when treated with exercise alone [4]. Conservative treatment remains the mainstay for spontaneous resorption of calcification at the long head of the biceps tendon, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy [40]. Topical glyceryl trinitrate should be included as part of nonsurgical management of chronic supraspinatus tendinopathy [42]. 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 [14]. STR/PRP is a safe treatment that effectively induces clinically significant improvements in elbow symptoms, general well-being, objective measures of strength, and imaging of the common extensor tendon within 6 months of treatment for elbow tendinopathy recalcitrant to standard treatments [36]. Autologous tenocyte injection provides evidence for midterm durability in the treatment of lateral epicondylitis [5]. Results have been mixed in the management of lateral epicondylitis with extracorporeal shock wave therapy, and this therapy has not been effective in managing noncalcific tendinosis of the supraspinatus [46]. 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 [37]. Tendinopathy associated with statins usually occurs within the first year of use and improves after the drug therapy is stopped [8].

Operative

Indications: Surgical treatment for chronic patellar tendinopathy leads to substantial improvements in functional outcomes [7], and arthroscopic debridement is reserved for cases of biceps tendon calcification where symptoms are not controlled by non-operative therapy [40]. Operative management of cuff tears is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology [58]. While most patients with lateral epicondylosis experience relief with non-operative management, controversy remains regarding the optimal modality for quickest recovery and the role of surgical intervention for refractory cases [44].

Surgical Approach / Technique: Both the Nirschl procedure and arthroscopic extensor carpi radialis brevis débridement are comparable and highly effective for treating chronic recalcitrant lateral elbow tendinopathy [43]. Fat pad debridement prolongs return-to-sport in surgical interventions for chronic patellar tendinopathy [7]. Ultrasound-guided needling is considered safe and effective for calcific tendinopathy based on Level I evidence, though inclusion criteria in the supporting study were less strict than ideal [63].

Adjuncts: Postoperative MRI findings reflect clinical outcomes, with improvement of tendinopathy area being 60% in recovered groups versus 16% in unrecovered groups [15]. A multi-center, blinded, randomized controlled trial is planned to provide evidence on the effectiveness of injection therapy in the treatment of lateral epicondylitis on pain, quality of life, and functional recovery [45]. The literature documents several nonsurgical approaches for the treatment of chronic patellar tendinopathy with important limitations in terms of study quality [50]. There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme [6]. In the group treated nonoperatively, results were better in patients with stage 2 patellar tendinopathy than in those with stage 3 [3].

Complications

Patellar / Extensor-mechanism: MRI-defined patellar tendinopathy is associated with current and past history of obesity assessed by BMI or body weight, but not with fat mass [26]. Surgical treatment for chronic patellar tendinopathy leads to substantial improvements in functional outcomes, though fat pad debridement prolongs return-to-sport [7].

Lateral Elbow: Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years [19]. Surgical treatment by complete resection of the tendinosis tissue with sparing of normal tissue can lead to durable results at long-term follow-up [16]. Favorable short-term outcomes such as reduction of pain and increase in function are maintained over a long-term follow-up for arthroscopic treatment [25]. Ultrasound-guided percutaneous tenotomy demonstrates good sustainability of pain relief and functional recovery at 7.5 years, accompanied by sonographic evidence of tissue healing [30]. Percutaneous ultrasonic tenotomy produces statistically significant improvements in pain and function over a 1-year follow-up period for chronic medial and lateral elbow tendinosis and is a safe and effective treatment [14].

Achilles: The exact aetiology and pathophysiology of non-insertional Achilles tendinopathy are not fully known, requiring additional research to improve understanding of causative factors [12, 81]. The absence of tendinopathic changes in the excised plantaris of 13 patients who clinically improved suggests plantaris involvement may not be fully understood [78]. This absence supports the concept that plantaris involvement with Achilles tendinopathy may be a compressive or a frictional phenomenon rather than purely tendinopathic [78].

Shoulder: Calcifying tendonitis appeared to be the most frequent pathologic condition associated with the onset of infraspinatus myotendinous junction tears [18]. The short-term clinical influence of biceps complications on shoulder outcome after tenotomy associated with arthroscopic rotator cuff repair is very limited [55]. Results of arthroscopic transosseous technique for rotator cuff tears were satisfactory in the early period, though long follow-up is needed to evaluate bone-tendon healing [28]. Improved clinical outcomes and an overall high rate of tendon healing were seen at midterm follow-up after arthroscopic isolated subscapularis tendon repair [24].

Other Considerations: Tendinopathies of the hand and wrist are common conditions diagnosed by history and examination [1]. Tendinopathy usually occurs within the first year of statin use and improves after statin drug therapy is stopped [8]. Enthesopathy of the extensor carpi radialis brevis origin is a benign, self-limiting disorder with a natural history of spontaneous resolution, yet no treatments have been proven to alter its course [27]. Tendinopathy and acute muscle injuries are common yet difficult-to-treat conditions with large gaps in knowledge regarding etiology and management [9].

Recovery

Light activity (weeks): Patients with self-limiting conditions such as extensor carpi radialis brevis origin enthesopathy or transient tennis elbow symptoms may resume desk work and light activities of daily living as the condition naturally resolves without specific intervention [27, 87]. For acute distal biceps short head tears, reconstruction yields good outcomes even when performed acutely or with delayed timing, allowing for early mobilization protocols [90].

Full activity (months): Functional recovery timelines vary by pathology and treatment modality. Patients with Achilles tendinopathy treated with exercise alone often achieve full symptom and functional recovery within the timeframe of the study duration [4]. Surgical management for chronic patellar tendinopathy leads to substantial improvements in functional outcomes, while arthroscopic isolated subscapularis tendon repair demonstrates high rates of tendon healing at midterm follow-up [7, 24]. Arthroscopic treatment of lateral epicondylitis maintains favorable short-term outcomes of pain reduction and functional increase over long-term follow-up [25].

Complete recovery / outcome plateau (months): Long-term durability is observed in specific interventions. Percutaneous ultrasonic tenotomy for chronic medial and lateral elbow tendinosis produces statistically significant improvements in pain and function over a 1-year follow-up, with good sustainability of pain relief and functional recovery demonstrated at 7.5 years and 90 months [14, 30, 67]. Surgical resection of tendinosis tissue in lateral epicondylitis with sparing of normal tissue leads to durable results at long-term follow-up [16]. Autologous tenocyte injection provides evidence for midterm durability in lateral epicondylitis treatment [5].

Rehabilitation protocol: Nonoperative management is the primary approach for many conditions, including statin-associated tendinopathy which improves after drug cessation [8]. For calcific tendinitis, optimal treatment requires determining the disease stage, with surgery preferably performed during the formative phase if conservative management fails [89]. In cases of symptomatic rotator cuff tendinopathy remaining symptomatic at a minimum of 1 year, progression to partial or full-thickness tears occurs in 39% of patients, necessitating careful monitoring [29].

Functional milestones: Clinical outcomes are stratified by disease stage and patient presentation. Nonoperative results for patellar tendinopathy are better in stage 2 than in stage 3 [3]. Patients with painful supraspinatus tendinopathy demonstrate increased tendon thickening with delayed return to baseline following loading [10]. Pain sensitization in early lateral epicondylitis correlates with initial severity and duration, predicting persistently increasing disability after 1 year of nonsurgical treatment [85]. An isolated traumatic full-thickness supraspinatus tear with an intact glenohumeral capsule demonstrated good clinical evolution with a Subjective Shoulder Value of 85% and no retear at 6 months follow-up [88].

Other Considerations: Long-term evaluation is critical for certain repairs; results for arthroscopic transosseous repair of rotator cuff tears were satisfactory in the early period, but long follow-up is needed to evaluate bone-tendon healing [28]. Tendinopathies of the hand and wrist are common conditions diagnosed by history and examination, with treatment similar for most, advancing both nonsurgical and surgical management [1].

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. (10.1177/2325967116670635)
  • [L3] In the group treated nonoperatively, results were better in the patients who had stage 2 tendinopathy than in those with stage 3. (10.1177/03635465000280031901)
  • [L4] The majority of patients with Achilles tendinopathy fully recovered in regard to both symptoms and function when treated with exercise alone. (10.1177/0363546510384789)
  • [L4] This study provides evidence for the midterm durability of ATI for treatment of LE tendinopathy. (10.1177/0363546515579185)
  • [L5] There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme. (10.5435/00124635-200901000-00002)
  • [L1] Surgical treatment for chronic patellar tendinopathy leads to substantial improvements in functional outcomes. (10.1002/ksa.70284)
  • [L4] Tendinopathy usually occurs within the first year of statin use and improves after the drug therapy is stopped. (10.2106/jbjs.rvw.15.00072)
  • [L3] Those diagnosed with painful supraspinatus tendinopathy demonstrated increased thickening with delayed return to baseline following loading. (10.1136/bmjsem-2017-000279)
  • [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. (10.1016/j.jhsa.2009.01.022)
  • [L5] The exact aetiology and pathophysiology of non-insertional Achilles tendinopathy are not fully known and warrant further studies. (10.1136/jisakos-2017-000164)
  • [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. (10.1016/j.jse.2014.07.017)
  • [L4] In the recovered and unrecovered groups, improvement of tendinopathy area was 60% versus 16%, indicating that postoperative MRI findings reflect clinical outcomes. (10.1016/j.arthro.2022.07.019)
  • [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. (10.1177/0363546507308932)
  • [L5] This article presents a landscape of emerging evidence on lateral epicondylitis, focusing on pathogenesis, diagnosis, and management to shed light on understandings and treatment for healthcare professionals. (10.1155/2020/6965381)
  • [L4] Calcifying tendonitis appeared to be the most frequent pathologic condition associated with the lesion onset. (10.1016/j.jse.2022.01.092)
  • [L5] Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years. (10.1302/0301-620x.95b9.29285)
  • [L3] These results stress the importance of monitoring both symptomatic and asymptomatic tendon structures and in addition highlight that the asymptomatic side should not be used as reference in clinical practice. (10.1007/s00167-019-05495-2)
  • [L5] Patellar tendinopathy is a degenerative disorder (tendinosis) rather than an inflammatory one. (10.5435/jaaos-d-15-00703)
  • [L4] The proposed MRI classification has emerged as one of the most reliable methods to define stages of chronic lateral epicondylitis. (10.1186/s12891-022-05758-z)
  • [L3] The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair. (10.1007/s11999-008-0585-9)
  • [L4] Improved clinical outcomes and an overall high rate of tendon healing were seen at the midterm follow-up after AISR. (10.1177/23259671241229429)
  • [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. (10.1186/1471-2474-15-266)
  • [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. (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. (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. (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. (10.1177/2325967120s00420)
  • [L4] A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further. (10.1302/2058-5241.1.160005)
  • [L1] Evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited. (10.1016/j.jht.2023.08.016)
  • [L4] The classification of midportion and insertional tendinopathy and retrocalcaneal bursitis in AT should strictly be used as a clinical diagnosis, as more specific pathologies may be identified during surgical evaluations. (10.1177/2325967114562371)
  • [L3] Nearly half (46.5%) of patients presenting with lateral elbow pain receive a diagnosis other than lateral elbow tendinopathy (LET). (10.1016/j.jse.2025.10.006)
  • [L4] Accurate detection of the painful area and stabilization of the tendon origin may lead to excellent clinical results. (10.1016/j.jseint.2022.03.004)
  • [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. (10.1016/j.jse.2018.09.007)
  • [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. (10.1016/j.jhsa.2011.10.029)
  • [L5] The aim of this review is to summarise the current understanding of the anatomy and diagnostic evaluation of the peroneal tendons, and to present both conservative and operative management options of peroneal tendon lesions. (10.1302/2058-5241.2.160047)
  • [L1] Rotator cuff tendinopathy is a common problem but uncertainty remains regarding the true extent and risk factors associated with onset. (10.1111/sae.12028)
  • [L4] Conservative treatment remains the mainstay, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy. (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. (10.1016/j.jht.2018.04.002)
  • [L1] Topical glyceryl trinitrate should be included as part of nonsurgical management of chronic tendinopathies. (10.1177/0363546504270998)
  • [L3] Both techniques are comparable and highly effective for treating chronic recalcitrant lateral elbow tendinopathy. (10.1016/j.jse.2016.09.022)
  • [L5] This article serves to provide an updated review of the various treatment options and management for lateral epicondylosis, noting that while most patients experience relief with non-operative management, controversy remains regarding the optimal modality for quickest recovery and the role of surgical intervention for refractory cases. (10.1016/j.jhsa.2024.07.003)
  • [L2] When completed, this trial will provide evidence on the effectiveness of injection therapy in the treatment of lateral epicondylitis on pain, quality of life and functional recovery. (10.1186/s12891-019-2711-0)
  • [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. (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. (10.5435/00124635-200801000-00004)
  • [L2] Ultrasonography was more accurate than MRI in confirming clinically diagnosed patellar tendinopathy. (10.1177/0363546506294858)
  • [L3] The clinical use of MRI in the management of patients with enthesopathy of the ECRB origin merits further study. (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. (10.1177/0363546518759674)
  • [L4] The modified, 4-graded, Öhberg score was found to be a reproducible instrument for assessment of tendon structure and neovascularisation. (10.1007/s00167-014-3270-4)
  • [L3] An improvement in isometric contraction in flexion of the elbow was observed, but this did not reach the flexion power of the contralateral healthy arm. (10.1007/s00167-018-5007-2)
  • [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. (10.1016/j.jhsa.2023.03.025)
  • [L4] This draws into question the diagnostic and prognostic value of MRI imaging in lateral epicondylar tendinopathy, especially in older patients. (10.1177/17585732221146731)
  • [L3] Nevertheless, the short-term clinical influence of biceps complications on shoulder outcome is very limited. (10.1177/2325967121s00362)
  • [L2] Magnetic resonance imaging is a reliable tool in determining radiological severity of lateral epicondylitis. (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). (10.1177/2325967119s00483)
  • [L3] Operative management of cuff tears is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology. (10.1016/j.jseint.2025.04.038)
  • [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. (10.1177/2325967116667058)
  • [L4] Although many treatments have been advocated for lateral epicondylitis, there is little clear consensus on which modality works best for both conservative and operative options, indicating that the understanding of the disease process is currently incomplete. (10.1016/j.jhsa.2007.07.019)
  • [L5] In this cadaveric shoulder model of the throwing shoulder, tears of the posterior rotator cuff cable lead to altered glenohumeral biomechanics and kinematics. (10.1177/2325967117s00373)
  • [L3] In addition to the elbow, focusing on the upper segments is essential in the management of LE. (10.1016/j.jse.2018.12.010)
  • [L5] The authors appreciate the Level I evidence provided by Kim et al. regarding the safety and effectiveness of ultrasound-guided needling for calcific tendinopathy, while noting that the inclusion criteria were less strict than ideal. (10.1016/j.jse.2014.12.006)
  • [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. (10.1177/0363546517753385)
  • [L4] Continuous tendon recovery assessed by MRI was found during a 2-year period after PRP treatment. (10.1016/j.jse.2022.01.147)
  • [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. (10.1177/0363546515612758)
  • [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. (10.1177/03635465211010158)
  • [L4] Dynamic elongation of repair tissue during scapular-plane abduction exhibited 1 of 2 distinct patterns, which may suggest different patterns of supraspinatus mechanical and neuromuscular function. (10.1177/23259671221084294)
  • [Abstract] The 3D glenohumeral kinematics at the early phase of arm elevation may affect the shoulder function in patients with massive rotator cuff tears. (10.1016/j.jse.2020.01.004)
  • [L2] Both orthoses improved elbow proprioception, pain severity, and force production in the hand. (10.1016/j.jse.2018.08.042)
  • [L4] The Discovery Elbow System resulted in improved function, reduced pain, and high patient satisfaction. (10.1016/j.jse.2014.08.013)
  • [L4] Significant differences were observed between tennis elbow patients and the control group regarding biomechanical parameters and clinical scores across manual, physical, and sports work groups. (10.1016/j.jse.2021.03.113)
  • [L3] This technique offers an objective measure of tendon pathology that may complement the current diagnostic approaches. (10.1186/s12891-025-08346-z)
  • [L4] The PRP treatment permitted a return to a normal architecture of the tendon as assessed by MRI. (10.1177/0363546513519964)
  • [L3] This study presents novel evidence of an adaptive motor pattern in lateral elbow tendinopathy, characterized by increased relative activation and coactivation of the anconeus muscle depending on grip force. (10.1016/j.jse.2024.11.001)
  • [L3] In patients with lateral epicondylitis, the grip strength decreases as one moves from a position of flexion to a position of extension. (10.1016/j.jhsa.2007.04.010)
  • [L4] The absence of tendinopathic changes in the excised plantaris of 13 patients who clinically improved suggests plantaris involvement with Achilles tendinopathy may not yet be fully understood and supports the concept that this may be a compressive or a frictional phenomenon rather than purely tendinopathic. (10.1177/2325967116673978)
  • [Abstract] There is a high correlation between several dimensions of the radial head and the capitellum, and there is also a high correlation between the left and right elbow, allowing estimation of radial head size based on capitellum measurements. (10.1016/j.jse.2015.05.018)
  • [L4] Additionally, all participant models eventually made contact with the glenoid by 150 of humerothoracic elevation, although anatomic factors influenced the precise angle at which contact occurred. (10.1177/23259671211036908)
  • [L3] Additional research is required to improve our understanding of the causative factors in Achilles tendinopathy. (10.1177/0363546509332250)
  • [L1] Both the surgery and placebo procedures improved patient rated pain frequency and severity, elbow stiffness, difficulty with picking up objects, twisting motions and overall elbow rating over 6 months and maintained the benefits after 12 months. (10.1016/j.jse.2017.06.019)
  • [L1] The fixation constructs that demonstrated the greatest overall biomechanical performance in distal biceps tendon repair were the extramedullary cortical button and two intramedullary cortical buttons. (10.1177/2325967121s00747)
  • [L5] Biomechanical analysis demonstrated that RSA and SCR models produce moment arms that vary between muscles, with some contributing more to abduction and some contributing less. (10.1177/2325967121s00333)
  • [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. (10.1016/j.jhsa.2018.06.013)
  • [L3] The most common diagnosis for posterior elbow pain was posteromedial elbow impingement, and all players returned to competitive sports activity levels within 77 ± 47 days. (10.1016/j.jse.2016.05.004)
  • [L4] The transient symptoms of tennis elbow seen in these two cases reflect the natural course of a self-limiting condition. (10.1007/s00167-012-1939-0)
  • [Case_report] The patient demonstrated good clinical evolution with a Subjective Shoulder Value of 85% and no retear at 6 months follow-up. (10.1016/j.xrrt.2023.10.005)
  • [L5] Chronic and acute calcific tendinitis are two phases of the same disease; optimal treatment requires determining the disease stage, with surgery preferably performed during the formative phase if conservative management fails. (10.5435/00124635-199707000-00001)
  • [L4] They present acutely, have a poor natural history akin to complete tears, and have good outcomes with acute and delayed reconstruction. (10.1016/j.jse.2020.04.038)

See Also

  • Tennis Elbow

References

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[61] The Effects of Posterior Rotator Cuff Cable Tears on Glenohumeral Biomechanics in a Cadaveric Model of the Throwing Shoulder. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00373

[62] Comparison of scapular position and upper extremity muscle strength in patients with and without lateral epicondylalgia: a case-control study. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.12.010

[63] Ultrasound-guided needling versus extracorporeal shock wave therapy. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.12.006

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[65] Repeated magnetic resonance imaging at 6 follow-up visits over a 2-year period after platelet-rich plasma injection in patients with lateral epicondylitis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.147

[66] Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy. The American Journal of Sports Medicine. 2015. DOI: 10.1177/0363546515612758

[67] Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Clinical and Sonographic Results at 90 Months. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211010158

[68] In Vivo Static Retraction and Dynamic Elongation of Rotator Cuff Repair Tissue After Surgical Repair: A Preliminary Analysis at 3 Months. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221084294

[69] Influence of subscapularis tears on three-dimensional glenohumeral kinematics in patients with massive rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.01.004

[70] The immediate sensorimotor effects of elbow orthoses in patients with lateral elbow tendinopathy: a prospective crossover study. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.08.042

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[72] Isotonic Evaluation of Wrist Extensors and Flexors of Tennis Elbow Patients Due to Job and Sport Related Factors. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.113

[73] Quantitative assessment of ECRB tendon degeneration in lateral epicondylitis using CT hounsfield units: correlation with histological and MRI findings. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08346-z

[74] Are Multiple Platelet-Rich Plasma Injections Useful for Treatment of Chronic Patellar Tendinopathy in Athletes?. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546513519964

[75] Chapter 6 Elbow Arthroscopy and the Thrower’s Elbow. 2019.

[76] Altered anconeus muscle activation characteristics during isometric gripping in individuals with lateral elbow tendinopathy compared with age- and sex-matched control. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.11.001

[77] Effect of Elbow Position on Grip Strength in the Evaluation of Lateral Epicondylitis. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.04.010

[78] Plantaris Excision Reduces Pain in Midportion Achilles Tendinopathy Even in the Absence of Plantaris Tendinosis. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116673978

[79] Anthropometric Study of the Radio-Capitellar Joint. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.05.018

[80] Supraspinatus-to-Glenoid Contact Occurs During Standardized Overhead Reaching Motion. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211036908

[81] No Influence of Age, Gender, Weight, Height, and Impact Profile in Achilles Tendinopathy in Masters Track and Field Athletes. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509332250

[82] Surgical treatment of lateral epicondylitis: a prospective, randomized, double blinded, placebo controlled clinical trial. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.06.019

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[86] Prevalence of posterior elbow problems in Japanese high school baseball players. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.05.004

[87] Natural course in tennis elbow—lateral epicondylitis after all?. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-1939-0

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[89] Calcific Tendinopathy of the Rotator Cuff: Pathogenesis, Diagnosis, and Management. Journal of the American Academy of Orthopaedic Surgeons. 1997. DOI: 10.5435/00124635-199707000-00001

[90] Distal biceps short head tears: repair, reconstruction, and systematic review. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.04.038

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i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.