proximal wrist extensor tendinopathy is a condition most commonly known as tennis elbow , which is pain at or just distal to the lateral humeral epicondyle within the proximal wrist extensor tendon .
many diagnoses have been used to describe this disorder including tendinosis of the lateral elbow , lateral epicondylitis , lateral epicondylalgia , or lateral epicondylopathy .
major first described this disorder in 1883 as a condition causing lateral elbow pain in tennis players .
while up to 40% of tennis players may experience this condition , it affects as many as 15% of workers in highly repetitive hand task industries , and can result in an average duration of 12  weeks of absenteeism in as many as 30% of all those afflicted . in a finnish population study ,
the prevalence was 1.3% of people aged 3064  years old and was more likely to occur in people who smoke , have type 2 diabetes , and are involved in occupations requiring repetitive movements of the arms and those handling loads heavier than 20  kg .
proximal wrist extensor tendinopathy occurs much more frequently than medial - sided elbow pain , with reported ratios ranging from 4:1 to 7:1 .
typically , after soft tissue trauma , there are three phases of healing : inflammation , repair , and remodeling .
the first phase is the inflammatory phase and can last up to several days . in this phase ,
once at the site of injury , immune cells release cytokines that bring fibroblasts to the area to begin the repair phase .
the repair phase begins during the inflammatory phase and can last weeks . in this phase ,
fibroblasts lay down collagen according to the tension placed across the area being healed . over time remodeling
occurs , and the tissue reorganizes and becomes stronger as a result of an expansion of the cross - bonds between collagen fibers and replacement of the collagen fibers themselves . while the term lateral epicondylitis is used most often for wrist extensor tendon pain in the lateral elbow , an inflammatory process is present probably only in the very early stages of the disorder .
the pathology is considered to originate within the extensor carpi radialis brevis musculotendinous unit , though up to one third of patients have involvement in the origin of the extensor digitorum communis .
histopathological studies have shown that specimens of tendon obtained from areas of chronic overuse , such as with proximal wrist extensor tendinopathy , do not contain large number of macrophages , lymphocytes , or neutrophils .
normal tendon contains bundles of type - i collagen that are arranged in line with the long axis of the tendon with a sparse number of fibroblasts .
in contrast , in patients with proximal wrist extensor tendinopathy , there appears to be a degenerative process that is characterized by the presence of fibroblasts , vascular hyperplasia , and disorganized collagen , which is commonly called tendinosis .
many will not be able to describe an inciting event , but may be able to remember the first time the symptoms were felt . prior to presenting to a health care professional ,
patients often will attempt to rest the area and may use ice and/or nsaids to try to alleviate the pain . unfortunately
, the pain often returns once regular use of the hand or forearm is resumed .
patients generally point to the lateral elbow as the source of their pain , but sometimes will point along the majority of the wrist extensor muscle mass . when the pain becomes more severe , symptoms
often are felt with gripping activities , shaking hands , turning doorknobs , or lifting objects with the forearm pronated .
the first is cozen s test , which involves asking the patient to make a fist , pronate the forearm , and extend the wrist toward radial deviation , while the examiner resists this motion ( fig .  1 ) .
another test is mill s test , in which the examiner palpates the lateral epicondyle with one hand , and with the other , pronates the patient s forearm , flexes the wrist fully , and extends the elbow ( fig .  2 ) .
a third test involves having the examiner resisting extension of the long finger of the patient s symptomatic side ( fig .  3 ) .
reproduction of the patient s pain in the area of the lateral epicondyle indicates a positive test . 

3resisted finger extension resisted finger extension some have attempted to describe clinical criteria for diagnosing proximal wrist extensor tendinopathy , listing three findings that should be present : lateral epicondylar pain , epicondylar tenderness , and pain on resisted extension of the wrist .
some suggest that grip strength should be tested to see if pain is reproduced during gripping or to compare strength to the unaffected side . with proximal wrist extensor tendinopathy
if numbness or tingling is present , then one must consider a neurologic cause for the pain , such as a cervical radiculopathy or entrapment radial neuropathy in the elbow .
other diagnoses that may be considered , especially in athletes , include radiocapitellar disorders , osteochondritis dessicans , lateral collateral ligament incompetency , and plica band syndrome .
routine radiographs of the elbow can assess for osteoarthritis of the elbow or calcific tendonitis of the wrist extensor mass , but often these are normal .
when a patient s symptoms are refractory to treatment , a diagnostic ultrasound or an mri may be useful to assess the wrist extensor tendons to confirm the diagnosis of proximal wrist extensor tendinopathy and rule out other causes of pain .
nonoperative treatment is generally effective and includes ice , nonsteroidal anti - inflammatory drugs ( nsaids ) , bracing ( e.g. , with a forearm strap ) , activity modification , physical therapy , and injections .
patients often try rest , ice , modified activity , a forearm strap , or nsaids before seeking care , but these may provide only short - term relief . given that the pathologic process is usually not inflammatory , the use of nsaids only provides relief of pain .
studies using nsaids to treat individuals who have a tendinopathy show minimal , if any improvement of pain . animal and in  vitro studies have not generated consistent data to suggest that nsaids are appropriate or beneficial in tendinopathy .
while icing may be recommended , a recent pilot study showed that a 4-week physical therapy exercise program was effective in decreasing pain in lateral epicondylitis , regardless of whether or not ice was used .
while multiple meta - analyses have been done to evaluate the effectiveness of physical interventions on proximal wrist extensor tendinopathy , the most recent is by bisset et  al . .
in this meta - analysis , the diagnosis of tennis elbow or lateral epicondylitis was given to those with lateral elbow pain that increased on palpation and/or had reproduction of pain on resisted wrist extension . while 74 randomized controlled trials with physical interventions for lateral epicondylitis were identified ,
based on those studies that were included , it was found that manipulation techniques ( including cross - friction massage ) , exercise , and acupuncture provided significant short - term relief .
studies that evaluated the efficacy of orthoses ( including a forearm strap ) , taping , laser therapy , extracorporeal shock wave therapy , electromagnetic field and ionization , ultrasound , and phonophoresis either did not demonstrate a significant effect or showed an inconsistent effect on outcomes .
however , given the small number of studies that met criteria for evaluation , more studies may be needed to determine the efficacy of physical interventions for this condition .
only one study that involved exercise therapy in the meta - analysis met criteria to be evaluated , whereas all the other physical interventions had two or more studies that met criteria .
a recent review on the effectiveness of eccentric exercise on chronic tendinopathy , including patellar and achilles tendinopathy , found three studies on lateral epicondylitis that met criteria for evaluation .
of the studies evaluated , there is conflicting evidence on the effect of eccentric training on outcomes .
one investigator , alfredson , has done multiple studies on tendinopathy has evaluated the efficacy of eccentric training on achilles tendinopathy , and did so while encouraging reproduction of the tendon pain during the therapy sessions .
a goal of reproducing patients pain during rehabilitative exercise is a paradigm shift in the treatment of musculoskeletal disorders , since , often patients pain symptoms are avoided or minimized during exercise sessions .
while achilles tendinopathy appears to have a similar histologic picture as proximal wrist extensor tendinopathy , the function of the achilles tendon is much different , so comparing treatments for these two conditions may be limited .
studies done to evaluate the effectiveness of eccentric strength training demonstrate that it can take weeks to be completely effective .
further research will clarify the exact role of exercise therapy and determine the specific exercises that help those with proximal wrist extensor tendinopathy .
injections should be considered in patients if above interventions have not provided relief , or in those whose pain on presentation is more inflammatory or debilitating .
the most common injection performed is a corticosteroid injection , which is injected at the maximal site of tenderness .
a recent review on the effectiveness of corticosteroid injections on lateral epicondylitis showed that a corticosteroid injection is more effective in the short - term ( less than 6  weeks ) compared to placebo , local anesthetic , and conservative treatments when analyzing pain , global improvement , and grip strength .
however , there is no conclusive evidence that suggests that corticosteroid injections are effective in providing long - term improvement of pain .
therefore , a corticosteroid injection is best used for short - term pain relief or in those with debilitating symptoms .
botulinum toxin injections have also been , used but given that these injections can have the side effect of causing digit paresis and weakness of finger extension , this should not be first - line injectable treatment . in a double - blind ,
placebo - controlled , randomized controlled trial of patients with symptoms lasting longer than three months , patients had a reduction of pain ( as reported by a pain vas , the main outcome measure ) in the group receiving botulinum toxin compared to those receiving a saline injection . however , the botulinum toxin group still had pain at 4 and 12  weeks follow - up and were not pain - free .
some authors suggest that if botulinum toxin is going to be used it should be used only on those patients with symptoms for more than 1  year .
more recently , research has been done on the efficacy of autologous blood injections around the lateral epicondyle .
while there was no control group in this study , some of the patients who had received multiple corticosteroid injections still responded favorably to the treatment .
it was postulated that introducing blood to the injured area would provoke the inflammatory cascade and restart the healing process .
those who do not respond to a focused , supervised , and intense course of several weeks of conservative care , and continue to have debilitating pain , may be considered to have failed nonoperative management .
surgery may be needed for these individuals , though some suggest waiting at least one year before considering this . when extensive conservative measures have been pursued , but are unsuccessful , then surgery is considered to alleviate pain and improve function . while there are multiple surgical treatments ,
the goal is to remove all the abnormal tissues and release any of the residual tension on the remaining extensor wad .
options include open surgery , arthroscopic lateral release , and percutaneous treatment to debride the gray , friable , angiofibrotic tissue . while one review   reported that studies have had excellent outcomes in those with lateral epicondylitis , a cochrane database systematic review did not identify any controlled trials investigating the effect of surgery on tennis elbow pain .
nonoperative treatment is generally effective and includes ice , nonsteroidal anti - inflammatory drugs ( nsaids ) , bracing ( e.g. , with a forearm strap ) , activity modification , physical therapy , and injections .
patients often try rest , ice , modified activity , a forearm strap , or nsaids before seeking care , but these may provide only short - term relief . given that the pathologic process is usually not inflammatory , the use of nsaids only provides relief of pain .
studies using nsaids to treat individuals who have a tendinopathy show minimal , if any improvement of pain . animal and in  vitro studies have not generated consistent data to suggest that nsaids are appropriate or beneficial in tendinopathy .
while icing may be recommended , a recent pilot study showed that a 4-week physical therapy exercise program was effective in decreasing pain in lateral epicondylitis , regardless of whether or not ice was used .
while multiple meta - analyses have been done to evaluate the effectiveness of physical interventions on proximal wrist extensor tendinopathy , the most recent is by bisset et  al . .
in this meta - analysis , the diagnosis of tennis elbow or lateral epicondylitis was given to those with lateral elbow pain that increased on palpation and/or had reproduction of pain on resisted wrist extension . while 74 randomized controlled trials with physical interventions for lateral epicondylitis were identified ,
based on those studies that were included , it was found that manipulation techniques ( including cross - friction massage ) , exercise , and acupuncture provided significant short - term relief .
studies that evaluated the efficacy of orthoses ( including a forearm strap ) , taping , laser therapy , extracorporeal shock wave therapy , electromagnetic field and ionization , ultrasound , and phonophoresis either did not demonstrate a significant effect or showed an inconsistent effect on outcomes .
however , given the small number of studies that met criteria for evaluation , more studies may be needed to determine the efficacy of physical interventions for this condition .
only one study that involved exercise therapy in the meta - analysis met criteria to be evaluated , whereas all the other physical interventions had two or more studies that met criteria .
a recent review on the effectiveness of eccentric exercise on chronic tendinopathy , including patellar and achilles tendinopathy , found three studies on lateral epicondylitis that met criteria for evaluation .
of the studies evaluated , there is conflicting evidence on the effect of eccentric training on outcomes .
one investigator , alfredson , has done multiple studies on tendinopathy has evaluated the efficacy of eccentric training on achilles tendinopathy , and did so while encouraging reproduction of the tendon pain during the therapy sessions .
a goal of reproducing patients pain during rehabilitative exercise is a paradigm shift in the treatment of musculoskeletal disorders , since , often patients pain symptoms are avoided or minimized during exercise sessions .
while achilles tendinopathy appears to have a similar histologic picture as proximal wrist extensor tendinopathy , the function of the achilles tendon is much different , so comparing treatments for these two conditions may be limited .
studies done to evaluate the effectiveness of eccentric strength training demonstrate that it can take weeks to be completely effective .
further research will clarify the exact role of exercise therapy and determine the specific exercises that help those with proximal wrist extensor tendinopathy .
injections should be considered in patients if above interventions have not provided relief , or in those whose pain on presentation is more inflammatory or debilitating .
the most common injection performed is a corticosteroid injection , which is injected at the maximal site of tenderness .
a recent review on the effectiveness of corticosteroid injections on lateral epicondylitis showed that a corticosteroid injection is more effective in the short - term ( less than 6  weeks ) compared to placebo , local anesthetic , and conservative treatments when analyzing pain , global improvement , and grip strength .
however , there is no conclusive evidence that suggests that corticosteroid injections are effective in providing long - term improvement of pain .
therefore , a corticosteroid injection is best used for short - term pain relief or in those with debilitating symptoms .
botulinum toxin injections have also been , used but given that these injections can have the side effect of causing digit paresis and weakness of finger extension , this should not be first - line injectable treatment . in a double - blind ,
placebo - controlled , randomized controlled trial of patients with symptoms lasting longer than three months , patients had a reduction of pain ( as reported by a pain vas , the main outcome measure ) in the group receiving botulinum toxin compared to those receiving a saline injection . however , the botulinum toxin group still had pain at 4 and 12  weeks follow - up and were not pain - free .
some authors suggest that if botulinum toxin is going to be used it should be used only on those patients with symptoms for more than 1  year .
more recently , research has been done on the efficacy of autologous blood injections around the lateral epicondyle .
while there was no control group in this study , some of the patients who had received multiple corticosteroid injections still responded favorably to the treatment .
it was postulated that introducing blood to the injured area would provoke the inflammatory cascade and restart the healing process .
those who do not respond to a focused , supervised , and intense course of several weeks of conservative care , and continue to have debilitating pain , may be considered to have failed nonoperative management .
surgery may be needed for these individuals , though some suggest waiting at least one year before considering this .
when extensive conservative measures have been pursued , but are unsuccessful , then surgery is considered to alleviate pain and improve function . while there are multiple surgical treatments ,
the goal is to remove all the abnormal tissues and release any of the residual tension on the remaining extensor wad .
options include open surgery , arthroscopic lateral release , and percutaneous treatment to debride the gray , friable , angiofibrotic tissue . while one review   reported that studies have had excellent outcomes in those with lateral epicondylitis , a cochrane database systematic review did not identify any controlled trials investigating the effect of surgery on tennis elbow pain .
once someone is diagnosed with proximal wrist extensor tendinopathy , then it is reasonable to modify the patient s activity and pursue physical therapy with eccentric wrist strengthening exercises , wrist extensor stretches , and cross - friction massage . in an athlete or someone with a job position that requires repetitive use of the hands
, a proximal forearm strap may be useful to attenuate the symptoms , while allowing patients to continue with their daily activities .
the strap is applied circumferentially around the proximal forearm and attempts to offload the injured area of the tendon . as part of physical therapy
if the patient is an athlete , then physical therapy should address any deficits that could lead to overloading the elbow , which would include evaluating the kinetic chain and the patient s form during sports play .
if pain is severe , then an injection with corticosteroid is reasonable . while autologous blood injections or botulinum toxin injections are more controversial , either is reasonable if above measures fail or if the patient does not want surgery .
proximal wrist extensor tendinopathy is a condition that can be debilitating , but generally responds well to nonoperative care . while there is a dearth of randomized controlled trials ,
there is some evidence that manipulation techniques , exercise , acupuncture , and corticosteroids can provide relief .
however , it is clear from recent meta - analyses and systematic reviews that more research is needed , with better methodology .
 proximal wrist extensor tendinopathy , which is also known as tennis elbow , is pain at or just distal to the lateral humeral epicondyle within the proximal wrist extensor tendon . 
 it occurs commonly in certain athletes but can also occur in people with jobs that require repetitive movements of the hand and upper limb . in most cases 
 the tendon involved shows no signs of inflammation or tendonitis , but instead shows fibroblasts , vascular hyperplasia , and disorganized collagen . 
 diagnosis is often made by history and physical exam alone . 
 most people respond to conservative measures including activity modification , analgesics , manipulation of tissue , and exercise . in some cases 
 , an injection of corticosteroid or botulinum toxin may be used . 
 surgery is rarely needed . 