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

Knee Surg Sports Traumatol Arthrosc. 2017 Jul;25(7):2255-2263. doi: 10.1007/s00167-017-4530-x. Epub 2017 Mar 24.


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.

Keywords: Elbow arthroscopy; Elbow instability; Lateral elbow pain; Lateral epicondylitis; Laxity.

MeSH terms

  • Adult
  • Arthralgia / etiology
  • Arthroscopy
  • Cartilage Diseases / pathology
  • Cartilage Diseases / physiopathology
  • Collateral Ligaments / pathology*
  • Collateral Ligaments / physiopathology
  • Elbow
  • Elbow Joint / pathology*
  • Elbow Joint / physiopathology
  • Female
  • Humans
  • Joint Instability / complications
  • Joint Instability / pathology*
  • Male
  • Middle Aged
  • Retrospective Studies
  • Synovitis / pathology
  • Synovitis / physiopathology
  • Tennis Elbow / pathology*
  • Tennis Elbow / physiopathology