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Tennis Elbow

Tennis Elbow. Definition: “Tendinopathy of the common extensor origin of the elbow” Previously known as “lateral epiconylitis” 1-2% population. Aetiology. Incompletely understood Acute injury Epicondylitis Chronic injury Epicondylosis Repetitive micro-tearing . Tendinosis.

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Tennis Elbow

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  1. Tennis Elbow • Definition: • “Tendinopathy of the common extensor origin of the elbow” • Previously known as “lateral epiconylitis” • 1-2% population

  2. Aetiology • Incompletely understood • Acute injury • Epicondylitis • Chronic injury • Epicondylosis • Repetitive micro-tearing

  3. Tendinosis • Mucoid degeneration • Loss of collagen tight bundled structure • Fibrosis • Neo-vascularisation (Khan et al. 1999)

  4. Presentation • Pain • Weakness • Difficulty opening door handles • Difficulty shaking hands

  5. Examination • Pain on palpation • Resisted elbow extension • Resisted middle finger extension

  6. Treatment • Non-operative • Rest • NSAIDs • Physiotherapy • USS • Injection therapy • Operative • Tennis elbow release

  7. NSAIDs • Cochrane review 2002 • Insufficient evidence to recommend or discourage the use of oral NSAIDs • No conclusion regarding oral versus topical

  8. Physiotherapy • Principles: • Eccentric loading • Close to limit of tendon without exceeding it • Avoid exacerbating activities

  9. Physiotherapy • Bisset et al BMJ 2006 • 52 week FU • No better outcome than “wait and see” • BUT took less adjunctive medications • Tyler et al JSES 2010 • Eccentric exercises beneficial • 7 weeks only FU

  10. Cortisone Injections • Common treatment • ? Beneficial with degenerative pathology • Significant local side-effects

  11. Effectiveness • Short-term improvement (6-8 weeks) • Long-term deleterious effect • Evident at 6 and 12 months Coombes et al Systematic Review Lancet 2010

  12. Injection of blood products • Attempt to address pathology • Growth Factors e.g. TGF-ß + FGF • Autologous blood • Platelet Rich Plasma (PRP) • Bone Marrow Aspirate

  13. Autologous blood • Connel D.A. et al (2006) Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiology 35;6:371-7. • Edwards, S.G. and Calandruccio, J.H. (2003) Autologous blood injections for refractory lateral epicondylitis. The Journal of Hand Surgery 28A; 2; 272-9.

  14. Platelet Rich Plasma • Treatment of Chronic Elbow Tendinosis With Buffered Platelet-Rich Plasma. Mishra A and Pavelko T, Am J Sports Med 2006 • Autologous growth factor injections in chronic tendinopathy: a systematic review Vos RJ et al. Br J Sports Med Sep 2010 • Ongoing Positive Effect of an Autologous Platelet Concentrate in Lateral Epicondylitis in a Double-Blind Randomized Controlled Trial Platelet-Rich Plasma Versus Corticosteroid Injection With a 2-Year Follow-up Gosens T, Peerbooms JC et al. Am J Sports Med 2011

  15. Botulinum Toxin A Injection • Paralysis of extensor musculature • Unloading of tendon • Gradual reload as toxin diminishes • Keizer et al 2002 Clin Orth Rel Research

  16. Extracorporeal shockwave therapy • Regular tennis elbow • Evidence lacking • Calcific tennis elbow (very rare) • Possible benefit

  17. Heal with Steel? • Reserved for refractory cases • Debridement of abnormal tendon of ERCB

  18. Conclusion • What should we do? • Corticosteroids should be used cautiously • Physiotherapy • Avoid exacerbating factors • Blood products appear promising • Surgery as a last resort

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