Lateral Epicondylitis David C. Harkins, D.O. Athens Orthopedic Clinic August 26, 2017

Lateral Epicondylitis (Tennis Elbow) Most common elbow complaint in patients seeking medical treatment Most commonly occurs in 4th decade of life Repetitive overuse syndrome (microtrauma) Wrist extension and forearm rotation Single Traumatic Event (less common)

Lateral Epicondylitis Degenerative Process (not inflammatory) Tendinosis not Tendonitis Histology – Angiofibroblastic hyperplasia Related to vocation more often than raquet sports, but: Affects 50% of all tennis players Most common elbow injury in golfers Risk factors – heavy raquets, inappropriate grip size, high string tension, poor technique

Anatomy Most commonly involves ECRB (Extensor Carpi Radialis Brevis) Can involve ECRL (Extensor Carpi Radialis Longus), EDC (Extensor Digitorum Communis), ECU (Extensor Carpi Ulnaris

Diagnosis Tenderness over lateral epicondyle (ECRB insertion) Exacerbated with: Resisted wrist extension Passive wrist flexion with elbow in extension Gripping Resisted long finger extension Grip strength often decreased compared to opposite side

Diagnosis Radial Tunnel Syndrome associated in 5% of patients Entrapment of radial nerve (PIN) as it courses into the proximal forearm and dives underneath Supinator muscle Multiple areas of entrapment (Arcade of Frohse, vascular Leash of Henry, fibers of supinator, undersurface tendon of ECRB) Complain of vague forearm pain Tenderness 4cm distal to lateral epicondyle Consider if lateral epicondylitis unrelieved with conservative management

Diagnosis Xrays (AP/Lat of elbow) MRI Typically normal Can have calcific deposits in tendon (especially with prior steroid injections) MRI May show increased signal, degeneration of tendon origin Not necessary for diagnosis

Treatment Mainstay is conservative management Rest – avoidance of aggravating activities NSAIDS Counterforce bracing Limit muscle fatigue Redirects force into muscle belly instead of tendon origin Physical Therapy/Occupational Therapy Extensor stretching & strengthening, ultrasonography, iontophoresis Extracorporeal shockwave therapy No difference at 6 months compared to Placebo

Treatment Corticosteroid injections Inject into tendon origin Penetration of fascia shown to be beneficial – multiple Recent double blind, randomized study showed no more efficacy than placebo May actually have detrimental long-term effects

Treatment PRP (Platelet Rich Plasma) Stem Cell Injections? Draw 10 ml of blood Centrifuge down to separate platelets Collect Plasma rich portion of blood Inject into tendon origin Delivers healing factors into tissues to stimulate healing – WBCs, Growth factors, Stem cell signaling markers Some studies show 70-80% effectivenes 4-6 weeks required for healing Stem Cell Injections?

Treatment Indications for surgery: Contraindications Pain interfering with occupation and ADLs Failure of conservative treatment for 6 months Contraindications Inadequate conservative treatment Active infection Inability to comply with rehab Ankylosis of elbow

Treatment Percutaneous US Guided Needle Tenotomy Break up scar tissue and stimulate healing response Local anesthetic, 20g needle Needling entire abnormal tendon Multiple passes through tendon origin Immediate Aggressive Physical Therapy

Treatment McShane, Shah, Nazarian. J Ultrasound Med, 2008;27: 1137 - 44 92% good to excellent results No complications

Treatment TENEX FAST (Focused Aspiration of Soft Tissue) Similar to cataract surgery US guidance Break up and extract degenerated (hypoechoic) tissue at tendon origin Minimally invasive Early return to work and recreational activities No lifting for 6 weeks Good results

Treatment Seng, et.al., American Journal of Sports Medicine, Nov 2015 Follow up of previous study done at 1 year post op 3 year follow up 20 patients 100% pain free Improved functional outcomes No complications No recurrences

Treatment Arthroscopic Debridement of degenerative tissue from origin of ECRB tendon Decortication or drilling of lateral epicondyle to create healing response Allows for inspection of elbow joint and treatment of other pathologic processes Up to 69% of cases Synovitis, Plica band, loose bodies, Chondral defects 85-90% pain relief and full function Possible earlier return to work

Treatment Open ECRB debridement Open incision over the lateral epicondyle Split tendon in line with its fibers Excise degenerated tissue at tendon origin Decorticate the epicondyle to create a healing response Repair the tendon 85 – 90% return to full activities and relief of pain

Treatment McDonald, et.al. Arthroscopic vs Open Lateral Release for the Treatment of Lateral Epicondylitis: A Prospective, Randomized, Controlled Trial. Journal of Shoulder and Elbow Surgery, October 2016 71 patients Followed for 1 year Both techniques showed improved pain and function No difference in quality of life or function

Complications Iatrogenic lateral ulnar collateral ligament injury (Open or Arthroscopic) Posterolateral rotatory instabilty Pain Posterior Interosseous Nerve injury (Arthroscopic) Median Nerve injury (Arthroscopic)

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