1. Lateral Epicondylitis(LE) Krishna Khanal, MD Cedar Rapids 04/12/2012

2. Case Scenario  52 yo Caucasian male presented with rt. elbow pain for 3 months. Pain worse with movement of the arm and better with rest. No recent h/o trauma, no h/o swelling or redness. No h/o direct trauma, does computer work. On examination, tender at lateral epicondyle which increased with resisted wrist extension with elbow on full extension.

3. Gross Anatomy

5. Demographics  Prevalent in 1-3% of population.  Common in manual laborers  >40 yrs  Dominant arm more common (70%)

6. Pathogenesis  Acute or chronic use of extensors and supinators of forearm with microinjury and healing attempts.  Non-inflammatory angiofibroblastic tendinosis with neovascularization.

7. Risk Factors  267 cases of LE compared to 388 controls in general practice; risk factors included manual job tasks, work involving repeated arm movements in women, work involving precision demanding movements in men, high physical strain and low social support at work in women. BMJ 2003 May 10; 326(7397):1044

8. Associated Conditions  Carpal Tunnel Syndrome  Cervical Neuropathy  Shoulder Impingement  Osteoarthritis of elbow  10-30% patients have absence from work.* *Br J Gen Pract 1996 Apr; 46(405):209 in J Fam Pract 1996 Sep;43(3):232

9. Diagnostic Dilemma  Lateral elbow pain in skeletally immature patient: Bone or cartilage injury.  True locking: Loose body in joint and X- ray indicated.  Numbness: Investigate for other causes.

10. Examination/Tests  Rule out: Radial tunnel syndrome, Plica Syndrome  Radiograph initially not indicated.

11. Prognosis  Prospective study of 266 patients with new case of LE participating in randomized trial of minimal intervention with encouragement to stay active and graded self-performed exercise; after one year; 83% had improvement with no significant differences based on interventions. Rheumatology (Oxford) 2003 Oct; 42(10): 1216

12. Progressive Resistance Exercise

13. Treatment: Success Rates  198 patients ages 18-65 yrs with untreated tennis elbow for at least 6 wks were randomized to 1 of 3 groups. Timewks Wait/ See PTInj. 316%23%75% 627%65%78% 1259%76%45% 2683%86%45% 5290%94%68% BMJ 2006 Nov 4; 333(7575): 939 Full text

14. Physical Therapy vs. Wait/See  NNT 13 at 3 wks (Statistically not significant).  NNT 3 at 6 wks.  NNT 5 at 12 wks (Statistically not significant).  Not significant at 26 and 52 wks.  Recurrences more common in inj. group(72%) than others (PT 8% and wait 9%). BMJ 2006 Nov 4; 333(7575): 939 Full text

15. Medications  12 trials with 1171 patients evaluated corticosteroid injection for LE.  More effective than non-injection for all outcomes measured up to 12 wks.  Less effective than other interventions at 26 wks and 1 yr.  Repeated inj. less effective than single inj. Lancet 2010 Nov 20, 376(9754): 1751

16. Steroid Injection  Systematic review of 20 trials comparing steroid injections vs. NSAIDs, physical therapy or placebo with 1113 patients with LE and 618 patients with shoulder tendonitis.  Significant pain reduction at 1-8 wks (p<0.001).  No significant difference during 12-24 wks and 48 wks. Ann Rheum Dis 2009 Dec; 68(12): 1843

18. Autologous Platelet Concentrate  100 patients with chronic LE randomized to autologous platelet concentrate inj. vs. corticosteroid inj. and followed for 1 yr.  Mean improvement in VAS 63.9% vs. 24%  Mean improve in DASH 66% vs. 17.4%  Successful treatment based on VAS criteria 73% vs. 49%, NNT 5  Successful treatment based on DASH 73% vs. 51%, NNT 5 Am J Sports Med 2010 Feb; 38(2): 255

19. After 2 yrs follow up…..  Successful treatment in 65% with autologous platelet concentrate vs. 35% with steroid, NNT 4.  Significant improvement in VAS and DASH scores from baseline in both over time but DASH score returned to baseline for steroid group.  No complications reported in both. Am J Sports Med 2011 Jun; 39(6): 1200

20. Sodium Hyaluronate  331 competitive racquet sport athletes w/ LE randomized to hyaluronate vs. saline.  Mean pain score at 30 days 2.2 vs. 7.1 (p<0.05)  At 90 days 2.5 vs. 6.7 (p<0.05)  At 356 days 2.4 vs. 7.7 (p<0.05) Sports Med Arthros Rehab Ther Technol 2010 Feb2; 2:4 Full text

21. Prolotherapy  24 adults with refractory LE were randomized to prolotherapy vs. saline injection.  Mean pain at rest scores baseline 5.1 vs. 4.5  At 8 wks 3.3 vs. 3.6  At 16 wks 0.5 vs. 3.5 (p<0.001) Clin J Sports Med 2008 May; 18 (3): 248 Full text

22. Topical Glyceryl Trinitrate  Controlled trial of 86 patients with LE treated with PT and either a transdermal GTN patch or placebo. The GTN group demonstrated significant improvement in symptoms and function through out 6 months course of therapy. Am J Sports Med. 2003; 31(6): 915

23. Other Management  Surgery: last resort (release of degenerated tendon from epicondyle)  Ice*: 40 patients w/ LE underwent exercise program 5 times weekly for 4 wks and were sequentially allocated to use ice or no ice for 10 min after exercise.  No significant difference in pain in between groups at the end of treatment or at 3 mo follow up. *Br J Sports Med 2006 Jan; 40(1):81

24. Dynamic Extensor Brace

25.  63 patients ages 18-70 yrs with LE randomized to dynamic extensor brace vs. no brace for 12 wks each in crossover trial.  Pain score at 12 wks 1.4 w/ brace vs. 4 w/o brace.  Functionality score at 12 wks 2.1 w/ brace vs. 4.1 with no brace (p<0.005). Clin Orthop Relat Res 2006 Jan; 442:149

26. Elbow Strap and Sleeve Orthosis

27.  52 adults with LE had maximum and pain free grip strength measured via digital handgrip dynamometer with application of each orthosis.  Compared with placebo and wrist splint, greater pain free grip strength with elbow strap or sleeve orthosis (p<0.02). J Ortho Sports Phys Ther 2009, Jun; 39(6):484

28. Counterforce Bracing

29. Forearm Brace and PT  180 patients with LE were randomized to fore arm brace vs. PT vs. forearm brace plus PT; at 6 wks PT significantly better than brace for pain, disability and satisfaction.  Brace significantly better than PT for performance of ADL and combination therapy better than brace alone for severity of complaints, disability and satisfaction; no significant differences at 26 wks and 51 wks. Am J Sports Med 2004 Mar; 32 (2): 462

30. Conclusion  Activity modification  Counterforce bracing  NSAIDs and physical therapy.  Glucocorticoid improves short term outcomes but does not prevent recurrence and may lead to worse long- term outcomes.