1. ELBOW EPICONDYLITIS – 2016 Therapy Course David Klein, M.D. Kennedy-White Orthopaedic Center Sarasota, Florida

2. me David Klein, MD Kennedy-White Orthopedic Center Sarasota, Florida

3. Talk Goals Clinical presentation Differential diagnosis (medial and lateral) Anatomy Pathology and failure mechanisms Natural history Non-operative treatment Operative treatment Current and future research developments

4. CLINICAL PRESENTATION

5. Diagnosis Usually just by physical examination of tenderness location

6. Tension pain with epicondylitis

7. Why does Epicondylitis hurt?

9. Nocioceptive nerve fibers to tendon – Substance P – generating – Calcitonin Gene-Related Peptide – generating – Prostaglandins – Prostacyclins – Thromboxanes Note Anti-inflammatory meds work on these

10. Tennis Elbow? …or Radial Tunnel? Location Symptoms

11. Pressure Pain over the PIN Usually a dull ache Worse with activity Often refers to dorsal wrist, without tenderness

12. Pressure on a nerve HURTS! (...even when the nerve’s not chronically compressed - normal EMG/NCS)

13. ANATOMY

14. Anatomy - the Lateral Epicondyle

17. Nirschl’s Lesion “Histologic study of these injuries reveals a pathologic pattern described as angiofibrotic hyperplasia. This pattern suggests that a degenerative process or failure of normal tendon remodeling has taken place prior to rupture. “ (AAOS Orthopedic Basic Science)

18. Anatomy - The Radial Tunnel

19. Anatomy - Cadaveric Dissection ECRL ECRBSupinator EDC P.I.N.

20. PATHOLOGY AND FAILURE MECHANISMS

21. Contributing Causes Deconditioning or above-normal activity – Often very specific Unusual force or unusual mechanics Commonly eccentric force (“negatives”) – Classic “Tennis elbow” – result of a powerful but late hit backhand shot, or oversized divot in golf Repeated use after the injury

22. Tennis Elbow - “-itis” or “-osis”? Original injury may be briefly inflammatory (‘-itis’) Afterwards, no inflammatory cells (just ‘-osis’) “-osis” – injured / diseased tendon

23. Injury under the Microscope Not inflammation – (after initial days) Micro-tears Lack of healing Cause of pain not precisely known

24. Histology – Not inflammatory Angiofibroblastic hyperplasia Fibrocartilaginous formation Mucoid or hyaline degeneration Fibrovascular proliferation Focal calcifications

25. Is it Inflammation? Inflammation:

26. Is it Inflammation? Angiofibroblastic Hyperplasia:

27. Is it Inflammation? Pick the photo – Who has inflammation?: All exhibit warmth, redness, swelling 1 2 3

28. Does Inflammation hurt?

29. Is Inflammation always bad? Inflammation is the first stage of healing “Everything in moderation” – Greek concept

30. NATURAL HISTORY

31. Occurrence rate of epicondylitis Lateral (2.8%) and medial (1.9%) of the general population, And a combined 12% for both in the repetitive worker

32. Natural History Many resolve in 3-4 months 80 to 90% significantly improve within a year

33. Golfer’s Elbow Surgery – MAY need ulnar nerve addressed

34. NON-OPERATIVE TREATMENT

35. Tennis Elbow? Non-operative treatment el numero uno: Activity Modification!!!

36. The Basics - Activity modifications Change to do lifting activities with palm up instead of down (for lateral epicondylitis) Increasing grip size as well as use of a counterforce elbow brace (Brotzman)

37. Therapy Ultrasound Ionto- or Phonophoresis Cross-friction massage Stretching Eccentric strengthening

38. Therapy protocols based on the phase of epicondylitis: Acute (reduce inflammation) Subacute (active strengthening) Final (return to sport and/or high-level work activities) (Brotzman)

39. Treatment – Therapy Effectiveness of physiotherapy for lateral epicondylitis: a systemic review. Smidt et al. 2003 Insufficient evidence for most physiotherapy interventions for lateral epicondylitis. Only for ultrasound, weak evidence for efficacy was found. Problems included insufficient power and low number of studies per intervention, as well as contradicting results.

40. Ice or Heat? Ice for acute injuries (~ first week - controversial) Whatever feels best otherwise Unlikely to shorten course of injury Rule: Warm up, Cool down (but can reverse this - for pain control)

41. Treatment - Oral and topical medication Oral NSAIDs may relieve pain Topical NSAIDs frequently relieve pain Neither of these appear to change the duration of the epicondylitis

42. Properties of NSAIDs Analgesia Anti-pyretic (fever-reducing) Anti-thrombosis (platelet effects) Anti-inflammation (high-dose only)

43. NSAIDS? Non-steroidal anti-inflammatories – Nonspecific (motrin, naprosyn, lodine, etc.) – COX-2 specific (Celebrex, Bextra, Mobic) Also have good analgesic properties May not want anti-inflammatory – Impairs healing and collagen formation

44. Orthoses Proximal forearm strap Wrist brace with volar stay

45. Forearm bands/tennis elbow straps Two theoretical mechanisms – Offload the proximal tendon, like putting your finger on the finger Board of a stringed instrument– disproven – Prevent full forearm expansion and thus decrease proximal tension

46. Wrist braces Theoretical mechanism – Offloads the ECRB – Holds the wrist elevated and stable

47. Kinesio Tape Kenzo Kase, DC – Founder - Japan - 1973 1988 Seoul Olympics - Introduced in USA in 1995 Stretches along longitudinal axis only Give muscle support or prevent over contraction

48. Kinesio Tape Proprioceptive input – Enhance kinesthetic awareness Different from other tape: – McConnell taping, athletic tape – Both of which are restrictive

49. Kinesio Tape

52. Kinesio Tape - Elbows

54. Eccentric Exercise

55. Treatment – eccentric exercise Chronic tendinopathy: effectiveness of eccentric exercise. Woodley et al. British Journal of sports medicine. 2007. Limited levels of evidence exists to suggest that eccentric exercise has a positive effect on clinical outcome such as pain, function, and patient satisfaction/return to work when compared to various control interventions such as con centric exercise, stretching, splinting, frictions, and ultrasound. This review demonstrates the dearth of high quality research in support of clinical effectiveness of eccentric exercise

56. Treatment - eccentric exercise

65. Adjuvant Therapies Add ‘Essential Oils’ to your treatments

66. Adjuvant Therapies Recommend massage rollers

67. Injection therapy Dry needling Corticosteroid Autologous blood Platelet rich plasma Botulinum toxin

68. Corticosteroids => Glucocorticoids Binds in the nucleus Regulates gene expression Anti-inflammatory effects Gluconeogensis effects

69. Corticosteroids => Glucocorticoids Other effects – Increased Vigilence, Delerium – Stimulate fat breakdown – Alter calcium metabolism – Delay wound healing – Cause edema – Reduce pain

70. Treatment – Cortisone Injections Short-term benefit Long-term no difference (for epicondylitis) Anti-inflammatory, but anti-everything Location-specific

71. Treatment – Corticosteroid injections Treating lateral epicondylitis with corticosteroid injections or nonelectric therapeutic physiotherapy: a systemic review. Olaussen et al. BMJ 2013. Corticosteroid injections have short-term beneficial effect but negative effect in the intermediate term. Evidence in the long term effect is conflicting. Manipulation and exercise, and exercise and stretching have a short-term effect, with stretching also having a long-term effect.

72. Treatment – PRP Injections Early results suggested no benefit More recent papers suggesting mild long-term (sustained) improvements

73. Treatment – Botox injections Botulinum toxin versus surgical treatment for tennis elbow: a randomized pilot study. Keizer et al. COOR. 2002 At one year, 65% in botulinum toxin group and 75% in operative group had good to excellent results. Botulinum group improved to 75% at two years.

74. Shockwaves Curious modality, similar to treating kidney stones – Low energy, multiple treatments – High energy, single treatment High energy requires anesthesia Mixed results in literature

75. OPERATIVE TREATMENT

76. Indication for surgery Six – 12 months course of pain causing dysfunctional use and/or disability

77. Surgery for Epicondylitis Release of RESTING tension Restarter of healing process (inflammation) Varying fractions of each (nerve decompression?)

78. Lateral Epicondylitis Surgery Location …Anywhere

79. Lateral Epicondylitis Surgery Location …Anywhere

80. Lateral Epicondylitis Surgery Location …Anywhere

81. Lateral Epicondylitis Surgery Location …Anywhere

82. Procedure - “If it’s WHITE, Cut it”

83. Procedure - “If it’s RED, Keep it”

84. Procedure - Released PIN (it’s not small)

85. Procedure - at 10 Days “Yay! I can bend my elbow again!”

86. Procedure - at 10 Days “...and look! It goes all the way straight again!”

87. Procedure - at 10 Days “Hold something? Like this?”

88. Procedure - at 10 Days “No Problem!”

89. Efficacy of surgical procedures? Most studies: 90%! (On paper, it doesn’t seem to matter which procedure you do)

90. Post-op regimen Some splint 10 days Some sling 10 days Some use wrist splint Some just use soft dressing (Me) Generally, wait 6 weeks to strengthen Some use therapists post-op Some avoid therapists post-op (Me)

91. Complications of surgery Instability/PLRI from release of lateral ulnar collateral ligament Posterior interosseous nerve palsy Elbow stiffness

93. “Take-Home” points Frequently occur spontaneously without clear cause Similarly, most resolve spontaneously Basic treatment: activity modification Scientifically Supported Therapy treatments: ultrasound, stretching, and eccentric strengthening Surgical treatment: almost all are “90% cures”

94. Genetics? Multiple enthesiopathies – Tennis elbow – Rotator cuff – Trigger fingers – DeQuervain’s tendinitis You get what your parents got!