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

2. 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)

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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?

11. 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

12. 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

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

14. 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

15. 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

16. 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

17. 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

18. 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

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

20. Thank You