Lateral Epicondylitis

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Lateral Epicondylitis Custom Counter Force Brace

• Presented by Robert Barbosa, D.O

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I - Upper Extremity Conditions

• Nonpathological
• Aches and pains
• Myofascial tightness
• Strains
• Benign exertional myalgia

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I - Upper Extremity Conditions

• Pathological frequently diagnosed disorders that
  may require either medical or surgical treatment
• Sprains
• Trigger digits
• Cubital tunnel syndrome
• Lateral epicondylitis
• De Quervains

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I - Upper Extremity Conditions

• Pathological frequently diagnosed disorders that
  may require either medical or surgical treatment,
  cont.
• Carpal tunnel syndrome
• Medial epicondylitis
• Ganglia
• Radial tunnel syndrome

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I - Upper Extremity Conditions

• Frequently misdiagnosed disorders
• Unspecified tendinitis (ex. Intersection
  syndrome)
• Reflex sympathetic dystrophy (complex regional
  pain syndrome)
• Thoracic outlet syndrome
• Cervical disc disease

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I - Upper Extremity Conditions

• Frequently misdiagnosed disorders, cont.
• Cervical myofascial pain
• Cervical spondylosis
• Synovitis of the radiohumeral joint
• Posterior interosseous nerve palsy

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I - Upper Extremity Conditions

• Subjective variable terms
• Cumulative trauma disorder?
• Repetitive motion disorder?
• Overuse syndrome?
• Work-related myoskeletal disorder
• Fibromyalgia

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II Lateral Epicondylitis

• Tennis Elbow
• Most common overuse syndrome?
• Effects 1 - 3 of the population
• Occurs in patients 40 to 60 years of age (over 35
  years)
• In clinical practice, less than 5 is related to
  tennis. Tennis players get the problem because of
  backhand swing

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II Lateral Epicondylitis

• Tennis Elbow, cont.
• Effects 50 of tennis players over 50 years of
  age
• Occurs 10X more frequently than medial
  epicondylitis (golfers elbow)

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Tendinitis implies an inflammatory condition and
  diagnosis should be limited to
• Anatomical location
• Specific muscle tendon unit
• Symptoms provoked by mechanically stressing the
  involved muscle tendon units
• Increase in temperature at the affected site
• Tenderness to palpation
• Swelling

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Tendinosis
• Aging equals degeneration
• Degeneration means wear and tear in the tendon
• Tendon becomes weaker than normal. It may also be
  caused by a decreased blood supply to the tendon,
  attritional changes (ex. rotator cuff Achilles
  tendon or patellar tendon)

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Tendinosis, cont..
• Degeneration in the same tendon. There is a loss
  of normal arrangement of the fibers of the tendon
• Tendons are made up of collagen. The individual
  strands become jumbled due to degeneration
• Other fibers lose elasticity, break and the
  tendon loses strength

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Tendinosis, cont..
• Healing process causes the tendons to become
  thickened as the scar tries to repair the tendon.
  This condition is called tendinosis
• One theory on the cause of tendinosis is
• Aging tendons sustain small tears
• The tendon begins to heal, but when it is
  re-injured, the tendon has difficulty healing and
  is further scarred
• Scar tissue is unable to reach maturity and
  develops a condition called angiofibroblastic
  degeneration

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Tendinosis, cont..
• Other causes and factors contributing to the
  lateral epicondylitis (tendinosis)
• Decompensation from
• Loss of strength secondary to decrease in
  conditioning. Patients now perform athletic-like
  activity at work that was tolerated at an early
  age (ex. Age 20), but now over 35 years of age
• Increased body mass
• Obesity
• Increase in the of fat content

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Tendinosis, cont..
• Other causes and factors contributing to the
  lateral epicondylitis (tendinosis), cont..
• Smoking?
• Poor nutritional habits
• Poor body posture (ergonomic factors at workplace)

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Tendinosis, cont..
• Scope of the problem
• The Bureau of Labor Statistics reported 73,195
  repetitive motion injuries, including tendinosis
  and carpal tunnel syndrome in private industry in
  1999
• That translates to 1 in every 1,250 full-time
  workers
• The AFL-CIO stated that 1.8 million suffer from
  repetitive motion injuries on the job each year
  (this included all back injuries)

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Tendinosis, cont..
• Scope of the problem, cont..
• The true figure lies somewhere between that
  reported by the Bureau of Labor Statistics and
  the AFL-CIO
• The division with the most repetitive injuries
  was manufacturing. The most common occurrence was
  in assemblers
• Interestingly enough, women sustain only 33 of
  the total injuries. They sustain 65 of the total
  tendinosis and carpal tunnel syndrome injuries

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Diagnosis of lateral epicondylitis (tendinosis)
• Pain over the lateral elbow with a gradual onset
• Maximum discomfort at the extensor carpi radialis
  brevis less commonly over the extensor carpi
  radialis longus rare over the extensor digitorum
  communis and rarely over the extensor carpi
  ulnaris

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Diagnosis of lateral epicondylitis (tendinosis),
  cont..
• History
• Aching pain and elbow pain over the lateral
  epicondyle with increased activity
• Simple activities increase pain lifting a cup or
  coffee or gallon of milk
• Pain may be present at night
• Symptoms are typically unilateral

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Diagnosis of lateral epicondylitis (tendinosis),
  cont..
• Exam
• Pain is increased with resisted extension with
  the elbow in full extension and resisted
  extension of the wrist with pain being reproduced
  directly at the origin of the extensor carpi
  radialis brevis
• Pain increased with resisted extension of the
  middle finger (middle finger sign)
• Pain is increased with palpation over the lateral
  epicondylar area, generally at the origin of the
  extensor carpi radialis brevis

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Diagnosis of lateral epicondylitis (tendinosis),
  cont..
• Exam, cont..
• Pain increases with resisted supination at the
  origin of the extensor carpi radialis brevis
• Decreased hand grip is noted by Jamar readings
• X-rays are generally normal. A CT arthrogram may
  be of some benefit if one suspects a tear fo the
  lateral collateral ligament in conjunction with
  pathology of the lateral epicondylar area. An MRI
  also may be of some benefit since it will
  demonstrate evidence of degeneration

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Diagnosis of lateral epicondylitis (tendinosis),
  cont..
• Exam, cont..
• EMG to rule out any other nerve problems, such as
  a cervical radiculopathy or nerve compression
  syndrome, such as posterior interosseous nerve
  syndrome
• Laboratory tests of no help

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment
• In the majority of patients, it is a
  self-limiting problem generally treated by a
  primary care physician or by the patient
  themselves
• Counterforce bracing plus rest and modifying
  their work and consideration can be given to
  utilizing oral nonsteroids

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Physical therapy to include numerous modalities
• Ultrasound
• Phonophoresis
• Acupuncture?
• Wait and see program. Treat the patient
  symptomatically and just instruct them in
  ergonomic use of their elbow

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Modalities, cont..
• Exercise
• Isometric
• Eccentric
• Concentric?
• Ice Massage
• Heat
• Electromuscle stimulation
• Laser?

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Modalities, cont..
• Sonocur Machine. This is an extracorporeal
  ultrasound device (outside the body), where the
  ultrasound is 100X the normal
• This was approved by the FDA in July of 2002
• Treatments once weekly X 3 weeks. Treatment takes
  about 8-10 minutes. May take 6-8 weeks
  post-treatment to see the best results, according
  to the manufacturer
• A German study done on lateral epicondylitis
  noted no difference between shockwave therapy and
  placebo treatment for tennis elbow

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Modalities, cont..
• Sonocur Machine, cont..
• An Australian study done by treating palmer
  fascitis also demonstrated no difference between
  placebo and shockwave treatment
• Average cost for treatment is between 1,000 and
  3,000 in the United States

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Nonsteroidals
• Why do they help if it is not an inflammatory
  condition?
• It may help to control pain
• The mechanism of action is not known
  specifically, but may inhibit cyclo-oxygenase
  (COX) activity and prostaglandin synthesis

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Cortisone injections
• Unknown why injection of steroid helps. It may be
  that steroid reduces pain with similar action to
  the nonsteroidals

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Manipulation of elbow
• Results, in my experience, are extremely variable
  and appear to give short term relief in the
  majority of patients
• Several patients that I have treated with
  manipulation have returned to regular work
  without further treatment

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Future treatment
• Stem cell injection
• I have personally used blood taken from the
  patient and injected it into the elbow. Have not
  reproduced the results reported in the published
  literature

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Several interesting papers combine treatment
• Utilizing injections Naprosyn and placebo
  utilizing Vitamin C
• 164 patients were divided into three groups. The
  first group was given a steroid injection. The
  second group was given Naprosyn. The third group
  was given Vitamin C
• At four weeks, the injection group did much
  better with 92 improvement in their pain,
  Naprosyn was at 57 and placebo was at 50

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Several interesting papers combine treatment
• Utilizing injections, cont..
• At six months, the Naproxine group and the
  placebo group were similar in their outcome
• At 12 months, there appeared to be no difference
  in the outcome of all patients

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Another study combined treatment with therapy and
  brace
• A group was divided into three
• The first group was treated with therapy
• The second group was treated with a brace
• The third group was treated with therapy and a
  brace

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Another study combined treatment with therapy and
  brace, cont.
• After analysis of the results, no statistical
  difference was noted with the treatment of the
  brace and therapy or the brace or the therapy
  alone. Short-term, it was noted that the brace
  and therapy was best to decrease pain. Patients
  were also most pleased with the brace that the
  brace with therapy. They did not like the idea of
  having to go to therapy and have that prolonged
  waiting period. Also, the brace appeared to
  benefit them in that the patient was able to
  perform most activities with the brace in place
  and reduce the overall pain pattern

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Surgical Treatment
• A select group of patients
• All patients were selected who failed all forms
  of non-operative treatment
• Minimum of six months duration with the diagnosis
  of lateral epicondylitis
• The technique is simple. Release of the origin of
  the extensor carpi radialis brevis at the level
  of the origin at the epicondylar area. The
  patients rarely underwent release of the extensor
  carpi radialis longus and extensor digitorum
  communis

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Surgical Treatment, cont..
• 62 patients were reviewed. Average age was from
  32 to 50 years of age. There were 40 females and
  24 males
• Several had radial tunnel syndrome release in
  conjunction with the lateral epicondylar release.
  Three of the females had bilateral release. One
  female had both medial and lateral epicondylar
  release.
• One failure. In essence, the patient was unable
  to progress with her elbow due to her concomitant
  injury to her rotator cuff. The rotator cuff
  injury started during the course of vigorous
  physical therapy

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Surgical Treatment, cont..
• Two patients required they be operated on twice
• Re-operation occurred one year after the first
  surgery
• Post-operative treatment consisted of cast
  immobilization for one week
• The cast was then removed and active range of
  motion was started
• The patient was then placed into a structured
  exercise program under the care of the therapist,
  and the patient was progressed to a strengthening
  exercise program with the goal of returning him
  back to a regular work status

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III Is Tennis Elbow a Tendinitis or Tendinosis?

• Treatment, cont..
• Surgical Treatment, cont..
• Poor Outcome? On two patients
• One developed rotator cuff symptoms
• The second patient has not returned to regular
  work since second surgery in April 2004