Tennis Elbow

1
Tennis Elbow

• Definition
• Tendinopathy of the common extensor origin of
  the elbow
• Previously known as lateral epiconylitis
• 1-2 population

2
Aetiology

• Incompletely understood
• Acute injury
• Epicondylitis
• Chronic injury
• Epicondylosis
• Repetitive micro-tearing

3
Tendinosis

• Mucoid degeneration
• Loss of collagen tight bundled structure
• Fibrosis
• Neo-vascularisation

(Khan et al. 1999)
4
Presentation

• Pain
• Weakness
• Difficulty opening door handles
• Difficulty shaking hands

5
Examination

• Pain on palpation
• Resisted elbow extension
• Resisted middle finger extension

6
Treatment

• Non-operative
• Rest
• NSAIDs
• Physiotherapy
• USS
• Injection therapy
• Operative
• Tennis elbow release

7
NSAIDs

• Cochrane review 2002
• Insufficient evidence to recommend or discourage
  the use of oral NSAIDs
• No conclusion regarding oral versus topical

8
Physiotherapy

• Principles
• Eccentric loading
• Close to limit of tendon without exceeding it
• Avoid exacerbating activities

9
Physiotherapy

• Bisset et al BMJ 2006
• 52 week FU
• No better outcome than wait and see
• BUT took less adjunctive medications
• Tyler et al JSES 2010
• Eccentric exercises beneficial
• 7 weeks only FU

10
Cortisone Injections

• Common treatment
• ? Beneficial with degenerative pathology
• Significant local side-effects

11
Effectiveness

• Short-term improvement (6-8 weeks)
• Long-term deleterious effect
• Evident at 6 and 12 months
• Coombes et al Systematic Review Lancet 2010

12
Injection of blood products

• Attempt to address pathology
• Growth Factors e.g. TGF-ß FGF
• Autologous blood
• Platelet Rich Plasma (PRP)
• Bone Marrow Aspirate

13
Autologous blood

• Connel D.A. et al (2006) Ultrasound-guided
  autologous blood injection for tennis elbow.
  Skeletal Radiology 356371-7.
• Edwards, S.G. and Calandruccio, J.H. (2003)
  Autologous blood injections for refractory
  lateral epicondylitis. The Journal of Hand
  Surgery 28A 2 272-9.

14
Platelet Rich Plasma

• Treatment of Chronic Elbow Tendinosis With
  Buffered Platelet-Rich Plasma.
• Mishra A and Pavelko T, Am J Sports Med 2006
• Autologous growth factor injections in chronic
  tendinopathy a systematic review
• Vos RJ et al. Br J Sports Med Sep 2010
• Ongoing Positive Effect of an Autologous Platelet
  Concentrate in Lateral Epicondylitis in a
  Double-Blind Randomized Controlled Trial
• Platelet-Rich Plasma Versus Corticosteroid
  Injection With a 2-Year Follow-up
• Gosens T, Peerbooms JC et al. Am J Sports Med
  2011

15
Botulinum Toxin A Injection

• Paralysis of extensor musculature
• Unloading of tendon
• Gradual reload as toxin diminishes
• Keizer et al 2002 Clin Orth Rel Research

16
Extracorporeal shockwave therapy

• Regular tennis elbow
• Evidence lacking
• Calcific tennis elbow (very rare)
• Possible benefit

17
Heal with Steel?

• Reserved for refractory cases
• Debridement of abnormal tendon of ERCB

18
Conclusion

• What should we do?
• Corticosteroids should be used cautiously
• Physiotherapy
• Avoid exacerbating factors
• Blood products appear promising
• Surgery as a last resort