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Epicondylitis

a chronic headache for patients and their doctors

Michael Glanzmann 25.10.2012

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Anatomie: Extensoren Gruppe

Bedeutend für radiale, insbesondere die posterolaterale Rotationsstabilität des Ellbogengelenkes

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Demographisches

4 – 7 pro 1000 pro Jahr 1 – 3% der Bevölkerung übers Leben Peak zwischen 35 – 54 LJ Medial : lateral → 1:3 Male : women→ 4:1 Mit Abstand das häufigste Ellbogenleiden

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Medial epicondylitis

Ueberbeanspruchung der flexor/pronator Einheit Werfer (pitchers) Microrupturen zwischen pronator teres and FCR Oft verbunden mit ulnarer Neuritis

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Differential diagnosis of ‘Tennis Elbow’

C6/7 radiculopathy Radial tunnel syndrome Posterior interosseous nerve syndrome Distal biceps tendon degeneration Radiocapitellar arthritis Capsular infolding Posterolateral instability

Management of nerve compression lesions of the upper extremity. Spinner M et al. Management of peripheral nerve problems 2nd ed. 1998 Philadelphia, pp.501-33

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Clinical tests: lateral epicondylitis

Cozen and Maudsley tests

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Management

Non-operative successful in 95%

Operative only after failed non-operative treatment usually successful

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Non-operative options

•  Analgesia •  Acupuncture •  Blood injection •  Bracing •  Botulinum toxin •  Casting •  Change of job •  Endurance training •  Extracorporeal shockwave Rx •  Heat •  Ice •  Iontophoresis •  Low-level laser therapy •  Manipulation

•  Massage •  Oedema control •  Phonophoresis •  Physio •  Polarized polychromatic non-

coherent light •  Pulsed electromagnetic field Rx •  Rest •  Splinting •  Steroid injection •  Taping •  TENS •  Topical NSAID gel •  Ultrasound

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Steroid injection Good short-term relief for 6 weeks Poorer outcome in the longer term than

watch and wait physio placebo

Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. Bisset L et al. BMJ 2006 Nov 4;333(7575):939-44

Steroid injection therapy is the best conservative treatment for lateral epicondylitis: a prospective randomised controlled trial. Tonks J et al. Int J Clin Pract 2007 Feb;61(2):240-6

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Physiotherapy

At 6 weeks: better than ‘watch and wait’ worse than steroid injection

Long-term: better than steroid injection same as ‘watch and wait’

Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. Bisset L et al. BMJ 2006 Nov 4;333(7575):939-44

Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Smidt N. Lancet 2002;359: 657-62

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Predictors of poor outcome Dominant hand (OR=3.4) Manual labour (OR=2.3) High physical strain at work (OR=3.6) High level of baseline pain (OR=2.3) Lower social class

83% improved at 1yr, regardless of occupational input Intervention did not reduce visits

Prognostic factors in lateral epicondylitis: a randomised trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice. Haarh J, Andersen J. Rheumatology. Oct 2003, 42(10):1216

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Non-operative options

•  Analgesia •  Acupuncture •  Platelet rich plasma injection •  Bracing •  Botulinum toxin •  Casting •  Change of job •  Endurance training •  Extracorporeal shockwave Rx •  Heat •  Ice •  Iontophoresis •  Low-level laser therapy •  Manipulation

•  Massage •  Oedema control •  Phonophoresis •  Physio •  Polarized polychromatic non-

coherent light •  Pulsed electromagnetic field Rx •  Rest •  Splinting •  Steroid injection •  Taping •  TENS •  Topical NSAID gel •  Ultrasound

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Was ist PRP überhaupt?

Blutbestandteil mit erhöhter Konzentration an Blutplättchen (platelets)

Konzentrationsfaktor ist aufbearbeitungsabhängig (2.5 bis 9x)

niedrig 2.5-3x

hoch 5-9x

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Vom Vollblut zu den Wachstumsfaktoren

Sedimentationsrate = (Durchmesser) ²

Rote BK: 7² = 49

Plättchen: 2² = 4

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IGF-1 TGF-β

VEGF PDGF bFGF EGF

Platelet-rich plasma

Inflammationsphase

Proliferationsphase

Molloy et al, Sports Medicine, 2003;33(5);381-94

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Bei subakuten und chronischen muskuloskelettalen Problemen

•  Tendinopathien (degenerativer Schaden) •  Bänderzerrung (beschleunigte Bandheilung) •  Muskelzerrung •  Knorpelschaden/Arthrose •  Diskopathien, Radikulopathien

Wann macht PRP/ACP Sinn ?

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•  Störung der Thrombozyten •  Infektionen •  Kortison Infiltration < 1 Monat •  Perorale Kortison Therapie < 2 Wochen •  NSAR < 48h

Wann ist PRP/ACP Unsinn ?

Kontraindikationen

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Peerbooms JC, Sluimer J, Bruijn DJ et al. (2011) Ongoing positive effect of Platelet-Rich Plasma versus Corticosteroid Injection in lateral Epicondylitis: A double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med 39:6

Cortison (n=49) ACP (n=51)

Schmerzreduktion >25% 43% 73%

DASH >25% 39% 73%

ACP®: Schulmedizinische Evidenz

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Peerbooms JC, Sluimer J, Bruijn DJ et al. (2011) Ongoing positive effect of Platelet-Rich Plasma versus Corticosteroid Injection in lateral Epicondylitis: A double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med 39:6

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Operative options

Open release Arthroscopic release Percutaneous release/Microtenotomy

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Lateral Epicondylitis

JBJS 1979 Sep;61(6A):832-9. Tennis elbow. The surgical treatment of lateral epicondylitis.

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Lateral Epicondylitis

Surgical Steps 1) Debride degenerative

tissue at ECRB origin 2) remove traction spurs 3) stimulate angiogenesis 4) repair defect/

superficial extensor closure

REINSERTION der EXTENSOREN !

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Lateral Epicondylitis

Hohmann: Quer-Einkerbung d. Extensoren-Sehnenspiegels

Wilhelm: Denervation

Goldie: Längssplittung des Sehnenspiegels

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Open Lateral Epicondylitis

Outcomes 85-90% return to FULL

activities 10% have some pain 2% do not improve 10 year experience

success rate 95% undetected/iatrogenic posterolateral rotatory

instability

Failures due to Incomplete resection of pathologic tissue Poor soft tissue

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Open release

Excellent / good 75 – 91% Poor / failed 2 – 11% 80 – 95% return to normal activity in 4 months

Lateral extensor release for tennis elbow. A prospective long-term follow-up study. Verhaar J et al. JBJS(Am) 1993;75(7):1034-43

The surgical treatment of chronic lateral humeral epicondylitis by common extensor release. Goldberg E et al. Clin Orthop 1998;Aug(233):208-12

Outcome of release of the lateral extensor muscle origin for epicondylitis. Svernlov B et al. Scand J Plast Recon Surg Hand 2006;40(3):161-5

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Percutaneous release

As good as open or arthroscopic May have earlier return to work

Long-term follow-up of open and endoscopic Hohmann procedures for lateral epicondylitis. Rubenhaler F et al. Arthroscopy 2005;21(6):684-90

Surgical treatment of tennis elbow: percutaneous release of the common extensor origin. Kaleli T et al. Acta Orthop Belg 2004;70(2):131-3

Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment. Szabo SJ et al. J Shoulder Elbow Surg 2006;15(6):721-7

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Arthroscopy

70% satisfactory to excellent 473 cases

4 deep infection 33 prolonged drainage 12 transient nerve palsies

Arthroscopic tennis elbow release. Kalainov D et al. Techniques in Hand and Upper Extremity Surgery. 2007;11(1):2-7

Arthroscopy leaves residual tendinopathy Gross and histological Results in poorer outcomes

Lateral Epicondylitis: In Vivo Assessment of Arthroscopic Debridement and Correlation With Patient Outcomes. Cummins CA. Am J Sports Med Sep 2006, 34(9):1486

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Open release of medial epicondylitis

83-94% success after max. follow-up of 7 years Less favorable results in concomitant ulnar

neuritis/treatment

Gabel GT, Morrey BT. Operative treatment of medial epicondylitis: the influence of Concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am 1995;77:1065–9.

Wittenberg RH, Schaal S, Muhr G. Surgical treatment of persistent elbow epicondylitis. Clin Orthop 1992;278:73– 80.

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Summary

95% settle without surgery Platelet rich plasma: low risk, aprox. 50% chance Short-term: steroids +/- physio Long-term: ‘watch and wait’ as good as any

Surgery only after failed non-operative treatment high success rate consider other diagnoses: PLR Instability, Plica, Chondral

defects

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Danke für die Aufmerksamkeit