Tennis Elbow

• Definition:

– “Tendinopathy of the common extensor origin of the elbow”

– Previously known as “lateral epiconylitis”

– 1-2% population

Aetiology

• Incompletely understood• Acute injury

– Epicondylitis

• Chronic injury– Epicondylosis– Repetitive micro-tearing

Tendinosis

• Mucoid degeneration

• Loss of collagen tight bundled structure

• Fibrosis

• Neo-vascularisation

(Khan et al. 1999)

Presentation

• Pain

• Weakness

• Difficulty opening door handles

• Difficulty shaking hands

Examination

• Pain on palpation

• Resisted elbow extension

• Resisted middle finger extension

Treatment

• Non-operative– Rest– NSAIDs– Physiotherapy– USS– Injection therapy

• Operative– Tennis elbow release

NSAIDs

• Cochrane review 2002

• Insufficient evidence to recommend or discourage the use of oral NSAIDs

• No conclusion regarding oral versus topical

Physiotherapy

• Principles:– Eccentric loading– Close to limit of tendon without exceeding it

– Avoid exacerbating activities

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

Cortisone Injections

• Common treatment

• ? Beneficial with degenerative pathology

• Significant local side-effects

Effectiveness

• Short-term improvement (6-8 weeks)

• Long-term deleterious effect– Evident at 6 and 12 months

Coombes et al Systematic Review Lancet 2010

Injection of blood products• Attempt to address pathology• Growth Factors e.g. TGF-ß + FGF

• Autologous blood

• Platelet Rich Plasma (PRP)

• Bone Marrow Aspirate

Autologous blood

• Connel D.A. et al (2006) Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiology 35;6:371-7.

• Edwards, S.G. and Calandruccio, J.H. (2003) Autologous blood injections for refractory lateral epicondylitis. The Journal of Hand Surgery 28A; 2; 272-9.

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 TrialPlatelet-Rich Plasma Versus Corticosteroid Injection With a 2-Year Follow-up

Gosens T, Peerbooms JC et al. Am J Sports Med 2011

Botulinum Toxin A Injection

• Paralysis of extensor musculature• Unloading of tendon• Gradual reload as toxin diminishes

• Keizer et al 2002 Clin Orth Rel Research

Extracorporeal shockwave therapy

• Regular tennis elbow– Evidence lacking

• Calcific tennis elbow (very rare)– Possible benefit

Heal with Steel?

• Reserved for refractory cases

• Debridement of abnormal tendon of ERCB

Conclusion• What should we do?

• Corticosteroids should be used cautiously• Physiotherapy• Avoid exacerbating factors

• Blood products appear promising

• Surgery as a last resort