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 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.

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