1. Epicondylitis: Why Bother? Graham Chuter SpR Teaching, Freeman Road Hospital March 2007

2. Overview Definition Demographics Presentation Differential Dx Management Results Summary

3. Names Epicondylitis Tendonitis Tendinosis Epicondylalgia Epitrochleitis

4. What is ‘Epicondylitis’? Pathological change in the musculo- tendinous origin at the epicondyle Acute (rare) Inflammatory cells Chronic No inflammatory cells Degenerative

5. Collagen degeneration due to ageing microtrauma vascular compromise Degeneration and inadequate repair Angiofibroblastic hyperplasia More accurate description Evidence for decreased microcirculation and anaerobic metabolism in ECRB Decreased intramuscular blood flow in patients with lateral epicondylitis. Oskarsson E et al. Scand J Med Sci Sports. 2006 Jun 28 Tendinosis

6. Definitions Medial “Golfer’s elbow” “Pitcher’s elbow” Lateral “Tennis elbow”

7. Medial epicondylitis (“Golfer’s”) Overuse syndrome of flexor/pronator mass Throwing athletes (pitchers) May be microtear between pronator teres and FCR Often assoc with ulnar neuritis

9. Medial epicondylitis (“Golfer’s”) Overuse syndrome of flexor/pronator mass Throwing athletes (pitchers) May be microtear between pronator teres and FCR Often assoc with ulnar neuritis Lateral epicondylitis (“Tennis”) Repetitive pro/supination with elbow extended Primarily involves ECRB

11. Demographics 4 – 7 per 1000 per year Affects 1 – 3% of the population Peak at 35 – 54 years 4 ♂ :1 ♀ Medial : lateral → 1:3 Most common elbow complaint

12. Demographics 15% of workers in ‘at-risk industries’ Millions of lost workdays per year Duration: 6 months to 2 years Self-limiting; 90% resolve within 1 year Recurrence is common

13. Risk factors Smoking (OR=3.4) Obesity Repetitive movements Forceful activities Prevalence and determinants of lateral and medial epicondylitis: a population study. Shiri R et al. Am J Epid Dec 2006, 164(11):1065

14. Presentation Pain over epicondyle on activity Reproducible local tenderness Lateral epicondylitis Resisted wrist extension Maudsley's test → pain on resisted extension of middle finger Medial epicondylitis resisted forearm pronation resisted wrist flexion

15. 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 2 nd ed. 1998 Philadelphia, pp.501-33 (10%)

16. Management Non-operative successful in 95% Operative only after failed non-operative Rx usually successful

17. 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

18. 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

19. 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

21. Brace / elbow clasp Between 12 and 24 weeks: Pain reduction Improved functionality Improved pain-free grip strength No better at 12 months Dynamic extensor brace for lateral epicondylitis. Faes M et al. Clin Orthop Rel Res 2006;442:149-57

22. 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 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 83% improved at 1yr, regardless of occupational input Intervention did not reduce visits

23. Predictors of poor outcome Workers’ compensation does not appear to affect outcome But: more workers changed jobs if symptoms persisted Outcome of surgery for lateral epicondylitis (tennis elbow): effect of worker's compensation. Balk ML et al. Am J Orthop. 2005 Mar;34(3):122-6

24. Operative options Open release Arthroscopic release Percutaneous release Suture anchor repair Microtenotomy Anconeus transposition Radiofrequency probe

25. Open release Incision ant to lateral epicondyle ECRL posterior fascial edge lifted Degenerate tissue within ECRB excised Defect firmly repaired +/- suture anchors ?Decompression of PIN

26. Open release Excellent / good 75 – 91% Poor / failed 2 – 11% 80 – 95% return to normal activity in 4/12 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

27. 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

28. 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

29. Summary Why bother? Poor high level evidence 95% settle without surgery Short-term: steroids +/- physio Long-term: ‘watch and wait’ as good as any Surgery only after failed non-operative Rx high success rate consider other diagnoses

30. Thank you