Post on 17-Dec-2015
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)
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