Tennis Elbow GP handout by BKKESqq0

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									                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 Trial
    Platelet-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

								
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