10/1/2009. October 15, 2009 Christina Kuo MD. Anatomy and pathophysiology of Epicondylitis Diagnosis

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1 October 15, 2009 Christina Kuo MD Anatomy and pathophysiology of Epicondylitis Diagnosis Treatment options Lawn tennis elbow Morris described as an injury occurring from the backhand stroke Age years old Similar incidence in men and women 1-3% of men and women will get it in their lifetime Lateral epicondylitis occurs 7-20 times more frequently than medial epicondylitis Up to 75% patients are affected in the dominant arm 1

2 Insidious onset of pain at the medial/lateral aspect of the elbow Associated with repetitive or strenuous activity +/- vibrating tools, non-neutral postures of elbow Often no identifiable acute event Lateral Epicondylitis Pain with lifting objects coffee cup Pain with wrist extension, supination Worse with elbow extended Can be exacerbated during rehabilitation for shoulder or wrist injuries Medial Epicondylitis Pain on medial aspect of elbow Pain with strong gripping Pain with wrist pronation and flexion Actual injury not known Rarely: acute events with avulsion Nirschl described angiofibroblastic tendinosis Degenerative, disorganized cells Not an inflammatory response Relative avascular zone at lateral epicondyle High eccentric loads experienced at elbow 2

3 Primarily a clinical diagnosis Xrays calcifications at the lateral epicondyle Influence treatment in less than 0.5% cases MRI Tendon thickening, degeneration, microtears, edema Changes can be seen in asymptomatic elbows, and will persist even after recovery Not necessary for diagnosis Can be helpful for preoperative planning Extent of disease Avulsion Intra-articular pathology Pain at lateral epicondyle and extensor origin pain with resisted wrist extension and supination esp with elbow extended Wait and see 1936 paper Cyriax suggesting spontaneous cure by end of 8-12 months Non-operative treatment is still the mainstay Trial for 6-12 months Expectant management NSAIDS Bracing Physical Therapy Injections Other modalities 3

4 Forearm brace reduces pull on tendon origin Variable placement and pressure Wrist brace - limit wrist movement to decrease stress at elbow Head to head studies comparing both splints showed no difference in outcomes at 6, 26, and 52 weeks Therapy may help patient satisfaction at early time points. Stretching, strengthening, education Ultrasound offers small to no benefit Iontophoresis (transcutaneous steroid delivery) may help in early pain alleviation, but no difference at 1 month lidocaine and steroid most common other substances botulinum toxin - finger paralysis and weakness autologous blood 4

5 Extracorporeal shock wave therapy (ESWT) Has been used in calcific tendinopathies with success Acupuncture may provide short term pain relief Topical Nitric Oxide small studies which demonstrate increased pain relief at 6 months Topical diclofenac offers pain relief and allows participation in other therapies One study had a 69% success rate for injections, 91%sucess for PT and 83% success for observation at 1 year. A second study showed that 92% of injection group had early relief compared to 57% of NSAIDS group and 50% of placebo group, but at 1 year all groups had approximately 80% pain reduction. Other studies comparing therapy to forearm band, steroid shot or doing nothing demonstrate no difference in long term outcomes ESWT one study cited 48% relief with compared with 6% without, but a recent meta-analysis of 1000 patients in 9 trials concluded that there was no notable effect Blood Injection 79% patients who had failed at least one conservative modality had complete relief at 9.5 months Bottom line At one year, regardless of mode of conservative treatment, or no treatment 80-90% of patients will be better No one modality dli has be proven to be significantly better than others. Caution with steroid injection some evidence to suggest that it may lead to lower recovery rates at one year than other modalitites. Use in conjunction with other treatments Use with caution on medial side 5

6 Only recommended after failing conservative treatment as described previously Goal is to debride ECRB origin or underside of flexor origin, with or without release. Open release with debridement Arthroscopic release Percutaneous release Denervation of Lateral epicondyle +/- drilling of lateral epicondyle +/- joint inspection and debridement. Splint for 2 weeks including wrist Weeks 2-6 +/- wrist splint Work on range of motion, light activity Strengthening begins at 6 weeks Formal physical therapy recommended Heavy laborer return to full duty on average 3-4 months. 6

7 For repetitive upper extremity injuries, isolated elbow injuries had best recovery rate at 3 years (10/21). Multiple sites of injury had worst Women RTW later, but more likely to stay at work than men Approximately 25% who present initially with a gradual onset will eventually relapse after RTW Pittsburgh study comparing surgery for WC and non-wc Lateral epicondylitis. Symptom relief highly successful in both groups WC patients more likely to change jobs due to persistent symptoms Clinical Diagnosis Conservative measures NSAIDS, oral or topical Bracing, wrist and forearm bracing Work modification, workstation evaluation, mouse use Physical Therapy +/- steroid injection Surgery 7

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