Percutaneous Tenotomy on a Golfer with Chronic Lateral Epicondylitis

Tiffany Hercules, Shawn D. Felton, Jason C. CraddockFlorida Gulf Coast University, Department of Rehabilitation Sciences, Fort Myers, FL USA

Abstract

Introduction

Case Report

Conclusion

ReferencesBarnes, D., Beckley, J., & Smith, J. (2015). Percutaneous Ultrasonic Tenotomy for Chronic Elbow Tendinosis: A Prospective Study. Journal od Shoulder and Elbow Surgery, 24(1).Bhambhani, S., Mitra, M., & Kaur, A. (2016). Effectiveness of Kinesiotaping along with Conventional Physiotherapy for Patients with Tennis Elbow. Indian Journal of Physiotherapy and OccupationalTherapy , 10(3).Boiragi, R., & Kaur, G. (2015). Treatment of Tennis Elbow. Indian Journal of Physiotherapy and Occupational Therapy , 9(2).Groppel, J. L., & Nirschl, R. P. (1986). A Mechanical and Electromyographical Analysis of the Effects of Various Joint Counterforce Braces on the Tennis Player. The American Journal of SportsMedicine, 14(3), 195-200. doi:10.1177/036354658601400303Hay, E. M., Paterson, S. M., Lewis, M., Hosie, G., & Croft, P. (1999). Pragmatic Randomised Controlled Trial of Local Corticosteroid Injection and Naproxen for Treatment of Lateral Epicondylitis ofElbow in Primary Care. Bmj, 319(7215), 964-968. doi:10.1136/bmj.319.7215.964Howitt, S. (2006). Lateral Epicondylosis: A Case Study of Conservative Care Utilizing ART and Rehabilitation. The Journal of the Canadian Chiropractic Association, 50(3), 182-189.Georgieva, D., Anastasika, P., Samardziski, M., Bozinovski, Z., & Dzoleva-Tolevska, R. (2016). Tennis Elbow: Its Origins and Treatments. Research in Physical Education, Sports, and Health, 5(1), 83-86.Kochar, M., & Dogra, A. (2002). Effectiveness od a Specific Physiotherapy Regimen on Patients with Tennis Elbow: Clinical Study. Phyiotherapy, 88(6), 333-341.Page, P. (2010). A New Exercise for Tennis Elbow. North American Journal of Sports Physical Therapy,5(3), 189-193.Pienimaki, T., Tarvainen, T., Siira, P., & Vanharanta, H. (1996).Progressive Strengthening and Stretching Exercises and Ultrasound for Chronic Lateral Epicondylitis . Physiotherapy, 82(9), 522-530.

There are several options as far as the treatment and management for lateral epicondylitis. It is recommended by most medical professionals that patients should start out by trying more conservative treatments, such as therapeutic exercises, and progressing to non-conservative treatments if warranted. Each case may differ, therefore, the course of treatment is primarily dependent on how the pathology presents in each respective patient. In this particular case study, the surgery was a success when considering the fact that his perceived pain was reduced significantly. However, further treatment was needed in order to reduce said pain to even lower levels.

Lateral epicondylitis, or tennis elbow as it is more colloquially known, is characterized by the pain on the lateral elbow and forearm extensor muscle mass (Georgieva et al., 2016). This is an overuse injury that causes damage to the forearm muscles and their tendons—particularly in the origin on the distal humerus(Boiragi and Kaur, 2015). Histologically, studies indicate that findings may include granulation tissue, microruptures, and degenerative changes (Georgieva et al., 2016). It is important to note however that despite the suffix “-itis”, lateral epicondylitis typically does not present with inflammation (Georgieva et al., 2016); therefore, in some of the published literature, it is termed lateral epicondylitis. Additionally, although it is known to be a pathology commonly experienced in tennis players, lateral epicondylitis is also moderately prevalent in populations that endure any repetitive use in the forearm extensors (Georgieva et al., 2016). In fact, some sources indicate that the annual incidence of lateral epicondylitis in the general population can be as high as 3% (Smidt et al., 2003). Unfortunately an average episode of lateral epicondylitis can vary anywhere between 6 months to 2 years in more chronic cases (Smidt et al., 2003). Because of this large time frame, there are a multitude of treatments that could prove to be beneficial to a patient’s condition.

Background: This case study examined the surgical treatment of a male 60-year-old golfer that presented with chronic lateral epicondylitis. After failing conservative measures and the typical treatments of “tennis elbow”, the athlete decided to undergo a percutaneous tenotomy of the common extensor tendon of the left elbow. Currently the case is ongoing. Patient: The patient was a 60 year-old male (175.26cm 92.98kg) avid golfer presented with a chronic case of left elbow lateral epicondylitis with no reported specific mechanism of injury. The patient’s prior history included an arthroscopic repair of the rotator cuff of the left shoulder 11 years prior. The initial evaluation revealed point tenderness along the left lateral epicondyle with no deficits in elbow and wrist range of motion. The patient reported the provocation of symptoms when partaking in golfing. Radiographic images revealed no fractures, subluxations, dislocations, or destructive lesions. However, magnetic resonance imaging (MRI) showed moderate calcific tendonosis of the common extensor tendon and a small ganglion cyst posterior to the lateral epicondyle of the humerus. Additionally, the MRI of the elbow showed evidence of moderate fraying ulnar collateral ligament and joint effusion. No bony abnormalities where revealed. After failing several modes of conservative treatment the patient has elected to undergo an elective surgery for the percutaneous tenotomy of the common extensor tendon of the humerus. Intervention or Treatment: Prior interventions attempted for the treatment of the patient’s lateral epicondylitis included physical therapy, home exercise programs, activity modification, anti-inflammatory medications, and corticosteroid injections. After years of enduring the pain associated with this condition, the patient has elected to undergo a percutaneous tenotomy procedure of the common extensor tendon of the left elbow via ultrasonic guidance. Outcomes or other Comparisons: It is estimated that between 90-95% of patients respond to the conservative treatment of lateral epicondylitis. However, the remaining 5-10% of patients that do not respond to the conservative management of lateral epicondylitis often turn to surgical treatments. Most studies consider the percutaneous tenotomy surgery as a viable alternative when conservative treatment fails. The patient is expected to respond well to the procedure. Conclusions: After following up 3 weeks post-surgery, the patient noted that his pain had reduced significantly to a 3 out of 10 on the pain scale with activity. Because his pain had not been yet eradicated the leading physician and the patient decided to revisit physical therapy as a post-op treatment. After 3 sessions of physical therapy, the patient’s pain levels decreased significantly to a 1 out of 10 when gripping and rotating, but otherwise stated his elbow felt better. Therefore, although the surgery was a success, further treatment was indicated to help completely eradicate the pain associated with chronic lateral epicondylitis.

The patient’s pertinent history included an arthroscopic repair of the rotator cuff of the left shoulder 11 years prior. Before electing to undergo the elective percutaneous tenotomy surgery (known as Tenex) the patient underwent several modes of conservative treatment. The patient went through physical therapy, home exercise plans, and had attempted to use tennis elbow bracing. Additionally, he previous had received corticosteroid injections that later proved to provide no substantial relief. The initial evaluation revealed point tenderness along the left lateral epicondyle with no deficits in elbow and wrist range of motion. The patient reported the provocation of increased symptoms when partaking in golfing activities and lifting heavy objects. Further, resisted pronation and wrist extension were weak and painful, scoring a 4/5 in the manual muscle testing scale. Radiographic images revealed no fractures, subluxations, dislocations, or destructive lesions. However, magnetic resonance imaging (MRI) showed moderate calcific tendinosis of the common extensor tendon and a small ganglion cyst posterior to the lateral epicondyle of the humerus. Additionally, the MRI of the elbow showed evidence of moderate fraying of the anterior bundle of the ulnar collateral ligament and joint effusion. No bony abnormalities were revealed.

The purpose of this case study to examine the effects of a ultrasound guided percutaneous tenotomy of the common extensor tendon in an patient with chronic lateral epicondylitis. The patient was a 60 year-old male (175.26cm 92.98kg) avid golfer that presented with a chronic case of left elbow lateral epicondylitis, commonly referred to as tennis elbow, with no reported specific mechanism of injury. Lateral epicondylitis, or tennis elbow, is an overuse injury commonly associated with tennis and other racquet-based sports. It is an overuse injury marked by the inflammation of common extensor tendon that originates on the lateral epicondyle of the humerus. In the case of the patient being study, his elbow was experiencing an overuse phenomenon due to golfing. This is consistent with the subjective findings in which the patient stated that the pain was insidious and worsened as he played more and more golf.

PurposeAfter being placed under general anesthesia, the physician performing the surgery used an ultrasound machine to locate the site of calcific tendinosis and then made a small incision in which the needling tool (TX MicroTip) was inserted. The 2 cm incision was made directly above the lateral epicondyle, were the patient expressed he was feeling the most pain. The TX MicroTip was then used to break up any abnormal scar tissue by oscillating at high frequencies back and fourth. The “needle” has a hollow opening in it’s center that allows the irrigation of the debris, in this case, the now loose calcium deposits. The total procedure takes only about 15 minutes. Finally, when the calcific tendon has been treated, the physician closed the incision with a steri-strip with an occlusive bandage placed over it. An elbow sling was then placed on the patient to protect the incision site while the anesthesia wore off.

Before undergoing surgery, the patient noted that his pain levels were at a 6 out of 10 on the pain scale. Postop examination revealed that the incision site had appropriate postop appearance with no signs of infection. The patient experienced the expected amount of point tenderness on and around the lateral epicondyle. Additionally, normal nerve function of the axillary, musculocutaneous, median, ulnar, and radial nerve were noted.

At the 3 weeks post-surgery examination, the patient noted that his pain had reduced significantly to a 3 out of 10 on the pain scale with activity. Because his pain had not been yet eradicated the leading physician and the patient decided to revisit physical therapy as a post-op treatment. After 3 sessions of physical therapy, the patient’s pain levels decreased significantly to a 1 out of 10 when gripping and rotating, but otherwise stated his elbow felt better.

Treatment