Epicondylitis

Subject of the presentation:Lateral Epicondylitis

Prepared by: Prepared by: Dr. Rasekh MS orthoDr. Rasekh MS orthoKabul afghanistan Kabul afghanistan

Date :19/04/2013

Elbow Anatomy

• Elbow joint is made of – 3 bones– 3 joints– One capsule – Hinge joint– Flexion(145) and extension(0-5)

(Diarthrosis)- freely moveable

• Planar Joint• Hinge Joint• Pivot Joint• Saddle Joint• Ball & Socket Joint• Condyloid or Ellipsoid Joint

• Convex surface of bone fits in concave surface of 2nd bone

• Unixlateral like a door hinge• Examples:

- Knee, elbow, ankle, interphalangeal joints• Movements produced:

- flexion- extension- hyperextension

• Rounded surface of bone articulates with the ring formed by the 2nd bone & ligament

• Monoaxial since it only allows rotation around longitudinal axis

• Examples:- proximal radioulnar joint

- supination- pronation

- atlanto-axial joint- Turning head side to side “no”

AnteriorMedialCollateralLigament

PosteriorMedial

CollateralLigament

Resists valgus forcesLimits extension

Medial Collateral Ligament (MCL)

Transverse ligament

© 2007 McGraw-Hill Higher Education. All rights reserved.

Lateral Collateral

Resists varus stress

Weaker than MCL

Tensed in flexion and extention

Secondary Stabilizers

Lateral epicondyle

Capitulum

Proximal radioulnarjt.Radial head

Radial neck

Radial tuberosity

Olecranon fossa

Medial epicondyle

Trochlea

Coronoid process

Coronoid Process Radial head Radial neck

Condyles

Trochlear notch

Olecranon process

Radial notch

– 1:Extensor carpi radialis longus– 2:Extensor digitorum– 3:Extensor carpi ulnaris– 4:Supinator– 5: Extensor carpi radialis brevis

6:Extensor digiti minimi

Common extensor origin

Epicondylitis

LATERAL EPICONDYLITIS

TENNIS ELBOW

Definition

• • “A pathologic condition of the common

• extensor muscles at their origin on the

• lateral humeral epicondyle. Epicondylitis

• suggests an inflammation at one of the

• epicondyles of the elbow.”

Lateral Epicondylitis (tennis elbow)

• Pathology– 30 – 50 years old– Repetitive micro-trauma – Chronic tear in the origin of the extensor

carpi radialis brevis

Lateral Epicondylitis (tennis elbow)

• Mechanism of Injury– Overuse syndrome caused by repeated

forceful wrist and finger movements – Tennis players – Prolonged and rapid activities

Risk factors

• Obesity• Repetitive movements• Forceful activities• Manual labour

Etiology

• Extrinsic factors • Repetitive movements• Forceful activities• Manual labour

• Intrinsic factors• Anatomical factors• Age related factors• Systemic factors

Tendon degeneration

Decreased vascularity

Decreased healing

Common Complaints

• Diffuse pain• • Morning stiffness• • Occasional night pain• • Dropping of objects/ weak grip strength• • Pain w/ palpation of lat. epicondyle• • Pain w/active or resisted extension• • Pain w/ grasping objects with the effected

hand

Symptoms

Lateral Arm / elbow /forearm pain Increased with use(holding/picking up items) If popping / clicking present, consider

problem within joint(loose bodies, osteochondral lesions )

Acute vs. Chronic

• Tendonitis• Localized edema• Inflammation of wrist

extensor tendons• Microtearing

• Tendinosis• Decreased edema• Non-inflammatory• Localized fibrosis • Collagen necrosis • Fibroblastic

hyperplasia

Acute vs. Chronic

Diagnosis: Physical examination

X-rays usually negativeElbow Swelling rare Maximum tenderness just distal to lateral

epicondyle ROM,-usually normal Check stability--normal

Maximum tenderness just distal to lateral epicondyle

Lateral Epicondylitis (tennis elbow)

Tests• AROM; PROM • Resisted tests: • Pain with resisted wrist extension • Pain with resisted middle finger extension• Pain with resisted supination(radial tunnel syn)

Special Tests• Cozen’s Sign

– Elbow flexed; Forearm pronated– Wrist extension and radial deviation against

resistance– Positive when pain at lateral epicondyle

• Mill’s Test– While palpating the lateral epicondyle– The examiner pronates the patient’s forearm, flexes

the wrist, and extends the elbow– Positive when pain at lateral epicondyle or lack of

full elbow extension

Special Tests

• Grip Strength Measures

• Middle Finger Test– Resistance just distal to PIP joint of the

middle finger with forearm in pronation– Positive in tennis elbow with pain at lateral

epicondyle

Differential diagnosis of ‘Tennis Elbow’

• C6/7 radiculopathy

• Radial tunnel syndrome

• Distal biceps tendon degeneration

• Radiocapitellar arthritis

• Capsular infolding

• Posterolateral instability

(10%)

C6/7 radiculopathy

50

Spurling sign• . Axial compression of

the spine and rotation to the ipsilateral side of symptoms reproduces or worsens cervical radiculopathy.

• Pain on the side of rotation is usually indicative of foraminal stenosis and nerve root irritation.

Radial Tunnel Syndrome• Compression of

radial nerve under extensors in forearm

• Deep, lateral forearm pain, often at night

• No sensory component

• Often confused with lateral epicondylitis (they co-exist 5% of the time) pain is more distal

Radial Tunnel Syndrome: Diagnosis• Extended middle finger

test

• Pain with resisted supination

• Electrodiagnostic tests not helpful

• Injection of local anesthetic into radial tunnel completely relieves symptoms and is diagnostic

Radial tunnel syndrome

Distal biceps tendon degeneration

Radiocapitellar arthritis

• Key points • It is a self limiting condition – no-one ever has it

forever. • 90% of people are better after 1 year. • Physiotherapy, activity modification and simple

exercises will control the symptoms in most people. • Injections are reserved for very resistant cases. • An operation is only considered as a last resort.

Management

Management

• Non-operative – successful in 95%

• Operative– only after failed non-operative Rx– usually successful

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

Physiotherapy• At 6 weeks:

– better than ‘watch and wait’– worse than steroid injection

• Long-term:– better than steroid injection– same as ‘watch and wait’

Brace / elbow clasp

• Between 12 and 24 weeks:– Pain reduction– Improved functionality– Improved pain-free grip strength

• No better at 12 months

Physical Therapy

• Ultrasound– Limited low quality evidence– Used as an adjunct; not independently

• Pulsed ultrasound to break up scar tissue, promote healing, and increase blood flow in the area

Manual Techniques

• Deep Transverse Friction Massage– No benefit when combined with concurrent

physiotherapy modalities when compared to control group

• Manipulation of the Wrist– Scaphoid Thrust Manipulation

• Cervicothoracic Spine Manipulation– Non-thrust manipulation and traction of cervical

spine– Lateral Cervical Glide Technique

Steroid injection

• Good short-term relief for 6 weeks

• Poorer outcome in the longer term than– watch and wait– physio

Injections

• Short-term benefits (2-6 weeks)

• Greater perception of benefits (pain reduction, global improvement, grip strength) but did not persist long term

• Several studies have found that oral NSAIDS and PT have greater benefits than corticosteroid injections at both 6 weeks and 6 month follow-ups

Platelet Rich PlasmaTherapy

• A 2006 study looking at the treatment of lateral epicondylitis with platelet rich plasma therapy– Over 90% of the patients were completely satisfied

with their results and did not opt for surgery in the weeks and months following a single treatment

• Eight weeks after the treatment, the platelet-rich plasma patients noted 60% improvement in their visual analog pain scores versus 16% improvement in control patients (P =.001).

►PRP Application TechniqueWithdraw peripheral blood

Place blood in canisterCentrifuge

►PRP Application TechniqueRemove PPP

Shake vigorously for 30 seconds

Platelet Poor PlasmaPlatelet Poor Plasma

(PPP)(PPP)

Platelet Rich PlasmaPlatelet Rich Plasma

(PRP(PRP))

Packed Red Blood CellsPacked Red Blood Cells

PRP: Contraindications• Thrombocytopenia

• Anticoagulation therapy

• Active infection

• Tumor

• Metastatic disease

• Pregnancy(Hall et al, JAAOS 2009)

Predictors of poor outcome • Manual labour • High physical strain at work • High level of baseline pain • Lower social class

Operative options

• Open release

• Arthroscopic release

• Percutaneous release

• Suture anchor repair

• Microtenotomy

• Anconeus transposition

• Radiofrequency probe

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

Open release

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

Surgery

ECRL

EDC

L. Cond

ECRB

Scratch maneuver

Lateral Epicondylar ReleaseReturn to Work Protocol

• Week 0 – 1: off work

• Week 1 – 4: one-handed work

• Week 4 – 12: light duty work

• Week 12: regular duty work

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

Conclusions

• Nirschl Mini techniques less risk, lower costs, best success

• Tendinosis surgery is not a release operation• Tendinosis surgery is resection of pain producing

tissue• Direct vision clearly identifies pathological tissue• No harm to normal tissue – rapid rehab• Can do combined procedures (medial and lateral)

when indicated

Management summery

• Activity modification,stretching,tennis elbow strap and cock up wrist splint

• NSAIDs• Therapy (Iontophoresis)• Corticosteroid injection• Offer PRP injection in some individuals• Surgery: Open technique Arthroscopic technique when intra-articular pathology suspected

or when more rapid recovery needed Perform concomitant radial tunnel decompression in patients

with both conditions

Questions?

Thanks for your kind attention