Elbow Tendinopathy

Elbow tendinopathy
update
Adam C Watts
Consultant Elbow Surgeon, Wrightington Hospital
Visiting Professor, University of Manchester
1

www.wrightington.com
Why is the elbow prone to
tendinopathy?
2

Tendinopathies around the elbow
Lateral epicondylosis (Tennis
elbow)
Medial epicondylosis (Golfer’s
elbow)
Distal biceps tendinopathy
Distal triceps tendinopathy
3
decreasingincidence

8
Pronator teres tendon origin

Presentation
Insidious onset
Change in activity/
technique
9
Weekend warrior >>> club athlete > elite

Clinical Diagnosis
10

O’Driscoll hook test for distal biceps
11

www.wrightington.com 12
Assess whole kinetic chain
90% of tennis
players have
scapula dyskinesia
84% have GIRD
Lopez Vidriero, ESSKA 2016

Assess whole patient!
- Psychological factors
Association between catastrophisation and tennis
elbow
Moderate association with distress
No relationship to kinesiophobia
13

When to get plain radiographs
Younger and older
patients
Past history elbow
trauma
Mechanical symptoms
Positive grip and grind
14
important to exclude OCD in the young

Is there a role for MRI?
15

16
NormalTendinopathic

What is a tendinopathy?
Chronic degenerative condition
Angiofibroblastic tendinosis
Myofibroblast proliferation
17
Still none the wiser!

Normal Tendon
18

Tendon Biology
Slow metabolism
Poor vascular supply
Neural elements
Tenocytes and mast cells
21

Neurocellular Model Tendon Homeostasis
22
Proteases
Chemotactic
factors

23
Nerve - Mast Cell Units
‘Normal’
physiological
loads
Tissue
Homeostasis
Exercise
- modest
overload
Functional
Adaptation
Overload
- acute
or chronic
Neurocellular
degeneration

Why does risk increase with age?
Crimping lost during adulthood
25

27
Ageing
Uncrimped fibres more sensitive to changes in load?

4 stages of tendinopathy
28

Suggested Algorithm
30

Eccentric loading for tendon dysrepair
Significant
improvement in
DASH score and
VAS pains score
when compared
to standard
treatment
31

Eccentric Loading Distal Biceps
Biceps predominantly a supinator of forearm
32

33
physiotherapy did not optimise long-term
outcome
short-term benefit in the absence of
corticosteroid injection

34
Steroid Injection
Physiotherapy

Is there any place for corticosteroids?
35

Corticosteroids
Inhibit tenocyte proliferation
Inhibit tenocyte activity
Inhibit collagen synthesis
Increase tenocyte necrosis
36

37
Steroid Injection
Physiotherapy
Natural History

38
Danger of steroid injection

Danger of steroid injection -
lateral ligament rupture (PLRI)
39

Dose dependent tenocyte death
40

Autologous blood source
Concentrated platelet solution (2 to 8x normal)
PDGF, TGF, VEGF, FGF
41
Platelet Rich Plasma

Mini GPS III Biomet
Many systems - many differences
42
RegenLab
Selphyl
Arthrex ACP

How does PRP work?
Stimulates an inflammatory process
Inflammation leads to healing
Is it organised healing?
43

44
Platelet Rich Plasma - does it work?
100 Consecutive Patients
All had symptoms for > 6/12
No treatment for tennis elbow for 6/12
Randomised to PRP or 40mg Kenacort Injection

45
Platelet Rich Plasma - does it work?
Steroid
PRP
Pain Score
PRP 73% Success
Steroid 51% Success
Follow Up (Weeks)

46
PainScores
Platelet Rich Plasma - better than steroid

47
PainScores
Platelet Rich Plasma - may not be
better than saline and needling

PRP v Dry Needling
PRP superior to dry needling
At 6 months
84% success with PRP
68% with needling (p=0.012)
48
Am J Sports Med. 2013 Jul 3. [Epub ahead of print]
Platelet-Rich Plasma Significantly Improves Clinical Outcomes in Patients With Chronic Tennis Elbow: A Double-Blind, Prospective,
Multicenter, Controlled Trial of 230 Patients.
Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, Vermillion DA, Ramsey ML, Karli DC, Rettig AC.

Autologous Whole Blood v PRP
Several RCTs
No convincing evidence of difference
49

Efficacy v Effectiveness
often efficacy seen in RCT is not reproduced in clinical practice so it is important to study ‘real life’ effectiveness
50
Single shot ultrasound guided PRP (1ml, Biomet Recover Miniplatelet) under LA
Personal series 59 patients with recalcitrant tennis elbow with
minimum 6 month follow up
Mean age 52 (range 19 to 79 years)
Further intervention
3 repeat injections
9 operative intervention
“Success” rate of PRP injection 85%

PRP and Distal Biceps
Case series
Improvement in pain scores and function
51

How does PRP compare to surgery?
Prospective single blind RCT single shot PRP v
open surgery
100 patient recruited (17 withdrawn)
83 patients randomised (2 lost to follow up)
Analysis of 81 patients
52
Morgan B, Trail IA, Watts AC, Birch A, Nuttal D
Wrightington Upper Limb Unit

Baseline data
53

54
Pre 1.5 3 6 12
Time
QuickDASH
PRP
Surgery

Patient Rated Tennis Elbow Evaluation
55
Pain Function Overall
No significant differences in outcome on any measure

but…additional interventions
1 Surgical patient(3%) had a subsequent PRP
injection
13 PRP patients (31%) had surgery within 12 months
“Success” rate 95% for surgery v 69% for PRP
56
p=0.001

Conclusion
No evidence yet that PRP is better than placebo
In practice at least 70% of patients treated with
PRP will avoid surgery
Useful second line treatment if no response to
physio?
57

Autologous cell implantation
Injection of functioning cells capable of
regenerating extracellular matrix
Autologous differentiated fibroblasts or tenocytes
or skin derived tenocyte like fibroblasts
Promising animal models
Early clinical trials promising
No good RCT
59

Ultrasound driven percutaneous
tenotomy
60

63
Advantages of Arthroscopic Tennis
Elbow Release
Better access to ECRB
Smaller Incisions = less post-operative pain
Treatment of associated intra-articular pathology
Earlier return to sports and work

Superior DASH scores in arthroscopic group at
average 4 years follow-up
Excellent outcome
Open group 67%
Arthroscopic group 78%
64

65
Wrong Diagnosis
Radiocapitellar plica
Posterolateral rotatory instability
Radial tunnel syndrome
Radiculopathy

66
Remove trigger
NSAIDS?
Isometric exercises
Eccentric exercises
Injection
Surgery

Where are we now?
67
Imaging
Insidious onset
No history trauma
Adult
History trauma
Adolescent
Elderly
Tendinopathy +/-
delamination
Analgesia
Activity modification
Physiotherapy -
eccentric loading
Tendinopathy +
macrotear/avulsion
Surgery
PRP injection
and physio
Initial Presentation

Future research
Double blind randomised controlled trial
PRP v HA v sham injection
150 patients
Recruiting soon!
68

Elbow Tendinopathy

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