Elbow Tendinopathy
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This document discusses elbow tendinopathy and various treatment options. It begins by explaining common types of elbow tendinopathy and risk factors. Non-surgical treatments like eccentric exercises, corticosteroid injections, platelet-rich plasma injections, and autologous cell implantation are reviewed. Surgical options like arthroscopic and open tennis elbow release are also summarized. The document concludes by discussing the current state of research and the need for further well-designed clinical trials to evaluate the efficacy of emerging non-surgical treatments.
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Elbow Tendinopathy
- 1. Elbow tendinopathy update Adam C Watts Consultant Elbow Surgeon, Wrightington Hospital Visiting Professor, University of Manchester 1
- 2. www.wrightington.com Why is the elbow prone to tendinopathy? 2
- 3. www.wrightington.com Tendinopathies around the elbow Lateral epicondylosis (Tennis elbow) Medial epicondylosis (Golfer’s elbow) Distal biceps tendinopathy Distal triceps tendinopathy 3 decreasingincidence
- 9. www.wrightington.com Presentation Insidious onset Change in activity/ technique 9 Weekend warrior >>> club athlete > elite
- 11. www.wrightington.com O’Driscoll hook test for distal biceps 11
- 12. www.wrightington.com 12 Assess whole kinetic chain 90% of tennis players have scapula dyskinesia 84% have GIRD Lopez Vidriero, ESSKA 2016
- 13. www.wrightington.com Assess whole patient! - Psychological factors Association between catastrophisation and tennis elbow Moderate association with distress No relationship to kinesiophobia 13
- 14. www.wrightington.com 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
- 15. www.wrightington.com Is there a role for MRI? 15
- 17. www.wrightington.com What is a tendinopathy? Chronic degenerative condition Angiofibroblastic tendinosis Myofibroblast proliferation 17 Still none the wiser!
- 21. www.wrightington.com Tendon Biology Slow metabolism Poor vascular supply Neural elements Tenocytes and mast cells 21
- 22. www.wrightington.com Neurocellular Model Tendon Homeostasis 22 Proteases Chemotactic factors
- 23. www.wrightington.com 23 Nerve - Mast Cell Units ‘Normal’ physiological loads Tissue Homeostasis Exercise - modest overload Functional Adaptation Overload - acute or chronic Neurocellular degeneration
- 25. www.wrightington.com Why does risk increase with age? Crimping lost during adulthood 25
- 27. www.wrightington.com 27 Ageing Uncrimped fibres more sensitive to changes in load?
- 28. www.wrightington.com 4 stages of tendinopathy 28
- 31. www.wrightington.com Eccentric loading for tendon dysrepair Significant improvement in DASH score and VAS pains score when compared to standard treatment 31
- 32. www.wrightington.com Eccentric Loading Distal Biceps Biceps predominantly a supinator of forearm 32
- 33. www.wrightington.com 33 physiotherapy did not optimise long-term outcome short-term benefit in the absence of corticosteroid injection
- 35. www.wrightington.com Is there any place for corticosteroids? 35
- 36. www.wrightington.com Corticosteroids Inhibit tenocyte proliferation Inhibit tenocyte activity Inhibit collagen synthesis Increase tenocyte necrosis 36
- 38. www.wrightington.com 38 Danger of steroid injection
- 39. www.wrightington.com Danger of steroid injection - lateral ligament rupture (PLRI) 39
- 40. www.wrightington.com Dose dependent tenocyte death 40
- 41. Autologous blood source Concentrated platelet solution (2 to 8x normal) PDGF, TGF, VEGF, FGF www.wrightington.com 41 Platelet Rich Plasma
- 42. Mini GPS III Biomet www.wrightington.com Many systems - many differences 42 RegenLab Selphyl Arthrex ACP
- 43. www.wrightington.com How does PRP work? Stimulates an inflammatory process Inflammation leads to healing Is it organised healing? 43
- 44. www.wrightington.com 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. www.wrightington.com 45 Platelet Rich Plasma - does it work? Steroid PRP Pain Score PRP 73% Success Steroid 51% Success Follow Up (Weeks)
- 46. www.wrightington.com 46 PainScores Platelet Rich Plasma - better than steroid
- 47. www.wrightington.com 47 PainScores Platelet Rich Plasma - may not be better than saline and needling
- 48. www.wrightington.com 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.
- 49. www.wrightington.com Autologous Whole Blood v PRP Several RCTs No convincing evidence of difference 49
- 50. www.wrightington.com 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%
- 51. www.wrightington.com PRP and Distal Biceps Case series Improvement in pain scores and function 51
- 52. www.wrightington.com 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
- 54. www.wrightington.com 54 Pre 1.5 3 6 12 Time QuickDASH PRP Surgery
- 55. www.wrightington.com Patient Rated Tennis Elbow Evaluation 55 Pain Function Overall No significant differences in outcome on any measure
- 56. www.wrightington.com 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
- 57. www.wrightington.com 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
- 59. www.wrightington.com 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
- 63. www.wrightington.com 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
- 64. www.wrightington.com Superior DASH scores in arthroscopic group at average 4 years follow-up Excellent outcome Open group 67% Arthroscopic group 78% 64
- 65. www.wrightington.com 65 Wrong Diagnosis Radiocapitellar plica Posterolateral rotatory instability Radial tunnel syndrome Radiculopathy
- 66. www.wrightington.com 66 Remove trigger NSAIDS? Isometric exercises Eccentric exercises Injection Surgery
- 67. www.wrightington.com 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
- 68. www.wrightington.com Future research Double blind randomised controlled trial PRP v HA v sham injection 150 patients Recruiting soon! 68