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Ultrasound Guided Percutaneous Tenotomy for the Treatment of
Chronic Tennis Elbow
John M. Mcshane, M.D.McShane Sports Medicine
Villanova, PA
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Tennis Elbow
• Disorder affecting the common extensor tendon at the the lateral epicondyle
• One of the most common tendon problems seen in musculoskeletal practice
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Tennis Elbow: Symptoms can be quite debilitating
• Pain at the lateral elbow with -.– picking up a cup of
coffee.– brushing teeth.– golf, tennis, etc.– keeping elbow in one
position (sleeping, telephone).
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Tennis Elbow: Why does it happen?
• Repetitive stress to the tendon leads to collagen breakdown
• “Inefficient” healing leads to fibrosis and even calcification
• Loss of elasticity leads to interstitial tearing
• Tears become “walled-off” from blood vessels
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Terminology - “Epicondylitis”
• -itis implies inflammation– Tendinitis implies
inflammation of a tendon
• Surgical specimens of affected tendons show NOsigns of inflammation– No WBC’s, no chemical
mediators of inflammation, etc.
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Inflammation• A fundamental pathologic
process consisting of … cytologic & histologic reactions that occur in response to an injury, including …the responses that lead to repair and healing.
• A NECESSARY component of healing
• Efforts to inhibit inflammation also inhibit healing
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Tennis Elbow is NOT Tendinitis:
IS Tendinosis
Degeneration of the tendon
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Histology of Healthy Tendon
• Dense fibers• Clearly-defined• Parallel• Slightly wavy bundles
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HEALTHY TENDON
• Densely packed
• Few nucleii
• Sparse amount of blood vessels
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Normal Tendon
• Has wavy pattern of regularity
• Termed “Crimp”
• Crimp provides “elasticity”
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Tendon Crimp
• “Elasticity” is actually the opening up of the wave pattern to straighten the collagen
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Tendinosis
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Tendinosis
• Disorganized array of Collagen fibers
• Loss of crimp• Loss of elasticity• Diffuse tendon
degeneration
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Tendinosis
• Dense, thick mass of scar tissue
• Inelastic• Collagen microtears• Attempted proliferation
of vessels• Tenocyte hypertrophy
and hyperplasia
• NO inflammation!
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Tendinosis
A Chronic, Degenerative Process
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So, What About Treatment?
• If no inflammation, do anti-inflammatory modalities, NSAIDS or steroid injections make sense?
• If the tendon is damaged, can the tendon remodel?
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NSAIDs
• May help reduce pain, but...
• ...No evidence that they improve long term outcome.
• In fact, they may impede healing
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Corticosteroid injections
• Rationale for use is unclear if there is no inflammation
• Treatment has lost favor in tendinopathy.• Possibly beneficial in early phase
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Corticosteroid injection2-6 Weeks
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Corticosteroid injection> 6 weeks
Assendelft WJJ, Brit J Gen Pract, 1996.
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Corticosteroid Injections
• Anecdotally, there is short-term, rapid symptom relief after injections.
• Why they help is unclear, but benefit is clearly short lived.
• NO EVIDENCE of long term benefit!
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“I’ve tried every brace on the market, every medication available, I’ve had 3 cortisone shots and 6 months of physical therapy. I’m still in pain! What now?!?”
-Frustrated Patient
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Surgery?
• Variable outcomes reported.– 46-85% success rate – Cochrane Review: “At this time there are no
published controlled trials of surgery for lateral elbow pain. Without a control group, it is not possible to draw any conclusions about the value of this modality of treatment.
– Most patients required 6-9 months after surgery to return to full activity.
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If Surgery, When?
• Reserved for failure of a non-operative treatment.
• Many surgeons will wait up to one year of symptoms.
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Technique• Variety of techniques described• Open debridement, release of ECRB most
common
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Any Other Option?
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Stages of Healing
• Break down scar• Open up channels for blood flow• Stimulate body’s healing response• Guide tissue remodeling• Restore strength and endurance
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Novel Procedure
• Diagnostic sonography
• Percutaneusneedle tenotomy
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Diagnostic Ultrasound• Tendinosis of Common Extensor Tendon is
easily seen with US– Hypoechoic regions– Calcifications– Bony irregularities– Fissures and peritendinous fluid– Thickening of tendinous insertion
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Sonographic Diagnosis• Normal Common
Extensor tendon– Homogeneous– Smooth bone– Not thickened
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Tendinopathy
• Irregular bone surface• Heterogeneous• Thickened• Tearing
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Novel Procedure
• Based on the actual pathology involved
• Attempt to break up scar
• Stimulate a healing response
• Guide that response with physical therapy
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Ultrasound Guided Tenotomy
• Local Anesthetic• 20g Needle
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Percutaneous Needling
• Tendinotic tissue is repeatedly fenestrated
• Calcification is broken up
• Not just random “poking”
• Systematic needling of the entire abnormal tendon
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Ultrasound Guided Tenotomy
• Post-Procedure• Aggressive rehab begun immediately!
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Post-Procedure
• Elbow is NEVER immobilized!
• MUST begin active stretching, isometrics immediately
• Elbow will be sore for several days, but will improve quickly with aggressive rehab
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Rehab
• Lasts @ 12 weeks• AGGRESSIVE!
– DFM– Stretching– Isometrics– Eccentrics– Push the envelope!– Activity as tolerated
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OUTCOMES
• Sonographically Guided Needle Tenotomy for Treatment of Common Extensor Tendinosis In The Elbow. McShane, Shah, Nazarian. J Ultrasound Med, 2008;27: 1137 - 44
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Patients
• 52 patients– Chronic “tennis elbow”– Average symptom length: 9 months
• Failed corticosteroid injection, NSAIDs, counterforce bracing, PT, wrist splints, and/or previous surgery
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Procedure
• All patients underwent percutaneous needling of origin of Common Extensor Tendon under US guidance
• 12 week rehab protocol immediately following the procedure
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Study Design
• Phone Interviews• Pt’s at least 6 months
out from procedure• Asked patients to rate:
– Current limitations– Current pain– Perceived success of
procedure– Would they
recommend it?
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Results
• 92 % of patients contacted reported EXCELLENT or GOOD results and would recommend the procedure to a friend or relative.
• NO ADVERSE EVENTS REPORTED.
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Since Study Ended
• Have treated several hundred additional patients
• Outcomes consistent• Physical therapy protocol has made the
biggest difference
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Summary
• Must understand the true pathology of “Tennis Elbow”– Tendinosis-- not tendinitis.
• Treatments must be aimed at treating the actual pathology
• Physical therapy should be aimed at tendon remodeling– Stretch, Isometrics, Eccentrics.
• Ultrasound guided percutaneous tenotomy provides a valuable option for recalcitrant cases.