elbow tendinopathy

Elbow tendinopathy update

Adam C Watts

Consultant Elbow Surgeon, Wrightington Hospital Visiting Professor, University of Manchester

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www.wrightington.com

Why is the elbow prone to tendinopathy?

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Tendinopathies around the elbow

Lateral epicondylosis (Tennis elbow)

Medial epicondylosis (Golfer’s elbow)

Distal biceps tendinopathy

Distal triceps tendinopathy

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www.wrightington.com4


Pronator teres tendon origin


Presentation

Insidious onset

Change in activity/technique

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Weekend warrior >>> club athlete > elite


Clinical Diagnosis

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O’Driscoll hook test for distal biceps

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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

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When to get plain radiographs

Younger and older patients

Past history elbow trauma

Mechanical symptoms

Positive grip and grind

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important to exclude OCD in the young


Is there a role for MRI?

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NormalTendinopathic


What is a tendinopathy?

Chronic degenerative condition

Angiofibroblastic tendinosis

Myofibroblast proliferation

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Still none the wiser!


Normal Tendon

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Tendon Biology

Slow metabolism

Poor vascular supply

Neural elements

Tenocytes and mast cells

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Neurocellular Model Tendon Homeostasis

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Proteases

Chemotactic factors


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

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Ageing

Uncrimped fibres more sensitive to changes in load?


4 stages of tendinopathy

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Suggested Algorithm

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Eccentric loading for tendon dysrepair

Significant improvement in DASH score and VAS pains score when compared to standard treatment

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Eccentric Loading Distal Biceps

Biceps predominantly a supinator of forearm

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physiotherapy did not optimise long-term outcome

short-term benefit in the absence of corticosteroid injection


Steroid Injection

Physiotherapy


Is there any place for corticosteroids?

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Corticosteroids

Inhibit tenocyte proliferation

Inhibit tenocyte activity

Inhibit collagen synthesis

Increase tenocyte necrosis

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Steroid Injection

Physiotherapy

Natural History


Danger of steroid injection


Danger of steroid injection - lateral ligament rupture (PLRI)

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Dose dependent tenocyte death

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Autologous blood source

Concentrated platelet solution (2 to 8x normal)

PDGF, TGF, VEGF, FGF


Platelet Rich Plasma

Mini GPS III Biomet


Many systems - many differences

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RegenLab

Selphyl

Arthrex ACP


How does PRP work?

Stimulates an inflammatory process

Inflammation leads to healing

Is it organised healing?

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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


Platelet Rich Plasma - does it work?

Steroid

PRP

Pain Score

PRP 73% Success

Steroid 51% Success

Follow Up (Weeks)


Pain

Sco

res

Platelet Rich Plasma - better than steroid


Pain

Sco

res

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)

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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.

http://www.ncbi.nlm.nih.gov/pubmed?term=Mishra%20AK%5BAuthor%5D&cauthor=true&cauthor_uid=23825183

http://www.ncbi.nlm.nih.gov/pubmed?term=Skrepnik%20NV%5BAuthor%5D&cauthor=true&cauthor_uid=23825183

http://www.ncbi.nlm.nih.gov/pubmed?term=Edwards%20SG%5BAuthor%5D&cauthor=true&cauthor_uid=23825183

http://www.ncbi.nlm.nih.gov/pubmed?term=Jones%20GL%5BAuthor%5D&cauthor=true&cauthor_uid=23825183

http://www.ncbi.nlm.nih.gov/pubmed?term=Sampson%20S%5BAuthor%5D&cauthor=true&cauthor_uid=23825183

http://www.ncbi.nlm.nih.gov/pubmed?term=Vermillion%20DA%5BAuthor%5D&cauthor=true&cauthor_uid=23825183

http://www.ncbi.nlm.nih.gov/pubmed?term=Ramsey%20ML%5BAuthor%5D&cauthor=true&cauthor_uid=23825183

http://www.ncbi.nlm.nih.gov/pubmed?term=Karli%20DC%5BAuthor%5D&cauthor=true&cauthor_uid=23825183

http://www.ncbi.nlm.nih.gov/pubmed?term=Rettig%20AC%5BAuthor%5D&cauthor=true&cauthor_uid=23825183


Autologous Whole Blood v PRP

Several RCTs

No convincing evidence of difference

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Efficacy v Effectiveness often efficacy seen in RCT is not reproduced in clinical practice so it is important to study ‘real life’ effectiveness

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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

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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

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Morgan B, Trail IA, Watts AC, Birch A, Nuttal D Wrightington Upper Limb Unit


Baseline data

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Pre 1.5 3 6 12Time

Qui

ckD

ASH

PRP

Surgery


Patient Rated Tennis Elbow Evaluation

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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

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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?

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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

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Ultrasound driven percutaneous tenotomy

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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%

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Wrong Diagnosis

Radiocapitellar plica

Posterolateral rotatory instability

Radial tunnel syndrome

Radiculopathy


Remove trigger

NSAIDS?

Isometric exercises

Eccentric exercises

Injection

Surgery


Where are we now?

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Imaging

Insidious onset No history trauma

Adult

History trauma

Adolescent

Elderly

Tendinopathy +/- delamination

Analgesia

Activity modification

Physiotherapy - eccentric loading

Tendinopathy + macrotear/avulsion

SurgeryPRP injection and physio

Initial Presentation


Future research

Double blind randomised controlled trial PRP v HA v sham injection 150 patients

Recruiting soon!

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elbow tendinopathy

Health & Medicine