Hand surgeons discuss what, if anything, works
Lateral epicondylitis—also known as tennis elbow—is “one of the most difficult problems in our practices,” said Jennifer Moriatis Wolf, MD, of the University of Connecticut, leading off a roundtable on the subject at the annual meeting of the American Society for Surgery of the Hand.
Lateral epicondylitis affects about 2 percent of the population, most often in the fourth and fifth decades, explained Graham J. W. King, MD, FRCSC, of the University of Western Ontario. Although it is common in tennis players, most patients who have this condition are not tennis players. A history of overuse is typical, although some injuries may be traumatic (Fig. 1).
The underlying pathology of tennis elbow is thought to be tendinosis of the extensor carpi radialis brevis (ECRB) tendon. The condition is not characterized by the presence of inflammatory cells, which is why “epicondylitis” is often described as a misnomer.
Fig. 1 Arthroscopic view showing a capsular tear in a patient complaining of elbow pain.
David C. Ring, MD, PhD, of Harvard Medical School, made the case for “self-limited treatment.” He said that patients often believe that they can’t depend on the arm if it is painful and have a hard time believing that the condition is one of the “self-limiting enthesopathies” of middle age.
“It’s hard for patients to shake the feeling that something needs to be done,” he said. He reassures patients that the arm is healthy and that they can depend on it even though it hurts.
Dr. Wolf summarized the various injection therapies available. The most common injection used is corticosteroids. Although studies support their efficacy for short-term pain relief, they do not demonstrate a benefit past 6 weeks. In fact, several studies show that most patients have pain relief at 6 months, whether they received steroids or not.
Another injection therapy is blood or blood products such as autologous blood injection (ABI) or platelet-rich plasma (PRP). The goal of ABI is to stimulate growth factor recruitment to the area of tendinopathy, while PRP is used to deliver a concentrated solution of growth factors. Study results have been mixed, showing no definitive evidence of better efficacy than other treatments. In one report, PRP showed better results than ABI at 6 weeks but no difference over time.
Dr. King noted that surgery might be considered after 1 year of failed nonsurgical management. A common surgical approach is either open or arthroscopic release of the ECRB tendon.
In an open lateral release, the lateral fascia is incised at the junction of the extensor digitorum longus and extensor aponeurosis, the extensor fascia is identified and opened, and pathologic tissue is removed. “Removing the tissue without taking out the lateral collateral ligament is key,” Dr. King said. He recommended the use of loops for better visualization of the pathologic tendon tissue and noted that some surgeons will perform an arthrotomy to inspect the joint.
The arthroscopic approach was described by Mark S. Cohen, MD, of Rush University. In this approach, the surgeon must incise and release the capsule from the humerus because the tendon is an extracapsular structure. Using a thermal device makes it easier to release the lateral soft tissues. Most surgeons no longer drill and débride the bone but are just “releasing, cleaning up, and getting out,” he said.
A recently developed surgical approach for tennis elbow—denervation of the lateral humeral epicondyle—was discussed by A. Lee Dellon, MD, PhD, of Johns Hopkins University. In this procedure, the cutaneous nerves at the elbow are severed and placed into the lateral head of the triceps muscle without a suture. According to Dr. Dellon, more than 80 percent of patients respond positively.
Is there a best choice?
A debate on the merits of various treatment approaches followed the presentations. Dr. Ring described tennis elbow as “an extremely common benign rite of passage through middle age,” and warned against “medicalizing or pathologizing this normal part of human development.” He stressed the importance of “self-efficacy” and suggested that administering ineffective treatments affects both financial and patient resources.
He quoted Voltaire’s observation that “the art of medicine consists in amusing the patient while nature cures the disease.” Although that may no longer be true for many aspects of medicine, “it is probably true for tennis elbow,” Dr. Ring said.
Dr. Wolf responded that Dr. Ring’s work had changed the way she practices. She tells her patients that tennis elbow is a self-limited entity that typically takes 1 to 2 years to resolve. But, she asked, “Why not offer patients conservative treatments such as injections to deal with the annoying pain of lateral epicondylitis during this time?”
Although Dr. Wolf explains to patients that people who do nothing generally do as well as those who get injections and that steroids do not help over the long term, she says that many patients want steroid treatment. “I let the patient decide what we should do, with full knowledge of what they can expect,” she said.
Dr. King also discussed his use of open lateral release surgery in light of Dr. Ring’s views. Although he has had “reasonable” results, he is cautious in recommending surgery for workers compensation patients because they tend to have poorer outcomes.
He relies on the open procedure because studies show results are as good as or better than arthroscopy. At his institution, the arthroscopic procedure takes three times longer and is therefore more expensive, requires general anesthesia, and involves more complicated equipment.
Dr. Cohen agreed that supportive results in the literature for arthroscopy are not convincing, saying, “Don’t get the idea that arthroscopic surgery is going to be the savior for the surgical treatment of tennis elbow.” But he has seen patients who no longer have symptoms a week after arthroscopy, something he did not encounter with the open procedure. “It’s anecdotal and there is a placebo effect,” he acknowledged.
Although one advantage sometimes claimed for arthroscopy is the opportunity to view loose bodies, “that’s not the reason you’re there,” Dr. Cohen said, “and that doesn’t justify the morbidity and time.”
Dr. Ring noted that controls and placebos are needed in researching effective treatments for subjective disorders. The only way to know if denervation is effective in relieving pain is to perform a patient-blinded, evaluator-blinded prospective randomized trial. Furthermore, it is difficult to have an enthusiast perform the trial because it is impossible to blind the surgeon. For illnesses that are entirely subjective (eg, pain, nausea, pruritus), sham-surgery controls are important. He called for trials performed by dispassionate surgeons with equipoise (uncertainty about which treatment will be beneficial), but noted that such trials would be difficult to establish for highly debated surgeries.
Disclosure information: Dr. King—Wright Medical Technology, Tornier Inc., Tenet Medical; Dr. Ring—Skeletal Dynamics, AO North America, AO International, Wright Medical Technology, Biomet, IlluminOss; Dr. Dellon—Pressure-Specified Sensory Device (patent), Sensory Management Systems; Dr. Cohen—Integra, Mylad. Dr. Wolf reported no conflicts.
Terry Stanton is senior science writer for AAOS Now. He can be reached at firstname.lastname@example.org
- Lateral epicondylitis is defined as tendinosis of the origin of the ECRB tendon and is not an inflammatory process.
- Common treatments include therapy; injection of corticosteroids, blood products, and glucose or saline; splinting; tendon release, whether open or arthroscopic; and watchful waiting. Denervation is a more recently developed procedure.
- No strong evidence exists to support the definitive efficacy of any treatment.
- More trials with placebos may be needed to evaluate treatments.
December 2012 Issue
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