Refractory Tennis Elbow Research Articles

Comparison between acupotomy and corticosteroid injection for patients diagnosed with different classifications of tennis elbow: a randomized control trial

BackgroundTennis elbow has long been one of the most controversial subjects in orthopaedics. Many scholars thought the use of open or arthroscopic surgery was reserved for patients with refractory symptoms. Therapy with percutaneous acupotomy performed under local anaesthesia also removes degenerated tissue, releases strain, and therefore provides an alternative treatment option to surgical excision.MethodsThe aim of this single-blinded randomized control trial was to examine the long-term clinical effectiveness of a nonsurgical percutaneous release technique (acupotomy) and the current recommended treatment (steroid injection) in people diagnosed with a refractory tennis elbow. Ninety patients with refractory symptoms were included. The intervention period was 6 weeks. According to the classification, 38 patients had extra-articular tennis elbow, 36 patients had intraarticular tennis elbow, and 16 patients had mixed type tennis elbow. Forty-five patients were randomly assigned to treatment with percutaneous release by acupotomy according to their classified condition, and 45 patients were randomly assigned to treatment with steroid injection alone. The visual analogue scale (VAS), a tenderness assessment, a grip assessment, and the Nirschl staging system were used for outcome evaluation at pretreatment and the posttreatment timepoints from 12 to 48 weeks.ResultsDuring the first weeks, there were no differences observed between the groups. By 6, 24 and 48 weeks, significant differences were observed between the two groups. The acupotomy group scored significantly better in visual analogue scale score (VAS) of pain, tenderness during palpation, pain-free grip strength (PFGS) and Nirschl staging than the corticosteroid group.ConclusionsFor patients with lateral epicondylitis, acupotomy is just as effective as corticosteroid injections in the short term (< 6 weeks). In the long term, acupotomy has greater efficacy and is associated with a lower rate of recurrence than corticosteroid injections in the management of lateral epicondylitis.Trial registration: The National Health Commission announced the "ethical review measures for biomedical research involving people" in 2019, which was not mandatory in previous studies.

Analysis of factors influencing the efficacy of extracapsular arthroscopic surgery for refractory tennis elbow

Objective: To investigate the mid-term efficacy of extracapsular arthroscopic surgery for refractory tennis elbow and explore prognostic factors. Methods: A retrospective study of 38 patients suffered from refractory tennis elbow and underwent extracapsular arthroscopic surgery performed by the same group of doctors during March 2012 to January 2016 at Institute of Sports Medicine, Peking University Third Hospital. There were 15 males and 23 females with age of 44.2 years(range: 32-59 years). Fifteen cases on the left and 23 cases on the right. Visual analogue scale(VAS), Mayo elbow performance score and Disability of Army, Shoulder and Hand (DASH) score were collected preoperatively and postoperatively, and compared by paired-t test. Independent sample t test, χ(2) test, multivariate logistic regression were used to analyze the relationship between scores and various potential influencing factors. Results: All 38 patients were followed up for 24 months. There was no complication such as infection or nerve injury recorded. VAS decreased from 7.0(1.2) (M(Q(R))) preoperative to 0(1) (Z=-5.40, P=0.00), Mayo increased from 55(26) to 100(0) (Z=-5.38, P=0.00),DASH decreased from 56.7(27.3) to 0.8(5.8)(Z=-5.37,P=0.00). The Mayo elbow performance score was excellent in 36 cases (94.7%) and good in 2 cases (5.3%). Women was significantly associated with poor prognosis. Conclusions: The mid-term effect of extracapsular arthroscopic treatment of refractory tennis elbow is satisfactory with few postoperative complications. Women was associated with poor prognosis.

Comparing leukocyte-rich platelet-rich plasma injection with surgical intervention for the management of refractory tennis elbow. A prospective randomised trial.

Patients with ongoing symptoms after non-operative treatment of lateral epicondylosis are usually treated with surgical release. Platelet-rich plasma injection is an alternative treatment option. This study aims to determine whether there is a difference in outcome from platelet-rich plasma injection or surgical release for refractory tennis elbow. Eighty-one patients with a diagnosis of tennis elbow for a minimum of six months, treated with previous steroid injection and a minimum visual analogue scale pain score of 50/100 were randomised to open surgery release (41 patients) or leucocyte rich platelet-rich plasma (L-PRP) (40 patients). Patients completed the Patient-Rated Tennis Elbow Evaluation and Disability of the Arm Shoulder and Hand at baseline, 1.5, 3, 6 and 12 months post-intervention. The primary endpoint was change in Patient-Rated Tennis Elbow Evaluation pain score at 12 months. Fifty-two patients completed final follow-up. Functional and pain scores improved in both groups. No differences in functional improvements were found but greater improvements in Patient-Rated Tennis Elbow Evaluation pain scores were seen after surgery. Thirteen patients crossed over from platelet-rich plasma to surgery within 12 months, and one surgical patient underwent a platelet-rich plasma injection. L-PRP and surgery produce equivalent functional outcome but surgery may result in lower pain scores at 12 months. Seventy per cent of patients treated with platelet-rich plasma avoided surgical intervention.

Technique and result of extra-articularly endoscopic treatment with refractory tennis elbow

Technique and result of extra-articularly endoscopic treatment with refractory tennis elbow

Long term results in refractory tennis elbow using autologous blood.

Tennis elbow (TE) is one of the commonest myotendinosis. Different treatment options are available and autologous blood injection has emerged as the one of the acceptable modalities of treatment. Long term studies over a larger group of patients are however lacking. The purpose of this study was to evaluate these patients on longer durations. One-hundred and twenty patients of TE, who failed to respond to conventional treatment including local steroid injections were taken up for this prospective study over the period from year 2005 to 2011 and were followed up for the minimum of 3 years (range 3-9 years). Two mL of autologous blood was taken from the ipsilateral limb and injected into the lateral epicondyle. The effectiveness of the procedure was assessed by Pain Rating Sscale and Nirschl Staging, which was monitored before the procedure, at first week, monthly for first three months, at 6 months and then 3 monthly for first year, six monthly for next 2 years and then yearly. Statistical analysis was done and a P value of <0.05 was taken as significant. The patients (76 females and 44 males) were evaluated after procedure. The mean age group was 40.67±8.21. The mean follow up was 5.7±1.72 (range 3 to 9 years). The mean pain score and Nirschl stage before the procedure was 3.3±0.9 and 6.2±0.82 respectively. At final follow up the pain score and Nirschl were 1.1±0.9 and 1.5±0.91 respectively. Autologous blood injection was found to be one of the modalities for treatment of TE. Being cheap, available and easy method of treatment, it should be considered as a treatment modality before opting for the surgery. Universal guidelines for the management of tennis elbow should be made as there is lot of controversy regarding the treatment.

The Boyd-McLeod procedure for tennis elbow: mid- to long-term results.

Tennis elbow is a common condition that usually responds to conservative measures. In refractory cases, surgical intervention is indicated. A plethora of surgical techniques have been described. We report the mid- to long-term outcomes of the Boyd-McLeod procedure for refractory tennis elbow. A retrospective analysis and current review of patients that had undergone the Boyd-McLeod procedure over a 12-year period was undertaken. Demographics, time to discharge, length of follow-up and outcome scores were collected. Seventy patients underwent surgery. Mean time to discharge was 15.35 weeks, with 88% successful outcomes. Fifty-four patients were available for current follow-up at mean of 5.52 years (range 1.17 years to 11.49 years). Range of motion in all patients was unchanged. There were no revision procedures. Mean (SD) Mayo Elbow Performance Score was 90.85 (13.11), with 75.5% returning a good or excellent score and 24.5% a fair outcome. The mean (SD) Oxford Elbow Score was 44.04 (6.92); mean (SD) pain score was 89.5 (17.58); mean (SD) function score was 95.34 (9.59) and mean (SD) socio-psychological score was 91.50 (17.01). Overall, 83% of patients had an Oxford Elbow Score of 43 or greater, suggesting excellent outcome. We show that the Boyd-McLeod procedure is an excellent option over both the short- and long-term for refractory tennis elbow.

Injection of bone marrow concentrates for treatment of refractory tennis elbow

Objective: The objective of this prospective study was the assessment of efficacy of bone marrow concentrate (BMC) (containing plasma rich in growth factors and mesenchymal stem cells) injection in treatment of refractory tennis elbow. Materials and Methods: A total of 30 adults with at least 6 months of refractory tennis elbow were administered single injection of BMC. This concentrate was made by centrifugation of iliac BM aspirate at 1800 rpm for 20-30 min and only upper layer containing platelet rich plasma and mononuclear cells was injected. Assessment was performed at baseline, 4 weeks and 12 weeks using Nirschl and visual analog scale (VAS) pain score. Results: Post-injection, significant reductions were reported in Nirschl, which decreased from a mean pre-injection score of 5.92 ± 0.85-3.19 ± 0.94 at 4 weeks (P < 0.001) and 1.65 ± 0.94 at 12 weeks (P < 0.0001). Similarly, significant reductions were found for VAS from a mean pre-injection score of 8.35 ± 0.94, to a mean VAS score of 5.23 ± 1.42 at 4 weeks (P < 0.0001) and to 1.85 ± 1.12 at 12 weeks (P < 0.0001). There were no adverse events. Conclusion: Treatment of patients with refractory tennis elbow with a single injection of BMC showed a significant improvement in short to medium term follow-up. This could be considered to be an alternative treatment for those patients who have failed non-operative treatment before surgical intervention is taken.

Platelet-Rich Plasma Versus Autologous Whole Blood for the Treatment of Chronic Lateral Elbow Epicondylitis

Background: Chronic lateral elbow epicondylitis is a tendinosis with angiofibrolastic degeneration of the wrist extensors’ origin. Healing of this lesion is reported with the use of autologous blood as well as with platelet-rich plasma (PRP). Purpose: A comparative study of these 2 treatments was conducted in an effort to investigate the possible advantages of PRP. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Twenty-eight patients were divided equally into 2 groups, after blocked randomization. Group A was treated with a single injection of 3 mL of autologous blood and group B with 3 mL of PRP under ultrasound guidance. A standardized program of eccentric muscle strengthening was followed by all patients in both groups. Evaluation using a pain visual analog scale (VAS) and Liverpool elbow score was performed at 6 weeks, 3 months, and 6 months. Results: The VAS score improvement was larger in group B at every follow-up interval but the difference was statistically significant only at 6 weeks, when mean improvement was 3.8 points (95% confidence interval [CI], 3.1-4.5) in group B (61.47% improvement) and 2.5 points (95% CI, 1.9-3.1) in group A (41.6% improvement) (P < .05). No statistically significant difference was noted between groups regarding Liverpool elbow score. Conclusion: Regarding pain reduction, PRP treatment seems to be an effective treatment for chronic lateral elbow epicondylitis and superior to autologous blood in the short term. Defining details of indications, best PRP concentration, number and time of injections, as well as rehabilitation protocol might increase the method’s effectiveness. Additionally, the possibility of cost reduction of the method might justify the use of PRP over autologous whole blood for chronic or refractory tennis elbow.

Arthroscopic treatment of refractory tennis elbow

目的 报告关节镜下手术治疗难治性网球肘的效果.方法 1999年12月-2006年3月,对15例保守治疗无效的网球肘患者,采用关节镜下肘关节前外侧、前内侧和后外侧入路手术,清理并松解损伤的伸肌腱腱性组织,术中同时处理合并损伤.采用VAS疼痛评分系统和改良美国肩肘关节外科协会评分系统(MASES)进行疗效评价.结果 15例中,Ⅰ型损伤(伸肌腱挫伤)9例,Ⅱ型损伤(线性裂伤)4例,Ⅲ型损伤(大部分或完全裂伤)2例(采用开放小切口修补术).术后15例恢复良好,未发生任何手术并发症.13例Ⅰ、Ⅱ型患者在术后7～28 d(平均18.3 d)恢复了原工作;2例Ⅲ型损伤者分别在术后2个月和3个月恢复了原工作.所有患者均获得12～48个月(平均25.1个月)的随访,VAS评分为0～4分,平均2.4分.MASES评分:优4例,良8例,一般3例,优良率为80%.结论 经肘关节镜下手术治疗难治性网球肘具有创伤小、术后恢复快的优点,同时能发现关节内合并的其他损伤并予处理。

Autologous Blood Injection In The Treatment Of Refractory Tennis Elbow

Tennis elbow is a common cause of pain and disability. It is more frequently seen in non-athletes, with a peak incidence in the early fifth decade on a nearly equal gender basis. Degeneration of the tendon of extensor carpi radialis brevis is believed to be the most common cause. Non-operative treatment is successful in effecting a resolution of symptoms in 90% of the patients. The remaining 10%, who do not respond to conservative treatment are labeled as resistant or refractory cases. Different modalities of treatment are used to treat these chronic cases. This includes multiple steroid injections, percutaneous tendon release, botulinum toxin injection, extracorporeal shock wave therapy, arthroscopic debridement, laser therapy, local injection of autologous blood and even platelet rich plasma and various surgical procedures. The fact that none of these procedures has been able to achieve a desirable outcome in a vast majority of subjects, research is on to reach a consensus in the non –operative treatment of this condition. The present study was undertaken to evaluate the clinical outcome in patients who failed to respond to other forms of non-operative modalities. The result of this study reveals that there was a significant improvement in pain and Nirschl stage in 58% of patients. There was no significant difference in the pain and Nirschl stage between the males and the females. There were, however, eleven patients (42%) who did not show a satisfactory response. There was no complication associated with the procedure. We conclude that autologous blood injection for refractory tennis elbow may be a viable option in these patients before being considered for surgery.

Magnetic resonance imaging findings of refractory tennis elbows and their relationship to surgical treatment

Treatment of tennis elbow is a problem. We performed magnetic resonance imaging (MRI) examinations of 11 elbows in 11 patients who were referred to us with refractory tennis elbow. Of the 11 elbows, 6 showed a high signal intensity focus on MRI T2 images in the tendon of the extensor carpi radialis brevis at the lateral epicondyle. The other 5 elbows showed various abnormal findings on MRI. The mean age of the 6 patients with a high T2 signal focus was 52.0 years, and the mean morbidity period was 25 months. We performed enucleation of the granulation focus through a surgical approach without detachment of the tendon origin of the extensor carpi radialis brevis. Pain was relieved and elbow function recovered in all 6 cases. This study demonstrates that MRI is an important decision-making tool in the surgical treatment of this condition. Enucleation of the granulation focus with high T2 signal has proved to be effective in 6 selected cases.

체외충격파를 이용한 테니스 엘보우의 치료에서 석회화 병변의 영향

Purpose: The aim of this study was to investigate effects of calcific lesion on shockwave therapy of the tennis elbow. Materials and Methods: twenty-four patients with refractory tennis elbow were treated with shock waves. The patients were evaluated by assessment of pain using visual analog scale (VAS) and simple elbow test (SET). Comparision of clinical outcomes for the patients with and without calcification in the extensor tendon and/or cortical irregularity of lateral condyle was tried to determine if this could be a possible prognostic factor in clinical settings. Overall clinical outcomes were evaluated by Roles and Maudsley score at 12 months after ESWT. Results: Significant improvement of symptoms were observed in 20 (83 %) patients at 12 months follow up according to Roles and Maudesley scores. The patients with calcification and/or cortical irregularity improved significantly better, when compared to the patients without calcification and/or cortical irregularity at follow up. Conclusion: This study suggests that shock waves therapy could be considered as effective and noninvasive treatment modality for refractory tennis elbow. Also calcific deposit in extensor tendon and/or cortical irregularity of the lateral epicondyle was seem to be good prognostic factor for shock wave therapy for tennis elbow