Tennis elbow (lateral epicondylitis or lateral elbow tendinopathy) is a self-limiting condition in most patients. Surgery is often offered to patients who fail to improve with conservative treatment. However, there is no evidence to support the superiority of surgery over continued nonoperative care or no treatment. New evidence also suggests that the prognosis of tennis elbow is not influenced by the duration of symptoms, and that there is a 50% probability of recovery every three to four months. This finding challenges the belief that failed nonoperative care is an indication for surgery. In this annotation, we discuss the clinical and research implications of the benign clinical course of tennis elbow. Cite this article: Bone Joint J 2023;105-B(2):109–111

Lateral epicondylitis, or ’tennis elbow’, is a common condition that usually affects patients between 35 and 55 years of age. It is generally self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment. This review discusses the mechanism of disease, symptoms and signs, investigations, current management protocols and potential new treatments. Cite this article: Bone Joint J 2013;95-B:1158–64

Objectives. Local corticosteroid infiltration is a common practice of treatment for lateral epicondylitis. In recent studies no statistically significant or clinically relevant results in favour of corticosteroid injections were found. The injection of autologous blood has been reported to be effective for both intermediate and long-term outcomes. It is hypothesised that blood contains growth factors, which induce the healing cascade. Methods. A total of 60 patients were included in this prospective randomised study: 30 patients received 2 ml autologous blood drawn from contralateral upper limb vein + 1 ml 0.5% bupivacaine, and 30 patients received 2 ml local corticosteroid + 1 ml 0.5% bupivacaine at the lateral epicondyle. Outcome was measured using a pain score and Nirschl staging of lateral epicondylitis. Follow-up was continued for total of six months, with assessment at one week, four weeks, 12 weeks and six months. Results. The corticosteroid injection group showed a statistically significant decrease in pain compared with autologous blood injection group in both visual analogue scale (VAS) and Nirschl stage at one week (both p < 0.001) and at four weeks (p = 0.002 and p = 0.018, respectively). At the 12-week and six-month follow-up, autologous blood injection group showed statistically significant decrease in pain compared with corticosteroid injection group (12 weeks: VAS p = 0.013 and Nirschl stage p = 0.018; six months: VAS p = 0.006 and Nirschl p = 0.006). At the six-month final follow-up, a total of 14 patients (47%) in the corticosteroid injection group and 27 patients (90%) in autologous blood injection group were completely relieved of pain. Conclusions. Autologous blood injection is efficient compared with corticosteroid injection, with less side-effects and minimum recurrence rate

Many procedures have been described for the operative treatment of tennis elbow (lateral epicondylitis). Arthroscopic tennis elbow release is a relatively recent development. The aim of this study was to review our early results of arthroscopic tennis elbow release. This was a prospective study of 29 consecutive patients (30 elbows) with tennis elbow refractory to conservative management, who underwent arthroscopic tennis elbow release performed by one surgeon. At surgery, arthroscopic assessment of the elbow joint was performed followed by capsulectomy and debridement of the Extensor Carpi Radialis Brevis (ECRB) tendon origin using the proximal lateral, anteromedial and anterolateral portals. Associated intra-articular pathology was noted. The ECRB lesions were classified according to their gross morphology and resected with a shaver but the insertion site was not decorticated. Patients were assessed preoperatively, at 2 weeks and at 3 months using the DASH score. 29 patients with tennis elbow were treated with arthroscopic release of the ECRB origin on the lateral epicondyle. Of the 30 elbows undergoing surgery, 22 were noted to have a Nirschl type I lesion (intact capsule), 7 had a type II lesion (linear capsular tear) and 1 had a type 3 lesion (capsular rent). Degenerative articular changes were noted in 18 elbows. Arthroscopic debridement was undertaken if appropriate. Three elbows had eccentric radial heads. Radial plicae which were impinging on the radial head were present in three patients. Mean follow up is 9 months (1–23). 1 patient was lost to follow up. There was a significant improvement in DASH scores (p< 0.05) at 2 weeks post operatively. This improvement became more significant at 3 months post operatively. This is a worst case scenario analysis using a paired t test. 6 patients failed to improve, 1 partially improved and 1 was revised and improved. There were no surgical complications; however, one patient has post operative stiffness which required an arthroscopic release. The early results of this study would suggest arthroscopic tennis elbow release is an effective treatment for tennis elbow, which in addition also allows assessment of the elbow joint and the potential to address associated intra-articular pathology if required. This minimally invasive technique has been demonstrated to be safe and affords early post operative rehabilitation and return to normal activities

Purpose: It is known from previous studies that reduced grip strength is associated with tennis elbow; however; assessment of muscular strength over other parts of upper limb, particularly wrist and shoulder, has received a little or no attention in the literature. To address possible other upper extremity muscular strength weakness-imbalances in Tennis Elbow, this study aimed to investigate the strength of various upper limb muscle groups in tennis elbow patients and compare them with those of healthy subjects. Methods: A total of 32 participants were assigned into two groups of Control (N=16) and Tennis Elbow (N=16). In both groups, upper limb maximal isometric muscular of dominant and non-dominant sides was measured at various joints including metacarpophalan-geal (extension & flexion), wrist extension & flexion), grip, and shoulder (internal and external rotation and abduction) using appropriate either commercial or purpose-built dynamometers. Muscular strength and important strength ratios were analyzed and compared in each group (dominant vs non-dominant) and also between Control and Tennis Elbow group using various statistical methods. Results: Significant dominance difference was found in all strength measurements for Control group but not for Tennis Elbow group indicating a generalized and widespread upper limb muscular weakness associated with tennis elbow. In addition, significant differences were found not only for various hand strength measurements but also for shoulder strength between Control and Tennis Elbow groups (p < 0.05). Conclusion: This is the most comprehensive study of upper limb isometric muscular strength assessment in Tennis Elbow during recent years. Distributed upper limb muscle strength weakness exists in Tennis Elbow which needs to be addressed within both preventative and treatment strategies

Many procedures have been described for the operative treatment of tennis elbow (lateral epicondylitis). Arthroscopic release is a relatively recent development. The aim of this study was to review our early results of arthroscopic tennis elbow release. This was a prospective study of 28 consecutive patients with tennis elbow refractory to conservative management, who underwent arthroscopic tennis elbow release performed by one surgeon. At surgery, arthroscopic joint assessment was performed followed by capsulectomy and debridement of the Extensor Carpi Radialis Brevis (ECRB) tendon origin using the proximal lateral and medial portals. The ECRB lesions were classified and resected with a shaver but the insertion site was not decorticated. Patients were assessed preoperatively, at 2 weeks and 3 months using the DASH score. Of the 28 elbows 21 were noted to have a Nirschl type I lesion (intact capsule), 6 had a type II lesion (linear capsular tear) and 1 a type III (capsular rent). Degenerative articular changes were noted in 19 elbows. If arthroscopic debridement was required it was undertaken. Three elbows were noted to have eccentric radial heads. Radial plicae which were impinging on the radial head were noted in three patients. 1 patient was lost to follow up. There was a significant improvement in DASH scores (p< 0.002) at 2 weeks post operatively. This improvement was sustained at 3 months. This is a worst case scenario analysis using a paired t test. 1 patient had post operative stiffness and 6 failed to improve of which 2 were revisions. The early results would suggest arthroscopic tennis elbow release is an effective treatment for tennis elbow, which in addition also allows assessment of the elbow joint and the potential to address associated intra-articular pathology. This minimally invasive technique has been demonstrated to be safe and affords early post operative rehabilitation

This study describes percutaneous method of tennis elbow release and medium term results. Materials and Methods: Eighteen patients (20 elbows) were reviewed following percutaneous tennis elbow release. All patients in this series underwent non-operative management with limited or no relief prior to surgery. The mean duration of treatment was 34.04 months prior to surgery. A percutaneous release of common extensor origin was performed under local anaesthetic. A small 1 cm skin incision was employed in all cases. Mean follow- up was 73 months with a range of 8–121 months. All patients except returned to work and normal level of activity. There was one poor result. The mean time to return to work was 5 weeks, with a range of 1 day –12 weeks. Thirteen patients (fifteen elbows) have been clinically examined. Five patients were contacted by phone. Results: Pain after surgery was evaluated with a visual analogue scale. Eighteen elbows (90% of cases) had an excellent result. Pain was rated at zero in seventeen cases. One case rated at zero at rest and two after heavy activity. One elbow (5%) had a good result with pain at zero at rest and raising four on the visual analogue scale after sporting activities (playing tennis for more than one hour). There was no improvement in one case (5%) with a visual analogue score of eight before and after surgery. There were no complications recorded. These results prove that percutaneous elbow release is a viable option in treatment of failed conservative tennis elbow management though astringent selection criteria should be observed

1. Tennis elbow is largely an affliction of middle age, and it is believed that degenerative changes in the orbicular ligament may underlie its pathology. 2. It has been shown that most patients may be relieved by either extra-articular or intra-articular injection of hydrocortisone, and operative intervention is required only in a minority of cases. 3. Contraction of the extensor carpi radialis brevis is considered to be the principal pain-producing factor, and Z-lengthening of the tendon of this muscle has been found to relieve the symptoms when conservative measures have failed. 4. The late results in fifty patients have shown that this operation causes diminution neither of the power of wrist dorsiflexion nor in the efficiency of the grip. The operation may therefore be undertaken with every prospect of relieving the discomfort of tennis elbow without inviting alternative disability

Aim: Description of and Prospective analysis of long-term outcomes of arthroscopic tennis elbow release. Materials and Methods: 70 patients (72 elbows) with lateral epicondylitis, recalcitrant to a minimum of 6 months of supervised conservative management, underwent arthroscopic lateral epicondylar release. Each patient was clinically evaluated pre operatively and post-operatively and a quantitative assessment of the grip strength was collected on both sides with a dynamometer, in full elbow extension and in 90 degrees flexion. Functional assessment with the Mayo Elbow Performance Score and dynamometer grip strengths were collected for the first two years post-operation. Results: Postoperative follow-up averaged 36 months (range 24–45months). The average MEPS increased from 57/100 to 89/100. 66 patients were graded as excellent outcomes, and 4 patients were noted to have fair outcomes. The latter 4 patients were assessed to have type 2 failure, with two subsequently requiring PIN releases, one requiring an osteochondroma excision from the distal laeral humerus, and one patient lost to follow-up. Dynamometr strength returned to above pre-operative level at an average of 3 months and were and average of 35% greater than the pre-operative level at final review. Complications consisted of synovial fistulae (n=8) all of which spontaneously resolved within one month, 2 portal superficial infections, 1 mild anterior capsular contracture, and no neurovascular injuries. Concurrent intra-articular pathology that was noted included radio-capitellar chondrosis (n=22), lateral trochlear chondrosis (n=20), anterolateral synovial plicae (n=17), synovitis (n=13), radial head instability (n=3), and synovial osteochondromatosis (n=1). Conclusion: Arthroscopic tennis elbow release is a valid technique for the treatment of recalcitrant lateral epicondylitis

The efficacy of extracorporeal shock-wave therapy for tennis elbow was investigated using a single fractionated dosage in a randomised, double-blind study. Outcomes were assessed using the Disabilities of Arm, Shoulder and Hand questionnaire, measurements of grip strength, levels of pain, analgesic usage and the rate of progression to surgery. Informed consent was obtained before patients were randomised to either the treatment or placebo group. In the final assessment, 74 patients (31 men and 43 women) with a mean age of 43.4 years (35 to 71), were included. None of the outcome measures showed a statistically significant difference between the treatment and control groups (p > 0.05). All patients improved significantly over time, regardless of treatment. Our study showed no evidence that extracorporeal shock-wave therapy for tennis elbow is better than placebo

Introduction: Different surgical options are available for the treatment of Tennis Elbow. One of the most simple is percutaneous lateral release. Patients and methods: This prospective study consists of 24 patients; who had persistent symptoms of tennis elbow for an average of 21 months before being operated. All patients received conservative treatment before surgery; only those who did not improve were surgically treated. All of them had percutaneous lateral release of the common extensor tendon under local anaesthetic as a day case. Results: Patients returned to work after an average of four weeks. Pain relief was achieved at an average of eight weeks. Patient satisfaction was 91.6%. The clinical results were evaluated according to pain relief, level of activity and patient satisfaction. The results were good in 22 patients, fair in 1 and poor in 1. Conclusion: We believe that percutaneous release should be offered at an earlier stage for patients who failed conservative treatment. It is a simple, reliable and cost effective surgical procedure

Tennis elbow (lateral epicondylitis) is a common upper limb condition, possibly resulting from angiofibroblastic degeneration. Conservative treatment comprises corticosteroid injections, rest and splints, however, occasionally surgery is necessary. Recent data comparing Botulinum Toxin Type A (BTX-A) (Botox®, Allergan Inc, Irvine, CA) with surgery suggested BTX-A is effective in treating resistant tennis elbow by providing temporary, reversible paralysis of affected muscle, thereby alleviating tensile forces and allowing tissue healing. This double-blind, randomised, controlled trial compared BTX-A with placebo in 40 patients with chronic tennis elbow (> 6 months). Recruited patients were randomised to 50U BTX-A+2mL normal saline or 2mL normal saline (placebo). Injections were administered 5cm distal to the maximal area of lateral epicondyle tenderness. Quality of life (SF-12), pain (visual analogue scale) and grip strength (Jamar dynamometer) were assessed pre- and 3 months post-injection in both affected and non-affected arms. Following BTX-A treatment patients had average 19% improvement in grip strength in the affected arm compared to average 2% for placebo, however, this difference did not reach statistical significance (p=0.08, 95% CI −2.31, 35.64). No difference between the groups was seen for the unaffected arm (BTX-A 4% improvement, placebo 1% improvement). Both groups showed similar improvements in pain assessment and also in quality of life. BTX-A treated-patients demonstrated improved grip strength in the affected arm compared to placebo, however this difference was not statistically significant

Introduction: Tennis Elbow affects 2% of the general population. 90% respond well to conservative management. Different surgical options are available for the treatment of recalcitrant Tennis Elbow. One of the most simple is percutaneous lateral release. Methods: Prospective analysis of 31 patients, who failed a trial of conservative treatment, and underwent a lateral release of the common extensor origin under local anaesthetic as a day case. The symptoms had been present for an average of 21 months. Patients were scored for pain, activity and satisfaction. Results: Pain relief was achieved in 90.3%, patient satisfaction in 90.3% and a return to full activity in 93.5%. The results were good in 28, fair in 2 and poor in 1. Return to work was on average after 4 weeks. Conclusion: It is a simple, safe and effective procedure. It should be offered at an earlier stage, in those who failed conservative treatment. If all other procedures are equally effective, it is logical to choose the simplest

Summary Statement. Applying appropriate upper limb regional-specific and joint-specific tools along with suitable psychologic tools provides an effective assessment of supportive, interventional, and treatment strategies in TE. Background. Tennis elbow (TE) is a painful pathologic condition with its origin in the common wrist extensor muscles at the lateral epicondyle. As the second most frequently diagnosed musculoskeletal disorder in the neck and upper limb in a primary care setting, with an annual incidence of 4 to 7 cases per 1000 patients in general practice (with a peak at 35 to 54 yrs of age), TE has considerable socioeconomic costs. As pain relief and improvement in functional performance are the 2 common aims of all treatment strategies, the importance of using appropriate tools for the assessment of pain and functional disability in TE is evident. In view of the high prevalence of TE, uncertainties about its treatment, and its substantial socioeconomic consequences, using more specific, patient-centred assessment tools is essential for providing more useful information on the level of pain and functional disability in TE. The Study aimed to: 1) compare pain and functional disability in tennis elbow (TE) patients with healthy controls; and 2) evaluate the relationship between the 2 major psychologic factors (anxiety and depression) and TE. Methods. Sixteen consecutive TE patients were recruited at an upper limb clinic: inclusion criteria were lateral epicondyle tenderness, pain with resisted wrist and middle finger extension and at least 3 months localised lateral elbow pain. Sixteen healthy controls with no upper limb problem were recruited from students and staff. Participants were given 4 questionnaires, together with instructions for completion: Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, Patient-Rated Wrist Evaluation Questionnaire, and Hospital Anxiety and Depression Scale. The independent t test was used to compare the total and subscale scores between the groups. Results. Significantly higher scores were found in TE for pain and function subscales and also total score for Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, and Patient-Rated Wrist Evaluation Questionnaire. For Hospital Anxiety and Depression Scale, both anxiety and depression subscales (P<0.001) and the total score (P<0.01) were significantly higher in TE. According to the anxiety and depression subscales, 55% and 36% of patients, respectively, were classified as probable cases (score >11). Discussion. TE patients showed markedly increased pain and functional disability. Significantly elevated levels of depression and anxiety pointed out the importance of psychologic assessment in TE patients. In the development of supportive and treatment strategies, we suggest the combination of “upper limb” and “psychologic” assessment tools

We propose a grading system for contrast free MRI images of tennis elbow and evaluate the inter and intra observer variability of their interpretation. Methods: Three senior orthopaedic surgeons were asked to blindly grade 0.2T dedicated extremity contrast free MRI images of elbows of patients who presented with varying degrees of symptomatic tennis elbow. Our proposed grading system of 1 to 5 based on the pattern around the common extensor tendon was used. Images of the symptomatic and contralateral non symptomatic elbows were graded blindly twice with an interval of 1 month by each surgeon. Each surgeon graded 176 MRI images twice. The grades were subsequently grouped into (I) grades 1 to 2 and (II) grades 3 to 5. Results: With regards to the intra observer agreement, consultant A showed 90.1% agreement, consultant B showed 90.6% agreement and consultant C 96.0% agreement. The mean intra observer agreement rate was 92.2%. The inter observer agreement between consultant A and B was 82.46%, between A and C 67.1% and between B and C 80.1%. It was also noted that there were systematic differences to the inter observer variability. Consultant A graded the images 3 to 5 on both occasions 52.9% of the time, consultant B graded 3 to 5 on both occasions 37.8% of the time and consultant C graded 3 to 5 on both occasions 23.3% of the time. Conclusion: The intra observer agreement rate is high. There is however a greater inter observer variation but this variation is consistent. We suggest that the inter observer differences can be improved by (1) reducing the grades to positive or negative and (2) by group reeducation of the observers

The aim of this study was to evaluate the analgesic effect of extracorporeal shock wave lithotripsy (ESWL) in patients with refractory tennis elbow, golfer’s elbow and plantar fasciitis. Patients with tennis elbow (34), golfer’s elbow (11) and plantar fasciitis lesions (14) who had not responded to a minimum of six months’ conservative treatment were included in this three-year study of ESWL. Patients who were pregnant or had neurological problems, coagulation disorder and tumour in the area of treatment were excluded. Patients received 2 000 shock waves of 0.04 to 0.12 mj/mnf three times at monthly intervals. Patients were followed up for a minimum of six months and maximum of 36 months. The effectiveness of ESWL was assessed in terms of improvement in duration and severity of pain, functional disability, complication of treatment and recurrence. Good or excellent results were achieved in 67.65% of patients with tennis elbow, 45.45% with golfer’s elbow and 71.42% with plantar fasciitis. ESWL seems a useful treatment option, as effective administered monthly as weekly. Its effectiveness in cases of golfer’s elbow in questionable

Failure of conservative treatment for tennis elbow is an indication for surgical decompression. The Topaz® technique utilises radiofrequency to decompress(detension) the tendon and in addition, it is thought to stimulate angiogenesis thereby facilitating healing. Initially we reviewed the three month follow up of 25 tennis elbow decompressions performed using the Topaz® technique. The case notes were reviewed and findings recorded on a structured proforma. After a minimum of 1 year we re-reviewed the case notes to identify recurrences or patients requiring revision surgery. The majority of patients were aged between 35–50 years. 87% of patients had symptoms for more than 12 months and symptoms experienced were mainly pain (100%). All patients had a full trial of physiotherapy and had minimum of two steroid injections. At three month follow up symptoms were completely relieved or improved in 88%. All patients were given an open appointment to review if symptoms recurred. On review of the notes after a minimum of one year, 84% had no further clinic attendances. Four elbows re-attended with symptom recurrence, two underwent traditional open release and two declined revision surgery. In the two patients who declined further surgery, symptoms had resolved at one year. The results of the Topaz® technique are comparable to that of the results of the traditional release from the literature both in terms of success and problems. It would be important to compare it to the traditional release to gauge its benefits against the standard practice

Objective: The main objective of our study was to compare the outcome and complications between open and percutaneous tennis elbow release using the Total Elbow Scoring System (TESS). Our null hypothesis is that there is no difference in patient based outcome measures and morbidity between both groups. Methods: We evaluated a cohort of 40 patients (41 elbows) with clinical evidence of tennis elbow that had surgery after failed conservative treatment. All patients were followed up for a minimum of 12 months and information entered into a structured questionnaire. Other outcomes measures assessed include; Visual Analogue Score (VAS), length of time to return to work, and wound complications. Results: Seventeen (17) and Twenty-four (24) elbows were managed by percutaneous release and open surgery respectively. There were twenty-one female patients (22 elbows) and nineteen male patients (19 elbows). The mean age of the study population was 45years (s.d.: 8.4yrs). The mean duration of symptoms before surgery was 20 months (s.d.: 9.1mths). All 17 elbows that had percutaneous release procedures had a TESS score greater than 80, in comparison to 19 out of 24 elbows with open procedures, although this was not quite significant. (p=0.06). A score of between 80 and 100 is considered good or excellent. Patients that had open surgery had a significantly higher pain (Visual analogue score) VAS in comparison to closed procedures (p=0.01). A significantly higher proportion of patients that had percutaneous procedures were able to return to work within 2 weeks in comparison to open procedures (p-=0.03). There were 4 cases of wound complication that occurred only in patients with open surgery. Conclusion: We conclude that percutaneous release for tennis elbow can produce satisfactory outcomes, with lower morbidity and earlier return to work compared with open procedures

We undertook a prospective, randomised study to compare the analgesic effect of injection of steroid and of extracorporeal shock-wave therapy (ESWT) for the treatment of tennis elbow. Group 1 received a single injection of 20 mg of triamcinolone with lignocaine while group 2 received 2000 shock waves in three sessions at weekly intervals. After six weeks there was a significant difference between the groups with the mean pain score for the injection group falling from 66 to 21 compared with a decrease from 61 to 35 in the shock-wave group (p = 0.05). After three months, 84% of patients in group 1 were considered to have had successful treatment compared with 60% in group 2. In the medium term local injection of steroid is more successful and 100 times less expensive than ESWT in the treatment of tennis elbow

We conducted a prospective, randomised, controlled trial of 45 patients (47 elbows), with tennis elbow, who underwent either a formal open release or a percutaneous tenotomy. All patients had pre- and post-operative assessment using the Disability of Arm, Shoulder and Hand (DASH) scoring system. Both groups were followed up for a minimum of 12 months. Statistical analyses using the Mann-Whitney U test and repeated measured ANOVA showed significant improvements for patient satisfaction (p = 0.012), time to return to work (p = 0.0001), improvements in DASH score (p = 0.001) and improvement in sporting activities (p = 0.046) in the percutaneous group. Those patients undergoing a percutaneous release returned to work on average three weeks earlier and improved significantly more quickly than those undergoing an open procedure. The percutaneous procedure is a quicker and simpler procedure to undertake and produces significantly better results

Aims of the Study: To compare the outcome of percutaneous release and formal open release for tennis elbow. Material and Methods: We conducted a prospective randomised controlled trial. 45 patients (total of 47 elbows) underwent either a formal open release or a percutaneous tenotomy (24 open, 23 percutaneous). All patients had pre-operative assessment by the DASH (Disability of the Arm, Shoulder and Hand) scoring system. The surgery was performed by 1 surgeon (BN Muddu). Both groups were followed up for a minimum of 12 months and re-assessed using the DASH scores, time for return to work and patient satisfaction. Statistical analysis using Mann-Whitney and repeated measures ANOVA were performed. Results: The groups were similar in respect of demographic and pre-test variables. Statistical analyses using Mann-Whitney showed significant differences for patient satisfaction (p=0.012), time to return to work (p=0.0001), improvements in DASH Score (p=0.002) and improvement in sporting activities (p=0.046). There was a trend to improvement in work related activity. Repeated measures ANOVA comparing the pre-operative data for each group were also significant for standardized DASH scores (p=0.0082) and sporting activities (p=0.043). Discussion/Conclusion: Our study has shown that there is a significant difference in outcome in the two patient groups. Those patients undergoing a percutaneous release returned to work on average 3 weeks earlier and their symptoms as shown from their DASH scores improved significantly more than those undergoing an open procedure. The percutaneous procedure is a quicker, simpler procedure to perform than an open procedure. Our study has shown that patients have significantly better outcome measures after a percutaneous procedure

Aim: To assess the outcome of open release of the common extensor origin in the management of tennis elbow after the failure of non operative treatment methods. Methods: 18 patients (24 elbows) between the age group of 38 to 59 who underwent open release of the common extensor origin by the same team after a mean waiting time of 23 months from the onset of pain and a trial of failed non operative methods like analgesics/nsaids, physiotherapy, local steroid injections were contacted and asked to score the effectiveness of surgery after a gap of six months. Since the predominant troubling symptom for all patients was pain they were asked to score the pain relief correlating with the surgery. Results: In 15 patients (83%) excellent pain relief (defined as an 8 or more out of 10 improvement) was achieved and they regained normal use of the limb. One patient (5%) had moderate improvement (score between 6 and 7 out of 10) and two further (11%) patients gained minimal benefit with persistent symptoms (score 5 out of 10). None of the patients suffered deterioration as a result of surgery. Conclusion: This study proves that despite new advances in the treatment of tennis elbow, release of the extensor origin by the open method which is a simple and economical day case procedure, still remains an excellent option in cases where trial of non operative management has failed

The aim of this study was to review the effectiveness of percutaneous release of the common extensor origin for tennis elbow. The operative technique is similar to that previously reported by Hohmann in 1949. There were 29 patients (31 elbows) that underwent the procedure between 1991 and 1998. There were 14 males and 15 females; 19 were right handed, and 17 had the dominant arm involved. The mean age was 51.8 years (range 34–65); the mean duration of symptoms was 21.7 months (range 8–60 months). All patients had a minimum of 12 months of conservative treatment including NSAIDs, splinting, physical therapy and local anaesthetic and steroid injections (2–6 injections). All operations were performed as day case procedures, with the majority (25) done under local anaesthetic. 24 patients were independently reviewed using Hospital for Special Surgery Elbow Assessment and a questionnaire. Grip strength measurements were performed using JAMAR Dynanometer and the level of patient satisfaction was recorded. 5 patients could not attend the special review clinics. They were contacted over the phone and necessary data recorded. The mean follow up was 45.2 months (range 8–88 months). 24 patients scored above 70 points and were very satisfied, 6 patients were considered failures as their symptoms warranted formal open release operation; only two reported an improvement following the open releases, with the remainder still symptomatic at the last follow up. An overall success rate of 81% was recorded. Complications were rare - one patient who had bruising of forearm after the procedure. In conclusion this procedure can be recommened as an efficacious first line of surgical treatment, with advantages of being safe, quick to perform and with minimal morbidity

We report a controlled, prospective study to investigate the effect of treatment by low-energy extracorporeal shock waves on pain in tennis elbow. We assigned at random 100 patients who had had symptoms for more than 12 months to two groups to receive low-energy shock-wave therapy. Group I received a total of 3000 impulses of 0.08 mJ/mm. 2. and group II, the control group, 30 impulses. The patients were reviewed after 3, 6 and 24 weeks. There was significant alleviation of pain and improvement of function after treatment in group I in which there was a good or excellent outcome in 48% and an acceptable result in 42% at the final review, compared with 6% and 24%, respectively, in group II

Aims: Primary aim of this study was to evaluate the inßuence of simultaneous local anesthesia on the clinical outcome after repetitive low-energy extracorpreal shock wave therapy (ESWT) for chronic tennis elbow. Methods: 51 patients were treated in a randomized single-blind international multicenter trial with a parallel-group design and blinded independent observer to evaluate low-energy ESWT with local anesthesia versus placebo ESWT with local anesthesia for patients with a chronic tennis elbow at three-month follow-up. 85% of patients of the verum group did not achieve good/ excellent results in the Roles & Maudsley score, they were offered once again application of the identical active treatment concept, this time without local anesthesia. 80% of the patients of the placebo group did not achieve good/excellent results, they were offered crossover therapy, i.e. identical active treatment with local anesthesia. Results: Reception of active therapy without local anesthesia resulted in excellent or good outcomes in 80% of patients of the original verum group at three-month follow-up, while application of active therapy with local anesthesia lead to good outcomes in 27% of the original placebo group (p= 0.0092, power= 0.8). Conclusions: Local anesthesia has a negative inßuence on the clinical outcome after repetitive low-energy ESWT for chronic tennis elbow

We performed a prospective, randomised trial on 106 patients to compare the effects of local corticosteroid injections with physiotherapy as advocated by Cyriax in the treatment of tennis elbow. The main outcome measures were the severity of pain, pain provoked by resisted dorsiflexion of the wrist, and patient satisfaction. At six weeks 22 of 53 patients in the injection group were free from pain compared with only three in the physiotherapy group. In the corticosteroid-treated group 26 patients had no pain on resisted dorsiflexion of the wrist compared with only three in the physiotherapy group. Thirty-five patients who had injections and 14 who had physiotherapy were satisfied with the outcome of treatment at six weeks. At the final assessment there were 18 excellent and 18 good results in the corticosteroid group and one excellent and 12 good results in the physiotherapy group. There was a significant increase in grip strength in both groups but those with injections had a significantly better result. After one year there were no significant differences between the two groups. Half of the patients, however, had received only the initial treatment, 20% had had combined therapy and 30% had had surgery. We conclude that at six weeks, treatment with corticosteroid injections was more effective than Cyriax physiotherapy and we recommend it because of its rapid action, reduction of pain and absence of side-effects

We have reviewed 185 articles published since 1966 to assess the scientific evidence for methods of treatment for lateral epicondylitis of the elbow. Of the 185 articles, 78 discussed treatment, but since the natural history of the syndrome is uncertain we considered only those series with concurrent control groups. Only 18 of these were randomised and controlled studies. We then graded these papers for scientific validity, using the methods of Chalmers et al (1981). The mean score of the 18 articles was only 33%, with a range from 6% to 73%. A minimum of 70% is required for a valid clinical trial, and we therefore concluded that there was insufficient scientific evidence to support any of the current methods of treatment. There were too many methodological differences to allow a quantitative meta-analysis, but our qualitative review established the importance of the natural evolution of the syndrome and of the placebo effect of all treatments. Properly designed, controlled trials are needed

Introduction and Aims: To compare the outcome of percutaneous release and fonnal open release for tennis elbow. Method: We conducted a prospective randomised controlled trial. 45 patients (total of 47 elbows) underwent either a formal open release or a percutaneous tenotomy (24 open, 23 percutaneous). All patients had pre-operative assessment by the DASH (Disability of the Arm, Shoulder and Hand) scoring system. The surgery was performed by one surgeon (BN Muddu). Both groups were followed up for a minimum of 12 months and re-assessed using the DASH scores, time for return to work and patient satisfaction. Statistical analysis using Mann-Whitney and repeated measures ANOV A were performed. Results: The groups were similar in respect of demographic and pre-test variables. Statistical analyses using Mann-Whitney showed significant differences for patient satisfaction (p=O.OI2), time to return to work (p=O.OOOI), improvements in DASH Score (p=O. OO2) and improvement in sporting activities (p=O. O46). There was a trend to improvement in eight in work related activity. Repeated measures ANOV A comparing the pre-operative data for each group were also significant for standardised DASH scores (p=O. OO82) and sporting activities (p=O.O43). Conclusion: Our study has shown that there is a significant difference in outcome in the two patient groups. Those patients undergoing a percutaneous release returned to work on average three weeks earlier and their symptoms as shown from their DASH scores improved significantly more than those undergoing an open procedure. The percutaneous procedure is a quicker, simpler procedure to perform than an open procedure. Our study has shown that patients have significantly better outcome measures after a percutaneous procedure

We conducted a prospective randomised controlled trial. 45 patients (total of 47 elbows) underwent either a formal open release or a percutaneous tenotomy (24 open, 23 percutaneous). All patients had pre-operative assessment by the DASH (Disability of the Arm, Shoulder and Hand) scoring system. The surgery was performed by 1 surgeon (BN Muddu). Both groups were followed up for a minimum of 12 months and re-assessed using the DASH scores, time for return to work and patient satisfaction. Statistical analysis using Mann-Whitney and repeated measures ANOVA were performed.

The groups were similar in respect of demographic and pre-test variables. Statistical analyses using Mann-Whitney showed significant differences for patient satisfaction (p=0.012), time to return to work (p=0.0001), improvements in DASH Score (p=0.002) and improvement in sporting activities (p=0.046). There was a trend to improvement in work related activity. Repeated measures ANOVA comparing the pre-operative data for each group were also significant for standardized DASH scores (p=0.0082) and sporting activities (p=0.043).

Our study has shown that there is a significant difference in outcome in the two patient groups. Those patients undergoing a percutaneous release returned to work on average 3 weeks earlier and their symptoms as shown from their DASH scores improved significantly more than those undergoing an open procedure. The percutaneous procedure is a quicker, simpler procedure to perform than an open procedure. Our study has shown that patients have significantly better outcome measures after a percutaneous procedure.

The August 2023 Shoulder & Elbow Roundup360 looks at: Motor control or strengthening exercises for rotator cuff-related shoulder pain? A multi-arm randomized controlled trial; Does the choice of antibiotic prophylaxis influence reoperation rate in primary shoulder arthroplasty?; Common shoulder injuries in sport: grading the evidence; The use of medial support screw was associated with axillary nerve injury after plate fixation of proximal humeral fracture using a minimally invasive deltoid-splitting approach; MRI predicts outcomes of conservative treatment in patients with lateral epicondylitis; Association between surgeon volume and patient outcomes after elective shoulder arthroplasty; Arthroscopic decompression of calcific tendinitis without cuff repair; Functional outcome after nonoperative management of minimally displaced greater tuberosity fractures and predictors of poorer patient experience

The June 2024 Shoulder & Elbow Roundup. 360. looks at: Reverse versus anatomical total shoulder replacement for osteoarthritis? A UK national picture; Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomized controlled trial; acid for rotator cuff repair: a systematic review and meta-analysis of randomized controlled trials; Metal or ceramic humeral head total shoulder arthroplasty: an analysis of data from the National Joint Registry; Platelet-rich plasma has better results for long-term functional improvement and pain relief for lateral epicondylitis: a systematic review and meta-analysis of randomized controlled trials; Quantitative fatty infiltration and 3D muscle volume after nonoperative treatment of symptomatic rotator cuff tears: a prospective MRI study of 79 patients; Locking plates for non-osteoporotic proximal humeral fractures in the long term; A systematic review of the treatment of primary acromioclavicular joint osteoarthritis

The August 2013 Shoulder & Elbow Roundup. 360 . looks at: the sternoclavicular joint revisited; surgical simulators: more than just a fancy idea?; arthroscopic tennis elbow release; costly clavicle stabilisation; a better treatment for tennis elbow?; shock news: surgeons and radiologists agree; overhead athletes and SLAP repair; and total shoulder arthroplasty more effective than hemiarthroplasty

Introduction. Lateral epicondylitis, also known as “tennis elbow,” is a degenerative disorder of the common extensor origin of the lateral humeral epicondyle. The mainstay of treatment is non-operative and includes physiotherapy, activity modification, bracing, nonsteroidal anti-inflammatory drugs, and injections. There is a subgroup of patients however who do not respond to non-operative measures and require operative intervention. Methods. We conducted a retrospective review of prospectively collected data to assess whether the introduction of PRP injections for lateral epicondylitis led to a reduction in patients subsequently undergoing surgical release. Results. Prior to the introduction of PRP injections, a mean of 12.75 patients a year underwent arthroscopic release for tennis elbow. Since PRP introduction this reduced to a mean of 4.25 patients a year. Using a Pearsons chi squared test this is a significant fall in the number of releases required, P<0.001. This significant reduction in patients requiring surgery since PRP introduction leads to an absolute risk reduction of 0.773 and number needed to treat on “as-treated” basis of only 1.3. Conclusion. In conclusion we consider PRP injection, for intractable lateral epicondylitis of the elbow, not only a safe but also very effective tool in reducing symptoms and have shown it has reduced the need for surgical intervention in this difficult cohort of patients

Surgical debridement for medial epicondylitis (ME) is indicated for patients with refractory ME. The clinical efficacy of simple debridement has not been studied sufficiently. Moreover, authors experienced surgical outcome of ME was not as good as lateral epicondylitis. In this regard, authors have combined the atelocollagen injection in the debridement surgery of ME. The purpose of study was to compare clinical outcomes between simple debridement and debridement combined with atelocollagen injection in the ME. Twenty-five patients with refractory ME and underwent surgical debridement were included in the study. Group A (n=13) was treated with isolated debridement surgery, and group B (n=12) was treated with debridement combined with 1.0 mL of type I atelocollagen. Pain and functional improvements were assessed using visual analogue scale, Mayo Elbow Performance Score (MEPS) and quick Disabilities of the Arm, Shoulder and Hand (DASH) scale respectively before surgery, at 3, 6 months after surgery and at the final follow-up. Demographic data did not show significant difference between two groups before surgical procedures. Both groups showed improvement in pain and functional score postoperatively. However, at the 3 months after surgery, group B showed significantly better improvement as compared to group A(VAS 3.1 / 2.0, MEPS 71/82 qDASH 29/23). At the 6 months after surgery and final follow-up, both groups did not show any difference. Surgical debridement combined with atelocollagen is effective treatment option in refractory ME and showed better short-term outcomes compared to isolated surgery

Musculoskeletal disorders have been recognised as common occupational risks for all orthopaedic surgeons. The nature of tasks performed by hip surgeons often requires both forceful and repetitive manoeuvres, potentially putting them at higher risk of musculoskeletal injuries compared to other orthopaedic sub-specialities. This study aimed to investigate the prevalence of musculoskeletal conditions among hip surgeons and evaluate the association between their workplace and lifestyle factors and musculoskeletal health. An online questionnaire consisting of 22 questions was distributed to UK-based consultant hip surgeons via email and social media platforms. This survey was completed by 105 hip surgeons. The mean age of the respondents was 49 years (range 35–69), with an average of 12 years (range 1–33) in service. 94% were full-time and 6% worked part-time. 49% worked at a district general hospital, 49% at a tertiary centre and 4% at a private institution. 80% were on the on-call rota and 69% had additional trauma commitments. 91% reported having one or more, 50% with three or more and 13% with five or more musculoskeletal conditions. 64% attributed their musculoskeletal condition to their profession. The most common musculoskeletal conditions were base of thumb arthritis (22%), subacromial impingement (20%), degenerative lumbar spine (18%) and medial or lateral epicondylitis (18%). 60% stated that they experienced lower back pain. Statistical analysis showed that being on the on-call rota was significantly (P<0.001) associated with a higher musculoskeletal burden. Regular resistance and/or endurance training and BMI<30 were statistically significant protective factors (P<0.001). Over the last few decades, most of the hip-related literature has focused on improving outcomes in patients, yet very little is known about the impact of hip surgery on the musculoskeletal health of hip surgeons. This study highlights a high prevalence of musculoskeletal conditions among UK-based hip surgeons. Hip surgeons have a pivotal role to play in the ongoing recovery of elective orthopaedics services. There is a pressing need for the identification of preventative measures and improvement in the surgical environment of our hip surgeons

Purpose: It is known from the literature that gripping, which is commonly used in various work-related, sport-related, and daily activities, activates both wrist extensors and flexors. Pain aggravation occurs during grip due to over-exertion of the extensor muscle group in lateral epicondylitis and grip strength is reduced. Of grip strength studies, few studies have simultaneously investigated muscular response using electromyography as a method of monitoring muscular fatigue or muscular activity of forearm muscles. The fatigability and activity of wrist antagonistic muscles in patients with lateral epicondylitis has not been previously investigated. Methods: 16 tennis elbow patients (Tennis Elbow Group) and 16 healthy volunteers (Control Group) were participated in this study. In both groups, local muscular fatigue and muscular activity were measured for 3 forearm muscles contributing to the wrist extension and 2 muscles contributing to the wrist flexion using EMG and during gripping at 50% maximum voluntary contraction (MVC). Fatigability and activity of muscles then were compared between control and tennis elbow groups. Results: Grip strength was significantly lower in tennis elbow group than that in control group (p < 0.05). Median frequency (MDF) and root mean square (RMS) of electromyographic signals were used as parameters to measure muscular fatigue and muscular activity, respectively. Further analysis showed no significant difference in the fatigability of forearm muscles between two groups. The activity of Extensor Carpi Radialis (ECR) showed statistically significant reduction in tennis elbow group compared to the control group (p < 0.05). Conclusion: This is the first study to simultaneously investigate the fatigability and activity of the forearm antagonistic muscle groups in patients with lateral epi-condylitis. The fact that ECR showed similar level of muscular fatigue to other muscles despite decreased muscular activity may indicate of higher fatigability of this muscle in tennis elbow. Furethermore, decreased muscular activity of ECR may be a part of mechanism to protect the muscle from further injury in tennis elbow patients

Several surgical techniques have been described of resistant lateral epicondylitis or tennis elbow with variable results. This retrospective study presents the long-term outcome of a single surgeons experience with a modified surgical technique for the treatment of resistant lateral epicondylitis. Between 1986 and 2001, the senior author performed 171 surgical procedures in 158 patients for resistant lateral epicondylitis. 147 elbows in 136 patients (88%) were independently evaluated at a mean time to follow up of 9.8 years. Patients were assessed using a functional questionnaire and physical assessment. In addition to physical assessment, provocative testing of the extensor origin and grip strength was performed. Patients subjectively rated the result of surgery and these results were compared to objective elbow performance scores. Subjectively, 97% of patients assessed the result from surgery as good to excellent. Objectively, 97% results were good to excellent using elbow performance scores. Synovial fistulate developed in two patients by day ten postoperatively. One patient required further surgery for a synovial fistula which healed with no sequelae. There were no other complications following surgery. The postoperative range of motion improved in all patients but remained reduced in four patients. There was a significantly worse outcome for patients with Worker’s compensation claim and for cigarette smokers. There was no difference between grip strengths between the operated arm and the non-operated arm. The majority of patients returned to work by six weeks and were pain free by twelve weeks. Less than 5% of patients experienced lateral epicondylitis pain in their elbow post-operatively. A small group of patients altered their occupation or recreational activities due to tennis elbow symptoms. The surgical technique described produces excellent results in greater than 87% of patients in the treatment of resistant lateral epicondylitis. This procedure produces a low complication rate and is associated with a high rate of patient satisfaction. Patient selection is critical in the surgical treatment of resistant lateral epicondylitis

Introduction and Aims: Several surgical techniques have been described for the treatment of resistant lateral epicondylitis or tennis elbow with variable results. This retrospective study presents the long-term outcome of a single surgeon’s experience, with a modified surgical technique for the treatment of resistant lateral epicondylitis. Method: Between 1986 and 2001, the senior author performed 171 surgical procedures in 158 patients for resistant lateral epicondylitis. 147 elbows in 136 patients (88%) were independently evaluated at a mean time to follow-up of 9.8 years. Patients were assessed using a functional questionnaire and physical assessment. In addition to physical assessment, provocative testing of the extensor origin and grip strength was performed. Patients subjectively rated the result of surgery and these results were compared to objective elbow performance scores. Results: Subjectively, 97% of patients assessed the result from surgery as good to excellent. Objectively, 97% results were good to excellent using elbow performance scores. Synovial fistulae developed in two patients by day 10 post-operatively. One patient required further surgery for a synovial fistula, which healed with no sequelae. There were no other complications following surgery. The post-operative range of motion improved in all patients, but remained reduced in four patients. There was a significantly worse outcome for patients with a Workers’ compensation claim and for cigarette smokers. There was no difference between grip strengths between the operated arm and the non-operated arm. The majority of patients returned to work by six weeks and were pain-free by 12 weeks. Less than 5% of patients experienced lateral epicondylitis pain in their elbow post-operatively. A small group of patients altered their occupation or recreational activities due to tennis elbow symptoms. Conclusion: The surgical technique described produces excellent results in greater than 87% of patients in the treatment of resistant lateral epicondylitis. This procedure produces a low complication rate and is associated with a high rate of patient satisfaction. Patient selection is critical in the surgical treatment of resistant lateral epicondylitis

OBJECTIVE: The purpose of this study is to examine the effect of a single percutaneous injection of platelet-rich-plasma compared to an injection of corticosteroids in patients with chronic lateral epicondylitis. BACKGROUND: Lateral epicondylitis is a common problem that usually resolves with nonoperative treatments. Platelet Rich Plasma (PRP) is a component of whole blood that contains concentrated amounts of powerful growth factors. PRP has been used for a variety of orthopedic applications including tendinopathy, wound healing and spinal fusion with varying degrees of success. Buffered PRP has also been used to enhance cell proliferation in-vitro. HYPOTHESIS: Treatment of chronic severe lateral epicondylitis with buffered platelet-rich plasma will reduce pain and increase function in patients considering surgery for their problem. METHODS: One hundred patients with persistent lateral epicondylar pain were evaluated in this study. All these patients were initially given a variety of nonoperative treatments. These patients had significant persistent pain for at least 3 months despite these interventions. All patients were considering surgery. This cohort of patients who had failed nonoperative treatment was then given either a single percutaneous injection of platelet-rich plasma (experimental group, n = 50) or corticosteroids (control group, n = 50). RESULTS: PRP has a significant better effect on lateral epicondylitis than corticosteroid injections. CONCLUSION: This in-vivo data suggest that tendon healing is occurring in lateral epicondylitis using PRP

Autologous injection of platelet rich plasma (PRP) stimulates healing process in degenerated tendons. The purpose of this study is to compare the functional outcome of lateral epicondylitis treated with PRP and steroid injection. Tennis elbow patients who failed conservative medical therapy were included and were allocated randomly steroid group (n=70) and PRP group (n=63). Data were collected before procedure, at 4, 8, 12 weeks, 1 year and 2 years after procedure. The main outcome measures were visual analogue score, Mayo elbow performance score, DASH score and hand grip strength. Successful treatment was defined as more than a 25% reduction in visual analogue score or DASH score and more than 75 score in Mayo elbow performance score. We observed that 35 of the 70 patients (50%) in corticosteroid group and 47 of the 63 patients (75%) in PRP group were successful, which was significantly different (p<.001), according to DASH score 37 of the 70 patients (53%) and 47 of the 63 patients (75%) in the PRP group were successful which was also significantly different (P = .005), Mayo elbow performance score was successful in 36 of the 70 patients (51%) in corticosteroid group and 49 of the 63 patients (78%) in PRP group. The improvement in hand grip strength of hand from 24.7kg (mean) 26kg in corticosteroid group and 23.5kg (mean) to 32.9kg (mean) in PRP group. PRP injection for chronic lateral epicondylitis reduces pain, improve functionality and hand grip strength when compared to steroid injection

The aim of this study was to document the findings and the pathology of tennis elbow during arthroscopy in patients who had failed conservative treatment for lateral elbow pain with a presumptive diagnosis of lateral epicondylitis (tennis elbow). Materials and Methods: We carried out a prospective study of a consecutive series of 397 patients who underwent elbow arthroscopy for lateral elbow pain previously diagnosed as lateral epicondylitis. All the patients had a period of atleast six months of various conservative treatment modalitiesin the nature of NSAIDS, bracing physiotherapy and ultrasound. The arthroscopy procedures were performed by one of two surgeons using identical standard techniques and the findings were carefully documented. Results: There were 238 men and 159 women in the study group: mean age 51 years (range 21 to 80 years). Synovitis was present in 173(44%), degenerative changes in 232 (58%), common extensor origin inflammation in 173(44%), radial head plica in 121(30%), loose bodies in 85(21%), ostephyte formation in 45(11%) and intra-articular adhesions in 26(6%). Of the 232 patients who had degenerative changes 186(80%) had articular cartilage changes in the lateral compartment(radial head & capitellum), partial thickness loss in n=94(51%) and full thickness cartilage loss in n=92(49%). Conclusion: The clinical diagnosis of lateral epicondylitis is applied to patients who have a variety of pathologies involving the tissues of the lateral compartment of the elbow. In addition to inflammation and degenerative tears of common extensor origin other pathologies such as synovitis, radial head plica, loose bodies and degenerative osteoarthritis should be considered. This diagnosis of tennis elbow is often applied to patients with degenerative changes(osteoarthritis) involving the lateral compartment. Advanced degenerative changes involving the articular cartilage of the lateral compartment can be present in patients with little or no abnormality visible on x-ray. We conclude that arthroscopy is a definitive diagnostic tool to evaluate the various pathologies giving rise to lateral elbow pain and also helps in planning and initiating the appropriate treatment plan directed against specific and accurate conditions causing lateral elbow pain(lateral epicondylitis)

Platelet Rich Plasma (PRP) has shown to be a general stimulation for repair and 1 year results showed promising success percentages. To determine the effectiveness of PRP compared with corticosteroid injections in patients with chronic lateral epicondylitis with a two-year follow-up. A double-blind randomized controlled trial was conducted between May 2006 and January 2008. The trial was conducted in two Dutch teaching hospitals. 100 patients with chronic lateral epicondylitis were randomly assigned to a leucocyte-enriched PRP group (n=51) or in the corticosteroid group (n=49). Randomization and allocation to the trial group were carried out by a central computer system. Patients received either a corticosteroid injection or an autologous platelet concentrate injection through a peppering needling technique. The primary analysis included Visual Analogue Scale (VAS) pain scores and Disabilities of the Arm, Shoulder, and Hand Outcome (DASH) scores. The PRP group was more often successfully treated than the corticosteroid group (p<.0001). Success was defined as a reduction of 25% on VAS or DASH scores without a re-intervention after 2 years. When baseline VAS and DASH scores were compared with the scores at 2 years follow-up, both groups significantly improved across time (intention-to-treat principle). However, the DASH scores of the corticosteroid group returned back to baseline levels, while the PRP significantly improved (as-treated principle). There were no complications related to the use of PRP. Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and increases function significantly, exceeding the effect of corticosteroid injection even after a follow-up of two years. Future decisions for application of PRP for lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible costs and harms as well as benefits

The February 2015 Shoulder & Elbow Roundup. 360 . looks at: Proximal Humerus fractures a comprehensive review, Predicting complications in shoulder ORIF, The Coronoid Revisited, Remplissage and bankart repair for Hill-Sach’s lesions, Diabetes and elbow arthroplasty, Salvage surgery for failed bankart repair, Sternoclavicular Joint Reconstruction, Steroids effective in the short-term for tennis elbow

The October 2014 Shoulder & Elbow Roundup. 360 . looks at: PRP is not effective in tennis elbow; eccentric physiotherapy effective in subacromial pain; dexamethasone in shoulder surgery; arthroscopic remplissage for engaging Hill-Sach’s lesions; a consistent approach to subacromial impingement; delay in fixation of proximal humeral fractures detrimental to outcomes

The April 2013 Shoulder & Elbow Roundup. 360 . looks at: biceps, pressure and instability; chronic acromio-clavicular joint instability; depression and shoulder pain; shoulder replacement and transfusion; cuff integrity and function; iatropathic plexus injury; the accuracy of acromio-clavicular joint injection; and tennis as a risk factor for tennis elbow

This study presents the clinical outcome of Boyd-McLeod procedure for lateral epicondylitis of elbow. 29 cases with lateral epicondylitis with failed conservative management (rest, physiotherapy, analgesia and steroid injections) were included in the study. There were 14 male, and 15 female cases of which two had bilateral surgery. Data collection included details of patients’ occupation, number of steroid injections, radiograph evaluation and postoperative complications. Post-operative clinical out come was evaluated by Hospital for Special Surgery Total Elbow Scoring System (HSS2), clinical notes review, and telephone questionnaire. Average age: 47 years (range: 34–65), mean post-op follow up time: 16 months (range: 6–32). 93% were manual workers. Dominant elbow involvement was seen in 64%. Mean number of steroid injections: 3 (range: 1–10). Conservative measures included NSAIDS (90%) and physiotherapy (83%). Average tourniquet time: 32 min (range: 18–59). Mean HSS2 score pre-op and post-op were 38 and 92 respectively (p value: 0.0001). 91% reported excellent/good results. Average post-op time for the continuation of professional/recreational activity was 5 weeks. 2 cases (9%) had poor results. One case had ectopic bone formation. Boyd-McLeod procedure is done as a day case procedure involving excision of degenerative tissue from common extensor origin, decortication and decompression of lateral epicondyle and partial release of annular ligament. Although an extensive procedure, this procedure addresses the management of all offending factors that are likely to contribute to pain and disability in tennis elbow. There are few studies regarding the outcome of Boyd-McLeod procedure. There was no evidence to suggest that late presentation had any adverse effect on the post-op success. This study revealed a high success rate and a low complication rate. We conclude that Boyd-McLeod procedure is an effective treatment option in patients with resistant lateral epicondylitis

This is a retrospective review and analysis of cases of tennis elbow or lateral epicondylitis treated from 1996 to 2002. Of 191 patients treated, only 150 were contactable. These were sent self-administered Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires, which 55% patients returned completed. The rest of the patients were interviewed telephonically. Treated conservatively with avoidance of painful activities,non-steroidal anti-inflammatory medication, steroid injection, bracing, and physiotherapy, 83% of patients responded favourably and did not require surgical treatment. DASH scores ranged from 38 to 105 (mean disability < 12%) and compared favourably with those reported in the literature. Conservative treatment of lateral epicondylitis is usually successful and minimal residual disability can be anticipated. The few patients who fail to respond to conservative treatment can be salvaged predictably with low residual disability

Following the recognition of platelet rich plasma (PRP) as an interventional procedure by NICE, patients who had failed standard conservative treatment for chronic elbow tendinitis and referred for surgery were recruited prospectively into a PRP injection study. 52 patients at Torbay Hospital, Devon, UK received PRP injections in 18 months and 37 had a minimum of 6 months follow up. The outcomes in these patients are summarised. There were 16 males and 21 females. 30 had tennis elbow and 7 had golfers elbow. All patients had their symptoms for a minimum of 6 months and had failed to improve with standard conservative treatment. 2 had a failed outcome from previous tennis elbow release surgery. The PRP injections were carried out under ultrasound guidance after correlating the tender spot with neovascularisation on flow Doppler. 31 patients had a single injection; the other 21 patients had 2 injections. Quick DASH score and patients own self-satisfaction was used to measure outcome. 18 patients (48%) were discharged by 6 months. DASH score worsened in 7 patients (19%) and 2 of these patients opted to have surgery, which had no benefit either. No complications were observed with the use of PRP. Overall, by using PRP injections, surgery was avoided in 35 patients (95%) at 18 months and nearly half of the patients were discharged from follow up by 6 months

The best surgical treatment of lateral epicondylitis remains uncertain. Recently radiofrequency microtenotomy (RFMT) has been proposed as a suitable surgical treatment. We aim to compare open release with RFMT and present the results of our randomised controlled trial. Patients with symptoms of tennis elbow for at least 6 months who had failed to respond to conservative management were included in the trial. They were randomised to open release or RFMT. Outcome measures included grip strength, pain and DASH scores. 41 patients were randomised, 23 to RFMT and 18 to open release, 2 patients withdrew from the study. Our results show that both treatments give a significant benefit at all time points for DASH and pain scores, but only open release gives a significant improvement in grip strength. Comparing the two treatments the only significant difference is the open group have better pain scores at 6 weeks, but this is not seen at later follow up. In conclusion both groups have shown benefit from the treatments, but one is not shown to be clearly superior