Tennis Elbow (Lateral Epicondylitis) - James T. Mazzara, MD

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Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest, Dr. Jim Mazzara. Dr. Mazzara did his medical school training at New York Medical College. He then went on to complete an orthopaedic residency at St. Luke Roosevelt Hospital, which is a teaching hospital affiliate of Columbia University. Good morning, Dr. Mazzara.

Dr. Mazzara: Good morning.

Dr. Sechrest: Dr. Mazzara, what I'd like to discuss over the next few minutes is a relatively common problem called tennis elbow. I think you and I know that as lateral epicondylitis, but that's pain at the outside bump of the elbow that is almost ubiquitous in the population. So, tell us a little about what that's all about.

Dr. Mazzara: Tennis elbow is actually a little micro tear or several microscopic tears in the tendon as it attaches to the bone. It's generally the wrist extensor tendon, so one of the wrist extensors, as it attaches to the outside bump on the elbow becomes torn as a process of the healing mechanism. There's a great deal of inflammation in the tendon and that inflammation causes pain. The body's in the process of trying to heal this but we are then in the process of the continually re-tearing it, and there's a lot of stress on that damaged segment of the tendon until patients finally have this continuous aching pain on the outside of the elbow and very commonly down the forearm to the top of the hand sometimes where they come in and they are locally tender over the tip of the elbow and, initially, it was probably described in individuals who played tennis. In my practice, it's generally seen in individuals who do other kinds of more physically demanding work or even repetitive work where the tendon is torn either from one large injury or thousands of little injuries like a repetitive task that they perform routinely for a period of months to years; you get this inflammatory reaction.

Dr. Sechrest: It's interesting, I try to explain to patients that I see as it's one of those injuries that occurs and it's not bad enough to sort of stop what you're doing. If it were bad enough we would probably rest it or put it in a splint and it would heal up and it would be fine. What I explain normally happens is that it's not bad enough to do that so we continue to go back. We get up the next day, we injure it again. Finally the body just gives up and says, "Okay, if you're not going to let it heal, I'm going to stop trying to heal it".

Dr. Mazzara: Right.

Dr. Sechrest: And we see that degeneration that occurs in the tendon and the inflammation and it just stops; it looks like it's not trying to heal anymore.

Dr. Mazzara: Right. It continually tears and re-tears and the inflammatory reaction is part of healing but that's really what causes the pain, and because we don't protect it, it never has the opportunity to heal.

Dr. Sechrest: Now tell us a little bit about the symptoms. When a patient presents with this or a patient is having pain in the elbow, how do they know they may have tennis elbow versus any other pain in the elbow?

Dr. Mazzara: Well, tennis elbow can certainly hurt when you use it, but it can also hurt when you don't. It tends to hurt a little bit less when you're at rest but it's a fairly local spot of tenderness. It's over the outside of the elbow on the little bony portion of the outside of the elbow, and just below that. That's typically where you have your point of maximum tenderness. You can also have pain down the arm. At any time you extend the wrist, you tend to have pain. Any time you lift something with your palm down to the ground you may also have a lot of pain in the outside of the elbow in the upper forearm. This particular kind of lifting or task will tend to bother patients as well.

Dr. Sechrest: I'm of a sufferer of tennis elbow in the past myself, and from my memory some of the worst things that could occur were shaking hands with someone, very painful, reaching for a doorknob, especially a car door. If I tried to open a car door, it was immediate pain and anything, like you say, that's extension like this with gripping tends to put those tendons on stretch and anything was just purely murder.

Dr. Mazzara: Well, in addition, sometimes when you just make a fist and lift something heavy, even if your arm isn't extended, because the power that you get out of flexing your fingers and making a tight fist involves a lot of stress up here on the outside of the elbow, even that can hurt some patients in more advanced cases.

Dr. Sechrest: When you try to make this diagnosis and try to narrow it down to lateral epicondylitis or tennis elbow, what do you go through in the office when you see a patient who presents with elbow pain and says, "Doc, I think I may have tennis elbow." How do you make that diagnosis?

Dr. Mazzara: Well, we want their history. We want to make sure that the pain is in the right location on the outside of the elbow. In general it's not unreasonable for the pain to get referred down towards the wrist. It's a little more uncommon for the pain to go up to the shoulder. We want to make sure that they don't have any numbness or tingling in the arm, and if they do, we want to examine the neck and the shoulder to make sure that's not the source of the arm pain. A lot of different things can cause arm pain on the outside of the elbow. Tennis elbow is probably the easiest one to diagnose, but there are other things like pinched nerves in the neck or referred pain from the shoulder that can go down as far as the elbow as well. You want to examine the joints both and below the elbow.

Dr. Sechrest: Yeah. One other thing that I think we as orthopaedists always keep in the back of our mind is that one of the nerves, the radial nerve, goes through that area and there is much less likely, but there is a condition called radial tunnel syndrome that can affect a similar area. A little different pain profile when you stop to see folks that have it, but it can fool you sometimes, and something you might think is tennis elbow actually may be affecting the radial nerve.

Dr. Mazzara: Well, about 5% of patients will actually have both tennis elbow and radial tunnel syndrome. Radial tunnel, unfortunately, is a little bit more difficult to diagnose. You might see patients who have a little pain, discomfort, and sensitivity over the radial nerve. The symptoms may be a little bit different in terms of location, but if you have exclusively radial tunnel syndrome, you're not generally going to be very tender over the outside of the elbow where the tendon is, you're much more tender over the nerve.

Dr. Sechrest: Now, do you make this diagnose just based on your physical exam and the history or do you find imaging, either x-rays, MRI scan, or anything else in terms of tests helpful to make this diagnosis?

Dr. Mazzara: Do you mean for radial tunnel or tennis elbow?

Dr. Sechrest: Either one, to distinguish the two.

Dr. Mazzara: Well, aside from clinical diagnosis and examination, sometimes diagnostic injections for radial tunnel, there's no real objective test that's going to prove somebody's got radial tunnel syndrome. EMG is not going to confirm it. EMG is a nerve conduction test and in many cases, radial tunnel is more of irritation of the nerve and is not going to cause any weakness or numbness and so a nerve test is not necessarily going to give us a definitive diagnosis. In terms of the tennis elbow however, you can certainly get an MRI, I would say in the majority of cases, I do not. I do an x-ray to make sure that they don't have any arthritis on the outside of the elbow. We look for little associated calcium deposits and bone spurs. I don't necessarily need to do an MRI to make a diagnosis of tennis elbow though.

Dr. Sechrest: Do you think that the MRI scan is helpful in any way in special cases?

Dr. Mazzara: I think if somebody's got a potential question as to whether or not it's exclusively tennis elbow or maybe tennis elbow and something else, I may do an MRI. But if I'm convinced that they have tennis elbow, I don't see the MRI is of great value. Are there other potential causes for elbow pain in that area? Well, certainly, you can have arthritis in the elbow joint. You can have a ganglion cyst in that area and you can certainly have other causes for elbow pain, such as a partial distal biceps tendon ruptures which can cause similar pain in that part of the arm, a little different location, a little bit different in terms of diagnosis and examination. So if, as I said, somebody comes in, they have a local tenderness, pain on the resistance testing, a negative x-ray of the elbow, I don't need an MRI to confirm that that's tennis elbow.

Dr. Sechrest: So at that point you're ready to say, "I think you have tennis elbow or lateral epicondylitis" and proceed on with treatment at that point.

Dr. Mazzara: Yes. Yes.
Dr. Sechrest: And how do you start treatment? Is this something that is treated conservatively or do I need an operation if I have tennis elbow?

Dr. Mazzara: Well, some patients eventually need surgery. The vast majority do not. We try to allow the arm to rest. There are two ways to put the tendon at rest. One is called a counter-force brace, or a little tennis elbow band, or a strap. It's actually worn up here just below the area of the painful tendon. What I find is that patients tend to not apply that properly and it tends not to be very effective. My own approach is to put people in a wrist immobilizer, and the purpose of the wrist immobilizer is because that is probably the best most reliable way to put the wrist extensor in a position where it's not going to any work. You can still move your fingers in the wrist immobilizer, but it puts the tendon at rest by putting the wrist in extension. It takes all the stress off the elbow. I find that to be a little bit more effective, and then you want to help control pain with anti-inflammatories. There are two approaches to anti-inflammatories, either cortisone injections or oral anti-inflammatories, both of which tend to be very effective.

Dr. Sechrest: How long do you have patients wear the wrist brace when you use that? Is this something that they're going to need to wear for a long prolonged period of time, or is this something that is just a short period of time?

Dr. Mazzara: No, I generally ask patients to wear it for about 3-4 weeks, and those people come back and, whether they're given the anti-inflammatory or the cortisone shot, it doesn't really affect how long we immobilize those people. I ask them to wear it as much and as often as they can; take it off when you wash your hands, you bathe, and if you have to do something outside of the splint, but otherwise you wear it full time. Three weeks later or four weeks later, I see people back and we re-assess the elbow. The vast majority of those people are better. Some are experiencing no pain, those people who have a little bit of pain are still better, and then we go on to the second step in treatment. The second step, at that point, is to start to rehabilitate the elbow. My experience has been if you do the rehabilitation early on, you sometimes take that painful tennis elbow and aggravate it and make it worse; so we try to allow for a little healing, control inflammation, and then get people off to physical therapy. Then we take them out of the wrist immobilizer, and then put them in the little tennis elbow band that gives them a little bit more flexibility of the hand and wrist while still protecting the tendon at the elbow.

Dr. Sechrest: Now, do you always do an injection when you see these folks with acute tennis elbow or not?

Dr. Mazzara: It's an option. I offer it to patients. I try to explain to people the shot itself is not a cure. Everybody know somebody who had one shot and was better forever and never had a day of pain after that, but I don't want to tell patients that a shot of cortisone is the cure. The cortisone or the anti-inflammatory is a way to control inflammation and a way to control pain. If we inject somebody, we're putting the anti-inflammatory in there, but we're also taking the needle and we're actually peppering the tendon. By peppering the tendon we're traumatizing the tendon on a microscopic level, and by doing so, jump-starting and stimulating the body's healing response once again, allowing the healing response to start over again. So what we're trying to do is stimulate a little healing of the tendon while we're controlling some of the pain, then what we'll do is give people the injection, explain to them that in 3 weeks you might feel better, but your tendon will not be healed. It takes a good 6 weeks for that tendon to heal and sometimes longer to rehabilitate it to the point where it doesn't bother you anymore.

Dr. Sechrest: Now, I've noticed that some physical therapists really like use an alternative steroid delivery system than the injection.

Dr. Mazzara: Yes.

Dr. Sechrest: Some people use ultrasound with a cortisone cream over the area; I think that's called "phonophoresis", and then some folks use "iontophoresis", and I think there are some newer things that actually have little battery packs and you can put on. The theory is that the electronic charge forces the cortisone molecule, the medication, down into that tendon. Have you found this to be equivalent to an injection? Do you see any use for this?

Dr. Mazzara: We begin iontophoresis at the 3 week mark and after the 3 weeks, after somebody has either had the anti-inflammatory or the cortisone and has been immobilized in the wrist immobilizer for that period of time, then they go off to therapy where they do some stretching and strengthening and iontophoresis. At the end of that 3 week period of therapy, what I hope they have is a good understanding of their injury, their do's and don'ts, their home exercise program, and minimal to no pain as they continue to heal their damaged, partially torn tendon.

Dr. Sechrest: Now, if they're successful at healing this without surgery, and you mentioned that most people are, how long is this going to take? What do you normally see?

Dr. Mazzara: What I generally tell patients is it takes a minimum of 6 weeks for the tendon to heal if it's going to heal. You have to protect it for at least 2-3 months, and I advise patients for at least a full 6 months after the pain is gone to continue to do some stretching and strengthening and to wear the tennis elbow band for really stressful stuff. So if they're out shoveling snow or doing heavy work, they don't have to wear the band all the time, but maybe they should wear it during those episodes of increased demand for about 6 months.

Dr. Sechrest: Now let's go back to the small population of patients that don't heal with this conservative treatment. When do you make that decision? What tips you off that those patients are going to need surgery?

Dr. Mazzara: Patients will generally come back and have done therapy, they may be a little bit better, but they're still having some pain. They may come back after several weeks to a couple of months of home exercises, modified activity, they don't seem to be responding. We really try to defer any kind of surgery for at least 4-6 months, closer to 6 months, I think that's been the recommendation. So if we can get somebody to do some exercises, modify their activity, and have good treatment for 6 months, and they still have pain and symptoms, they become a very good candidate to have surgery to treat that. Statistically, I think if you look at patients who've had tennis elbow for a year who, after a year of good treatment still have pain, those people just don't get better. So, somewhere at the 6 month mark, they start to be a realistic candidate to have surgery.

Dr. Sechrest: Now, tell me a little bit about the surgery to repair or treat tennis elbow. What are you trying to do when you suggest to a patient that, "I think surgery would help you", what are you going to do during that surgery?

Dr. Mazzara: What we're doing is it's a quick general anesthesia, or a regional block. It's a small incision on the outside of the elbow. We go down to the damaged segment of the tendon. Now there's always an area, a very precise area of the tendon, that's torn. It's a portion of the extensor carpal radialis brevis which attaches to a very precise area in the outside of the elbow. When you go in surgically, you always see a damaged area. The tendon doesn't look normal, and in more extreme cases, there will actually be a gap between the tendon and the bone where the tendon is actually just pulled away from the bone; and those are significant cases and all of those tend to do very well with surgery. What we do is we go in and we excise the damaged piece of the tendon, and then we take a little motorized burr and we burr up the outside surface of the bone. What that does is that stimulates some bleeding into this little area, this little defect that we've created surgically, and in that blood are the stem cells that then differentiate into a new tendon attachment. My own approach is right after surgery, 2 days after surgery, take off the dressing. You have my okay to do anything and everything you want with the elbow, pain permitting. What I've found is that people who get to use the elbow sooner immediately after surgery, do much better than those patients who were immobilized and protected for a week or two. Years ago, what I did was protect the patient for 10-14 days after surgery in a splint and then start therapy. Those people would eventually get better but took much longer. What I've found is if you're in there and you're taking out the damaged segment of the tendon, get those people moving faster, no restrictions – they can go out and do whatever they want 48 hours after surgery – those people do better, faster, with a more reliable degree of pain relief sometimes at about the 2-3 month mark where they could do just about anything they want to do at that point.

Dr. Sechrest: Now explain to me what you think is happening when you go in to do this operation and you open up that tendon, excise that area of abnormal tendon and burr that bone down. What are you trying to accomplish as a surgeon?

Dr. Mazzara: Well, what we're doing is removing the inflamed damaged segment of the tendon, and what we're trying to do when we burr the surface of the bone down is to create an avenue for new circulation, new blood to come into that damaged segment of the tendon; and in that blood, from the patient's own system, are the stem cells that will heal the tendon. The stem cells will fill in that little area with a tiny little blood clot and through normal activity the elbow tendon is stressed and strained in such a way where there are little signals exchanged between the new stem cells and the adjacent cells that tell the new stem cells that they need to become strong, flexible, durable tendon cells. So the more you use that tendon, the more normally you use the elbow, the more likely you are to get a good outcome, a good flexible tendon, and a pain-free joint.

Dr. Sechrest: So your feeling in the postoperative course is that, rather than immobilize that elbow to allow this to heal, your experience is that the faster patients begin to use their elbow, the faster that process occurs.

Dr. Mazzara: Absolutely. I encourage people to take off the dressing at 48 hours and do anything and everything they can tolerate right after the surgery with no limitations. If they want to go out and cut the lawn and shovel snow, if they're not having postoperative pain that prevents them from doing that, they have my blessing to do so.

Dr. Sechrest: One other question. This procedure today is done with a block. It's an outpatient procedure I'm assuming. This is not something you have to stay in the hospital for.

Dr. Mazzara: No. It's an outpatient procedure. It's either a quick general anesthesia or a nerve block, a regional block, that puts your arm to sleep. It actually takes about 15 minutes to do. It's a very straightforward process.

Dr. Sechrest: How long do you think it takes for a patient to recover after this operation? When do you see them completely normal where they've forgotten they had this problem?

Dr. Mazzara: That's probably going to be closer to 4-6 months although people at the 2 and 3 month mark will come back and say, "I feel great. I have no pain or discomfort". That's a great number of patients. But I'm a little hesitant to say that at 3 months out of a tennis elbow release they can do anything they want, and I would tell you it's probably not until they're about 4-6 months where I'd say, "Good, do whatever you want".

Dr. Sechrest: Okay. Let's move on to potential complications. This seems like a relatively simple operation that's done as an outpatient and is done through a very small incision. What are some of the complications you worry about as an orthopaedic surgeon when you perform this operation?

Dr. Mazzara: Nerve damage is always a concern but in this part of the elbow there is only a small sensory branch of a nerve and we're always able to avoid that nerve. Bleeding potentially into the area – we actually need some bleeding to get the healing process to occur, so bleeding is generally not excessive. Infection is always a potential risk, and as I mentioned earlier, we always like to think that our patients are going to get a perfect result every time we operate on them and the success rate of this operation is 80-90% of the time it works very well and people come back with no pain. There is a very small number of patients, however, who may have other pathology and that's a little bit more unusual, and that's generally something that perhaps wasn't initially thought of at the time of the initial evaluation. People will potentially have ligament injuries or arthritis in the joint that can affect their eventual outcome. Those are things that need to be treated a little differently. But if we're talking about exclusively tennis elbow surgery, or lateral epicondylitis, it's really the nerve damage, bleeding, infection risks that we are most concerned about.

Dr. Sechrest: So if that patient comes back and they've been out of surgery 4-6 months, you're going to start at least thinking in the back of your mind, have I missed something? Should I be looking for something else? Should I do some more testing to see if one of these other problems is going on?

Dr. Mazzara: Yes, and that's when we may do an MRI. We may do something else to evaluate the elbow. But, in most of those cases, we come back and just say, "This is one of those unusual cases where, for reasons that we don't fully have an answer for, the patient just didn't get better". Many of those cases are actually in individuals who may have been a little hesitant or may not have healed very well from the very beginning. They may have been one of those individuals who's a little reluctant to go out and use the arm, and so they've healed the tendon, but it's not flexible, durable, and strong enough to do what they wanted to do so they end up tearing it again, and some of those people end up benefitting from another surgery. I've had the opportunity to see patients who've come in from other practices who've had continued pain following a tennis elbow release, and it looks to me like they had a good treatment initially, and those individuals who came to me, I operate on them after their failed previous surgery; I quite honestly don't think anything different or better than the previous orthopaedic surgeon did, but somehow they get better, and I don't think I have a good answer as to why. Maybe it's the postoperative course, maybe it's a more aggressive approach to therapy, but it looks like those individuals that I'm thinking of had good treatment initially and for reasons that just aren't really clear, they never got the kind of pain relief they were hoping for.

Dr. Sechrest: Well, I think you probably answered my question. But one of the questions I would have is: Are these people at risk over a long period of time? If I've had tennis elbow at one time in my life, am I more prone to develop this later on? Or once I've had that operation, am I pretty much healed and should not expect another problem with it?

Dr. Mazzara: Well, we're treating the condition, we're getting you to heal, but we're not making you indestructible. So can you re-tear it at a future point? The answer is yes. You can always sustain a future injury to the tendon that may continue to bother you over a period of time. So what we're doing is treating the injury as it is, but to assure a patient that you'll never this again is unrealistic.

Dr. Sechrest: Okay. Well, let me summarize our discussion up to this point. It sounds like it's been a pretty comprehensive discussion of a very common problem. What I heard you say is that tennis elbow is very common and it occurs in a lot of folks, and the vast majority of people are easily treated with conservative means, that they're never going to need an operation.

Dr. Mazzara: That's correct.

Dr. Sechrest: But, if they don't get better with a relatively simple conservative treatment plan, there is a good solid operation that works pretty effectively and is successful in the vast majority of the cases.

Dr. Mazzara: Correct.

Dr. Sechrest: Excellent discussion. Thanks for helping us with this, and I look forward to any future discussions.

Dr. Mazzara: Thank you very much.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you're an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you'll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.

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