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Rheumatology
Clinical Rounds
39
Nonsurgical Treatment Option
Relieves Tennis Elbow Pain
BY BRUCE K. DIXON
Chicago Bureau
abraded the edge of the bone . . . to stimulate the periosteum to send in new blood
vessels. So we tried to mimic that with the
tip of the needle,” Dr. Nazarian said.
Tenotomy was then followed with injections of 40 mg of triamcinolone acetonide. Dr. Nazarian noted that he stopped
the drug in 2002 because the team had
found no difference between the steroid
and nonsteroid cohorts in their study. This
step ultimately created a second, nonsteroid group which Dr. Nazarian reported separately.
The procedure is complete and the needle removed “when it looks like we’ve
treated the entire abnormal tendon, and
when the tendon has changed texture . . .
C H I C A G O — The pain of common extensor tendinosis, or backhand tennis elbow, can be alleviated with ultrasoundguided percutaneous needle tenotomy,
according to Dr. Levon N. Nazarian of
Thomas Jefferson University Hospital in
Philadelphia.
“This is a safe and effective procedure
for lateral elbow tendinosis and may represent a viable alternative to surgery in patients who have failed conservative management,” Dr. Nazarian said at the annual
meeting of the Radiological Society of
North America.
Also known as
lateral epicondylitis,
this chronic repetitive injury leads to
degeneration of the
common extensor
tendon in the elbow
and scant—if any—
inflammation,
which is why this
problem of tendinosis should not be
confused with tendonitis, Dr. Nazarian explained. When
tennis elbow does
not respond to
physical therapy, pa- Using a 20-gauge needle, the physician fenestrates the
tients can reach a tendon to stimulate development of new blood vessels.
crossroads where
they have to either live with the pain or from sort of gritty and rubbery to a softer texture. If there’s a calcification, spur, or
have surgery, he said.
Physicians first began performing per- enthesophyte at the insertion, we’ll then
cutaneous tenotomy by inserting a scalpel go in and use the tip of an 18-gauge neethrough the skin at the insertion of the dle to chip off the enthesophytes and break
common extensor tendon on the lateral them up,” he said, adding that patients deepicondyle and using the scalpel tip to re- scribe the procedure as a little like having
lease the tendon fibers and induce a heal- their teeth cleaned.
Immediately following needle tenotoing response, Dr. Nazarian said.
The procedure was taken a step further my, said Dr. Nazarian, it’s important that
by using a needle to repeatedly jab the ten- patients do 2 weeks of stretching and
don at its insertion into the bone (Clin. Or- range-of-motion exercises; then comes 2thop. Relat. Res. 2002;398:127-30). Re- 6 weeks of physical therapy that should insearchers took this approach “with the clude deep-tissue massage and a 6- to 10theory that they were breaking up scar tis- week program of strengthening, followed
sue, creating bleeding, and stimulating a by a gradual return to normal activities.
To evaluate the outcomes, the rehealing response,” he said, explaining that
the next step was to perform the proce- searchers used a modified patient-rated
forearm evaluation questionnaire that indure under ultrasound (US) guidance.
The Thomas Jefferson investigators per- cluded a 10-point scale to assess pain and
formed US-guided percutaneous needle activity levels. In the group of 55 steroidtenotomy on 58 consecutive patients. In- injected respondents, 64% reported “exclusion criteria included chronic pain and cellent” results, 16% had “good” results,
disability and having failed at least three of 7% had “fair” results, and 13% had a
the following treatments: NSAIDs, local- “poor” outcome.
Of the 55 patients, 47 said they would
ized corticosteroid injection, counterforce
bracing, wrist splints, and physical therapy. refer a friend or close relative for the pro“We used aseptic conditions and local cedure. Average follow-up time from the
anesthesia—lidocaine or mepivicaine—and date of the procedure to the date of the
then advanced an 18- or 20-gauge needle interview was 28 months.
In the nonsteroid group treated after
through the abnormal region of the tendon. If there were no calcifications within 2002, the results were even better: 58%
the tendon, we preferred a 20-gauge nee- (30/52) had excellent results, 35% (18/52)
dle. But if there were large calcifications had good results, and 7% (4/52) had fair
that needed breaking up, we used a num- or poor results.
There were no major complications reber 18. With the needle we gently and
steadily fenestrated the tendon to create ported in either group, according to Dr.
windows along its long axis, and we also Nazarian.
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F RED R OSS /T HOMAS J EFFERSON U NIVERSITY H OSPITAL
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