The persistent pain of the lateral epicondyle of the elbow caused by the angiofibroblastic tendinosis of the extensor carpi radialis brevis, described by Nirschl, is well-known in the literature. While nonoperative treatments are generally effective in 75% to 90% of patients, 10% to 25% remain largely symptomatic following nonoperative treatment.
A recent epidemiologic study at the Mayo Clinic demonstrates patients who have not responded by 6 months may not become symptom free with nonoperative methods for 24 months. Tendinosis is treated by resecting the damaged tissue, which has historically been done through an open technique with various modifications. During the past 20 years, however, arthroscopic techniques have also been used for this type of resection.
The use of ultrasound as a diagnostic tool to identify the tissue has been well-described. In this technique, we use ultrasound to identify the pathologic hypoechoic area of the extensor carpi radialis brevis (ECRB) and use a percutaneous ultrasound with a specific wavelength to resect and aspirate the damaged tissue. This technique allows for a less invasive treatment under a local anesthetic that is well tolerated with minimal morbidity. This procedure resects the diseased tendon with no effect on normal tendons.
This treatment modality can be used for tendinosis at any tendon/bony interface and has been successful in the treatment of conditions, such as plantar fasciitis, Achilles tendinitis, patella tendinitis, and medial, as well as lateral, epicondylitis. Future applications, with modifications of the needle length, will likely include gluteal tendinitis, calcific tendinosis and possibly partial rotator cuff tears and biceps tendinitis at the shoulder. The technique for lateral epicondylitis will be described.
Indications include point tenderness over the lateral epicondyle at the insertion of the ECRB without relief for nonoperative treatment for at least 4 months. Contraindications include local infections or open wounds.
The surgery is performed in either an outpatient surgical setting or a hospital. This allows for reimbursement of the facility fee for using the energy module. The procedure does not require use of a sterile OR (Figure 1). The patient is placed supine on the examining table with the affected arm across the chest (Figure 2). The site of maximum tenderness is palpated and marked after being confirmed by ultrasound as an area of hypoechoic signal.
The area is prepped and draped in a sterile fashion with the ultrasound probe placed in the sterile sleeve (Figure 3). It is important to have gel over the sensor before it is wrapped in the sleeve, as well as an area of gel between the sleeve and skin. The area is anesthetized with 0.5 Xylocaine. A skin wheal is made 1.5 cm from the point of maximum tenderness and advanced through the skin into the area of hyper-tenderness. The needle should go down to the bony insertion.
An 11-blade then excises the skin through the skin wheal and is directed through the tissue and fascia to the bone. This allows the probe to be more easily inserted in its full length (Figure 4). The sterile ultrasound is used to identify the tissue again, and the needle is inserted through the puncture portal (Figure 5a). The probe is usually seen in the long axis, though it can also be viewed in the short axis. The needle is visualized and when it reaches the area of pathology, a foot pedal is depressed. This activates the ultrasonic energy to be delivered at the tip, which in turn cuts the diseased tendon (Figure 5b). The needle oscillates nearly 20,000 cycles per second. There is continuous irrigation aspiration to remove tissue. This is employed as a safety feature so no unwanted heat is generated.
The needle is advanced in a linear manner in and out of the lesion. When the hypoechoic area is no longer seen, usually at 45 seconds to 60 seconds of treatment, the needle is removed. The wound is closed with Steri-Strips and a Tegaderm dressing.
Aftercare and results
We employ the concept of 3, 3 and 3: 3 days of modified use, 3 weeks of regular use of the elbow without restriction and another 3 weeks for strengthening. A return to normal activities is expected by 6 weeks postoperatively.
The probe and ultrasound are used to view the affected tissue.
An ultrasound image of the affected elbow is shown.
As the tendon has been resected, new collagen forms. Results fall in a pattern of approximately 20% resolution within a month and another 60% to 70% healed within 2 months to 3 months. Results show close to 90% of patients with marked improvement in symptoms within 3 months.
The procedure is nearly complication-free. There have been more than 40,000 procedures performed and fewer than 10 reported complications. These included two local infections and two nerve injuries, all of which were temporary. While it requires a basic utilization of ultrasonography techniques, ultrasound-guided tenotomy is a safe, less invasive, well-tolerated and cost-effective outpatient procedure that allows for rapid recovery in the treatment of lateral epicondylitis.
- Chusheng Seng P, et al. Am J Sports Med. 2016;doi:10.1177/0363546515612758.
- Koh JS, et al. Am J Sports Med. 2013;doi: 10.1177/0363546512470625.
- Morrey BF. Techniques in Shoulder and Elbow Surgery. 2013;doi:10.1097/BTE.0b013e318291487e.
- For more information:
- Champ L. Baker Jr., MD, can be reached at the Hughston Clinic, 6262 Veterans Pkwy., Columbus, GA 31909; email: firstname.lastname@example.org.
Disclosure: Baker reports he is a stockholder, medical advisory board member and the assistant medical director for Tenex Health.