Welcome to the American Journal of Sports Medicine's webinar, presented in conjunction with the Asia-Pacific Knee, Arthroscopy, and Sports Medicine Society. Thank you for joining us. I am Christine Watt, Publishing Manager at AOSSM, and I will be the operator for the webinar today. There is CME available for this online activity. Here are the learning objectives and the disclosures for our faculty and organizers. At the conclusion of today's program, we ask that you complete a brief evaluation to collect CME for this activity. Details will be given at the end of the program and in an email to attendees. At this time, I would like to introduce our moderator, Dr. Erica Kholinne. Dr. Kholinne is a shoulder and elbow orthopedic surgeon based in Jakarta, Indonesia. She is also a member of the AJSM Editorial Board and will be moderating our webinar. And with that, I'll turn the program over to Dr. Kholinne. Thank you, Christine. Good evening, everyone, and welcome to the AJSM webinar series for October 2024. I'm Dr. Erica Kholinne, joining you from Jakarta, Indonesia. I'm very honored to be your host this evening for this special AJSM and Asia-Pacific Knee, Arthroscopy, and Sports Medicine Society, APKASS. This is a collaboration on the overview and current concepts in lateral epicondylitis. Thank you all for joining us for what we promise is to be a highly educational and engaging session. Today, we will be diving deep into the latest insights, diagnosis, and treatment options for lateral epicondylitis. Our agenda this evening features a series of focused talks on different aspects of lateral epicondylitis. Dr. Joaquin Sanchez-Sotelo from the USA will start by discussing the approaches to diagnose lateral-sided elbow pain. Dr. Clara Wong from Hong Kong will then take us to the surgical management options. Next, Dr. Lu Jiu Zhou from China will address a typical presentation of lateral epicondylitis. And Dr. In-Ho Jeon from Korea will conclude with insights into cases, lateral epicondylitis cases with elbow instability. After these presentations, we'll have a panel discussion to answer your questions. So feel free to submit them in the chat as the session progresses. Without further ado, I would like to invite our first speaker, Dr. Joaquin Sanchez-Sotelo, who is a leading orthopedic surgeon specializing in shoulder and elbow surgery, currently serving as a division chair at the Mayo Clinic and professor of Mayo College of Medicine. He has over 450 peer-reviewed publications and co-authored the textbook, The Elbow and Its Disorders, recognized with the Mayo Clinic Teacher of the Year Award. He is also the current president of the American Shoulder and Elbow Surgeons and associate editor for the Journal of Shoulder and Elbow Surgery. Dr. Joaquin Sanchez-Sotelo, the time is yours. Thank you very much, Dr. Kholinne, and thank you to AOSSM for the opportunity to participate in this wonderful webinar. I think it's important to recognize that when we tackle the subject of lateral epicondylitis or ECR with tendinopathy, many individuals that don't have a lot of training in the elbow may think that everything that hurts on the outside of the elbow is actually lateral epicondylitis, but I don't think that's the case and I think it's important to kick off this program by understanding what is it that can create lateral-sided elbow pain other than tennis elbow. These are my disclosures which are not relevant for the content of this presentation. And I would argue that the elbow joint is fascinating in terms of the anatomy, mechanics and pathology. It's actually pretty complex but it's not very commonly taught properly and at least as I said when I was a resident, every patient that came to the elbow clinic we thought had tennis elbow, but as the famous esthetician Claude Bernard said, if you don't know what you're looking for, you will not understand what you find. So I think it's important to understand what is it that you're looking for when we have a patient in the clinic with lateral elbow pain. In general, when a patient comes with elbow pain, it is wise to divide the elbow in quadrants and think about what creates anterior elbow pain, posterior elbow pain, medial elbow pain and lateral elbow pain because there are different conditions that are responsible for pain in these four different locations. If we think about anterior elbow pain, the most common reasons are problems with the distal biceps, which could be that a complete tear which is easier to diagnose or a partial thickness tear, as well as occasionally patients that will have a compression of the median nerve underneath the laceratus fibrosus. For patients that complain of pain on the posterior aspect of the elbow, the most common reasons include something really common, like an oracanum bursitis, something less common like a distal triceps tear, and then problems that are related to degeneration either of the entheses, like a fractured enthesophyte at the triceps insertion or osteophytes that may be fractured on the posterior compartment of the elbow joint in patients with primary osteoarthritis and very rarely posterior cutaneous neuromas. Medial elbow pain has a number of common reasons, like medial epicondylitis or golfer's elbow or patients that have different degrees of entrapment of the ulnar nerve with either a sensory or a motor ulnar neuropathy and at least in North America and I think also in Japan and other countries in Asia, tears of the medial collateral ligament, especially in the setting of baseball and other foreign sports. Rarely neuromas of the medial anterior cutaneous nerve. But tonight we're talking about lateral elbow pain and of course the most common statistically is ECRB tendinopathy, which will be the topic of the following three presentations, also known as tennis elbow or lateral epicondylitis, but there are other things that can present either in isolation or like you will learn tonight, in conjunction with ECRB tendinopathy, like for example instability. A patient may have a combination of ECRB tendinopathy and also insufficiency of the lateral collateral ligament complex. There can be also cases of entrapment of the posterior interosseous nerve, more in the upper third of the forearm. An entity that is not very well known by non-elbow experts, so-called radiocapital alplica. Of course, lateral sided arthrosis can be a reason and in younger individuals osteocondylitis dissecants. So how do you make the diagnosis? How can you use your history, physical examination, and maybe x-rays, MRI, CT scan to make a diagnosis? Starting with ECRB tendinopathy, most patients will confess of overuse or repetitive activities and commonly tennis, actually more commonly using a keyboard or other activities. And classically, the pain is located right over the ECRB origin and will worsen with resisted rick sensation and forearm supination. So activating the muscles that take off the lateral epicondylar region will create more pain. There is a great test that I will demonstrate in a video later on, called the laptop test, where if a patient has to hold a laptop with their fingers, they will typically pull it out of a laptop bag, increases pain substantially, and there is also the so-called tennis elbow shear test or test, described by my partner Dr. Odisco that I will also illustrate in a video later on. It's controversial whether you need imaging studies for these patients with ECRB tendinopathy. For me, I typically only get an X-ray, but I will also get an MRI in a patient that is presenting with prolonged symptoms despite adequate treatment, especially if I suspect instability. What about the patient that has an injury or insufficiency of the lateral collateral ligament complex? These patients may complain of either an injury that they had once upon a time, maybe a dislocation, maybe a car accident, or they may have had multiple corticosteroid injections that have eventually weakened the origin of the LCL from the lateral epicondyle, and not uncommonly they complain of quote-unquote mechanical symptoms, catching, locking, sometimes they will have a sense of subjective instability. The best test in the office is the so-called post-lateral drawer test, where someone as an examiner tries to sublux the forearm posterolaterally in reference to the distal humerus. The pivot shift test, which is similar to the knee pivot shift test, is much more difficult to perform with a patient awake, easier with a patient under anesthesia, and in these patients I think an MRI can be useful, but probably the best confirmation as you can see on the images on your right is confirming instability under image. So you can see on the upper right how there is valgus stress that is creating opening of the lateral genial space, and on the lower image you can see how the center of the radial head is posterior to the center of the capitulum with post-lateral stress. This entity some argue does not exist, I do see it maybe three or four times a year, and something that may be reason for this entity to occur is the use of a counter pressure brace. So the typical circular brace that we may discuss tonight, that is used for some patients for tennis elbow, will have the lower edge of the brace right over the location of the posterior interosseous nerve. So if a patient has had tennis elbow initially, uses this brace non-stop for weeks, secondarily there can be a compression of the posterior interosseous nerve. There is this scratch collapse test that some people talk about where a patient may be resisting external rotation and if one scratches on the skin overlying the PIN location, all of a sudden the patient has weakness in external rotation with the shoulder, and classically this is confirmed by using a diagnostic injection with just a local anesthetic, and of course nowadays we are great at following the course of nerves with ultrasound to identify the areas of compression. Another entity that can be confused with tennis elbow is the so-called radiocapillary placa. This is a fold of the capsule that can be mostly thickened anterior to the radial head or posterior, and the patient will complain of pain and very often clicking or snapping. When the placa is anterior, the clicking is unmasked with the flexion pronation test that you can see on your right. So the forearm is placed on forced pronation and as the elbow is driven from extension to flexion, that repeated flexion will create a click. On the contrary, if there is a posterior placa, this will be unmasked with the extension supination test, meaning that the forearm is placed in supination, the elbow almost in complete extension, and then with repeated extension one can feel that click on the posterior aspect of the compartment between the capitalum and the radial head, and this is confirmed with MRI, but most commonly with arthroscopy, since on MRI there may be folds of the capsule that may be benign and difficult to confirm in the absence of a positive physical examination. And then in children and adolescents, one reason for lateral sided elbow pain is osteochondritis dissecans or OCD. You can see images on your right of a plain x-ray on the AP view, a 2D CT scan on the lateral view, and then a coronal CT scan through the reconstruction. In these patients, typically the age will give you a hint, typically these are younger kids that are involved in lots of sports, either baseball or throwing a javelin or gymnastics, and sometimes all they have is pain, sometimes they will have also mechanical symptoms like catching and locking, sometimes they have a contracture, which typically expresses that the rest of the joint is reacting to the little particles of cartilage that are being detached from the joint surface and creating this contracture. One way to unmask the pain of osteochondritis dissecans is the moving valgus stress test in extension, where the patient's elbow is placed in 45 degrees of extension and as the elbow is forced into valgus to compress the occipital joint, the elbow is moved between flexion and extension, and of course the evaluation depends on x-rays, MRI and CT scan. Typically in older individuals, maybe people that already had in the past a fracture of the elbow, radial fracture, coronoid, that can be their primary or secondary osteoarthritis where sometimes the radial head is the best area that is involved, and in those patients if one asks the patient to grip and then rotate the forearm, that may aggravate the pain and of course they may have eventually widespread OA with impingement pain and resisted pain in flexion and extension, and this is of course confirmed with x-rays and a CT scan. So I think that as we approach the patient with lateral sided elbow pain, it's important to in our minds think about all these different possible explanations for pain and realize that as we talked about, some of them are actually combined. So this quick video demonstrates how to examine the patient with lateral sided elbow pain. This elbow will have pain right over the origin of the ECRB, whereas my index finger is not in the typical location of the posterior interstitial nerve entrapment. If the pain increases with resisted either wrist extension as you can see here, or forearm supination especially, if the pain is directly over the origin of the ECRB, that typically is confirmatory of lateral epicondylitis. We talked before about the tennis elbow shear test, where the idea is to place the wrist in forced extension and hold it there, and request the patient to quickly move the elbow from flexion to extension as trying to hit the hand of the examiner, and typically that side movement is painful. The same is true with the laptop test, here we're using a book, and as the patient has to hold a book or a laptop and raise the elbow, that will also generate more pain on the lateral aspect of the elbow over the origin of the ECRB. So those are the typical exam maneuvers that I typically use in these patients. For aplica, as we talked about, this is anterior, we're going to do the flexion pronation test. You can see on the video on the right how there is a pretty substantial fold that is covering the head, and it jumps over the real head with flexion and extension, so with the front pronation and flexion you will have pain. If the aplica is posterior, it will be the extension supination test. Instability is best assessed with the patient laying supine and the arm over her head. It's important not to constrain the forearm, so the right hand is locking the arm, but the forearm is actually free to rotate, and then the index and adjacent fingers are basically trying to drive the forearm posterolaterally and demonstrate if there is subluxation of the elbow joint in reference to the distal humerus. This can be difficult to perform in the office, especially in the patient that has apprehension, but it's much easier to demonstrate in the operating room. So here you can see a video of a patient under anesthesia where with forced hypersupination the radial head is subluxing posterior to the capitellum, and then with release of the hypersupination or with elbow flexion and extension, there is a relocation because the instability disappears with elbow flexion and is more evident with elbow extension. The key again is not to constrain the forearm, but to let the forearm rotate and let it go in that direction. And finally in patients with instability there can also be the benefit of using a pull test. So in summary, I think it's important to realize that there are multiple conditions that can present as lateral sided elbow pain. Not every patient with lateral elbow pain has ten inch elbow, and the examination is very rich. Thank you very much for your attention. Okay, thank you for Dr. Sanchez-Sotelo. That is an excellent PE video and review of the lateral elbow pain. Next, I would like to welcome our second speaker, Dr. Clara Wong from Hong Kong. Dr. Wong is a distinguished orthopedic surgeon and educator specializing in hand, wrist and elbow surgery, serving as a chief of hand, wrist and elbow and microsurgery center at the CUHK Medical Center. She is also a clinical professional consultant at the same center. Known for her expertise in microvascular, congenital upper limb and nerve surgeries, Dr. Wong has contributed extensively to education, earning CUHK's best teacher award in 2021. With over 60 peer review publications, numerous book chapters and active roles in professional societies, she is a leading figure in local and international orthopedic communities. Welcome, Dr. Wong, and the time is yours. Thank you, Erica. Thank you very much for inviting me to join this webinar. I'm now excited to talk on the surgical management for lateral epicondylitis. So I hope that after my talk, you'll be able to know what are the surgical options for lateral epicondylitis, which surgical option is the best and who should be operated. To know the surgical options, I'd like to bring you to the history of surgeries on the lateral epicondylitis. Previously, many pathological lesions at the elbow had been postulated to explain the pain symptoms and each hypothesis generated one operative technique. In 1910, Frank postulated the problem occurring in the lateral epicondyle and advocated resection of the lateral epicondyle with clinical success. In 1922, Osgood thought that tennis elbow was related to radiohumeral bursitis and reported improvement after radiohumeral bursitis, but later it was found that bursitis was just an associated condition. In 1926, Hortman was the first to publish that lateral epicondylitis was related to the common extensor origin problem. He reported good results of stripping the common extensor origin from the bone. In 1929, Tretholwin reported good results from excision of the synovial fridge from the radial capillary joint in patients, but later Kondrak later confirmed that the synovitis would often resolve after the extensor tendon origin was removed or repaired. So the synovitis at the radial capillary joint should be an association only. In 1950, Hilges reported good results from removal of a penis-like tissue from the underneath of the common extensor origin. However, calcification or penis-like lesion should also be an associated condition or a different disease entity. In 1953, Spencer reported 96% of good or excellent results in 23 patients treated by fasciotomy of the proximal common extensor origin. In 1955, Bosworth described chronic inflammation of the annular ligament arising from the rotation of the radial head, which is asymmetrically and eccentrically located. He reported good results in resection of the orbicular ligament, that means annular ligament, and attributed tennis elbow to the annular ligament. In 1959, Kaplan investigated the nerve supply to the lateral elbow joint and suspected that pain and weakness were associated with the complex nerve distribution of that region, so he advocated denervation surgery for the tennis elbow. In 1961, Garden advocated lengthening of the ECRB tendon in the distal forearm to reduce the transmitted forces, and the results he reported were very good. In 1966, Kaplan hypothesized that tennis elbow was caused by the entrapment of the PIN and advocated the release of the radial tunnel. But later, Hasey Moore had shown by anatomical dissection studies that the origin of ECRB and the superficial part of the supinator are blended and inseparable. So they theorized that the relief of the tennis elbow symptom that followed surgical division of the fibrous arch of the supinator was the result of lessening the tension of the lateral epicondyle rather than the radial nerve decompression. So the concept that recalcitrant tennis elbow is the radial tunnel syndrome should be abandoned. In 1970, Gardner reported good results in non-severe tennis elbow treated by reaving up the common extensor tendon, limited lateral epicondylectomy, and repair the deceased common extensor tendon back onto the bone. In 1973, Conroy reported good results on patients operated by resection of the torn and scar portion of the common extensor tendon and repair the remaining normal tendon if possible. And in 1975, Newman attributed tennis elbow to deceased articular cartilage surface of the radial head and suggested to excise of that lesion of the radial head. However, Banata in 2007 stated that the ECRB tendon has a unique anatomical location that makes it is undersurfaced vulnerable to contact and abrasion against the lateral edge of the capitulum during elbow motion. So the radial head lesion, the cartilage lesion, may be an associated condition with the lateral epicondylitis and might not be a cause of the lateral epicondylitis. In 1978, Pars reported excellent and good results on 43 patients with tennis elbow had fasciotomy done over the common extensor. It was his feeling that the entity of tennis elbow was caused by small multiple tears in the common extensor muscle origin and that by performing a fasciotomy there and lengthening of this origin, there was a transference of stress and relief of the intense forces causing continuous small tearing of the common extensor origin from the lateral epicondyle and then allowed the tendon to heal. In 1979, Robert Nasher reported consistent lesion in the tennis elbow patients. And histologically, the lesion named angiofibroblastic hyperplasia and he advocated surgical exposure of the ECRB, excision of the identified lesion in the ECRB and sometimes also in EDC, decorticate the bone and also he did the bone drilling on the lateral condyle and repair the remaining normal tissue. His overall improvement rate was 98% and 85% of the patient returned to full activities including the regular sports. The theory of his surgery was to remove the painful culprit and release the force generator and thereby decrease the potentially abusive forces. Because of his great work of the identification of the angiofibroblastic hyperplasia of the ECRB tendon, he advanced the understanding and treatment of lateral epicondylitis. With a lesion over the ECRB, removal of the lesion, release of the tension over the lesion and strategies to promote the tendon healing or blocking the pain symptom to buy time for the tendon healing to come are reasonable goals of the surgery. So for the removal of the nursery lesion, it can be performed under open, arthroscopic or endoscopic way. The open technique advocated by Nershwit in 1978 that I had mentioned before. It was a dissection in between the ECRL and EDC. There are many modifications after the original nursery technique such as using a mini open incision, using a single drill hole only by done or multiple drill holes, lateral epicondyla, osteotomy, using the L-shaped fascial tendinous flap or making use of the interval between the EDC and ECO and etc. are all the modifications related to nursery technique. Bosworth added partial excision of the anal ligament to the nursery technique and described the evolution of his treatment from complete division of the common extensor origin to the resection of the anal ligament. Boyle-McLeon technique is similar as Bosworth 3 technique with limited lateral epicondylectomy and less excision of the anal ligament of only 2 mm. Richard Jarvons clearly demonstrated Boyle-McLeon technique in his publication. The technique involved dissection of the anterior half of the common extensor elevated from the lateral epicondyle, excised the nursery lesion, the tendon flap dissected distally to expose the anal ligament, and the proximal 2 mm of the anal ligament was resected, the synovial lining of the radial capillar joint was resected, and the lateral epicondyle decorticated and several drill holes made and then the tendon flap repaired. Lateral epicondylectomy is also a method of nursery lesion removal with the lesion removed together with the lateral epicondyle. In 1996, Baker advocated arthroscopic release of the tennis elbow. He suggested accelerated rehabilitation, return to work and normal activities at around 2 weeks. It also offered better visualization of associated intraarticular pathologies, but also 10% of his patients had pain with everyday activities. But indeed, the overall results were quite similar as the open technique. Cramar first reported endoscopic surgery for tennis elbow in 1993, with results published in English by Grifka in 1995. Although the published endoscopic operation involved only release, but the technique was subsequently taken up by others for the excision of the nursery lesion as well, such as by Dr. Brooks Hill. For the release of the tension on the lesion, then it can be performed under the open technique, arthroscopic technique, endoscopic, percutaneous or making use of the radiofrequency microtenotomy. Hortman procedure and parsed fasciotomy were discussed before to release the common extensor origin. Gordon reported good results from distal ECRB tendon lengthening at the forearm. However, the pain relief at the elbow was not always reproducible. Arthroscopic tennis elbow release is now commonly done. The release is done by removal of the deceased ECRB tendon. Yang in Shanghai compared between the arthroscopic debridement with the arthroscopic tenotomy distal to the ECRB insertion without excising the nursery lesion, and he showed similar results between the two. Elbow release by Cormier as mentioned previously. In 1982, Baugart described percutaneous release operation with division of the common extensor origin and also produced good results. It can also be done under the ultrasound guidance. To block the pain sensation, lateral epicondylectomy is also regarded as a form of denervation surgery by interrupting the neural pathway. William removed the collateral branches from the radial nerve and this insertion of the related muscles around the lateral epicondyle. He reported success rate of 90%. Formal denervation can also be performed by resection and bury of the posterior branch of the posterior cutaneous nerve forearm into the tricep muscle. After nursery lesion being removed or the tennis elbow being released, there should be a tissue gap. Although there is no evidence of weakening of wrist extension or grip power after the release or excision surgery, reconstitution of the defect should be beneficial for restoration of normal healthy tendon anatomy. The tendon defect can be occluded by the original tissue, such as side-to-side repair by repairing ECRL to the EDC after the excision, or use of suture anchor to repair the ECRB back to the bone. The repair can be performed operally or arthroscopically. The results of reattaching ECRB with anchors seem satisfactory and gave faster rehabilitation, better functional outcome, and wrist extension strength. The use of adjacent tissue, such as a conius flap as advocated by Elmquist in 1998, can also reconstitute a big defect. I try to fill the big defect with autologous tendon graft with good success. It may also be an option. Bone drilling of the lateral condyle performed by Nurshe garners reattachment of the degenerated tendon flap to the lateral condyle after lateral epicondylectomy. Both these techniques theoretically provide good nutritional bed for spontaneous regeneration of the defect. Use of the biologics, like the PRP, exosomes, stem cells, etc., can be incorporated with different kinds of surgery, and they are now under investigation of the results. So overall, all the above procedures reported to have high success rate of 65 to 100% besides the ECRB tendon distal lengthening in garden procedure. Then which one is the best surgery? Many individual comparative studies were performed previously, and a systemic review published five years ago with 12 studies included also gave no consensus on the most suitable operation for lateral epicondylitis. Therefore, understanding the theory behind each operation and knowing the advantages and disadvantages of each allow us to use what is most comfortable in our hands. Interestingly, there was shame operation compared with a nursery release, and the results show there is no definite difference. It seems that surgical intervention were no more effective than non-surgical and shame operation. Moreover, Kajananin pooled data from patients in the control arms of published randomized control trials studying the effects of various forms of treatments. They found that at every three to four months interval, half of the patients in the control arms not receiving active treatment reported that their symptoms were either much better or completely resolved. This rate seems constant, with only 10% of people and patients reporting no recovery after one year, despite most having symptoms for many months before joining the trial. They found that the longer duration of symptoms were not associated with poor prognosis, which suggests that persistent symptoms are not justification to recommend surgical interventions. So does it mean that for those being labeled as recalcitrant tennis elbow failed conservative treatment may eventually have symptom resolved if the insulting factors causing the lesion minimized? Therefore, indications for surgery is failure of non-operative treatment to provide lasting relief in a reasonable length of time. Assessment of individual's patient's functional requirement provide a critical factor in timing to go ahead to an operation. Some may be willing and able to endure a year or more of pain and disability, whereas others, particularly professional athletes and medical workers, are given the option of earlier surgical repair to shorten the period of disability. Failed conservative treatment for six months should no longer be the reason for the surgery. So in summary, lateral epicondylitis is a self-limiting pathology. 90% of cases resolved over one year. Removal of the nerve lesion, release of the tension of the lesion, strategies to promote tendon healing, or blocking the pain symptoms to buy time for the tendon healing to come are reasonable goals of the surgery. Overall surgical outcomes are satisfactory. Careful patient selection and counseling are important to meet the patient's expectation on the surgery. So that's all for my presentation. Thank you. Thank you, Dr. Wong, for the review of the history of lateral epicondylitis surgery. And it's very interesting, isn't it, about who should be operated. Next, I would like to welcome and introduce our third speaker, Dr. Lu Jiu Zhou from China. Dr. Lu is a prominent expert in shoulder, elbow, and wrist surgery, serving as a professor in the Department of Hand Surgery at the Huashan Hospital, Fudan University. With his leadership roles as such as a director of the shoulder and elbow group of the Shanghai Orthopedic Association, Dr. Lu specialized in managing complex elbow and wrist trauma. He has performed over 2,000 elbow surgeries and mentors hundreds of surgeons. Significantly, he is advancing elbow surgery techniques and education in China. So please welcome Dr. Lu for his talk, Atypical Lateral Epicondylitis. Thank you, Erica. I'm Jiu Zhou Lu from Shanghai Huashan Hospital. My talk today will focus on atypical lateral epicondylitis. Lateral epicondylitis, commonly known as tennis elbow, typically presents as a lateral elbow pain exasperated by wrist extension, and the pathological changes primarily occur at the origin of the extensor carpi, that is, brief tendon. And the symptoms are usually self-limiting, often resolving within two years. So what is atypical lateral epicondylitis? In my practice, I have observed three types of atypical lateral epicondylitis. The first involves more pathological changes occurring alongside lateral epicondylitis. The second arises from new pathological changes following improper treatment of lateral epicondylitis. The last type includes symptoms of lateral epicondylitis caused by other disease. Today, I will describe these three types. Pathological changes accompanying lateral epicondylitis are not rare. These include arthritic changes on the lateral side of the elbow, radial tendon syndrome, placa, loose body, OCD, and so on. Diagnosis can be particularly challenging when these issues coexist. So differential diagnosis is crucial, especially considering the patient's history of elbow trauma, manual labor, overuse of the hand, or sports. Physical examination is also vital. Tendonitis may be localized anteriorly, posterior, or distal to the lateral epicondyle, depending on the specific condition. MI and 3DCT are useful for identifying pathological changes, while the final diagnosis often relies on the intraoperative exploration. Treatment is determined based on the diagnosis established through history, physical examination, and auxiliary examination. The key is to avoid misdiagnosis. The second type of atypical lateral epicondylitis involves new pathological changes resulting from improper treatment of lateral epicondylitis. This may include previous typical lateral epicondylitis that developed a new issue due to the inappropriate interventions, such as injections, injections, and so on. Injections, such as injections, percutaneous procedures, or surgeries, potentially leading to severe synovitis or ligament and tendon injuries. Synovitis with soft tissue injury is relatively common after repeated injection or percutaneous procedures, often without persistent pain, without joint instability. MI may reveal synovitis and occasionally partial tendon and ligament injuries. The treatment for these complications is currently controversial. Some advocate for tendon repair, while others insist that debridement procedures, whether open or arthroscopic, are effective. The most challenging scenario is symptomatic tendon and ligament injuries leading to joint instability, often caused by surgery, particularly arthroscopic procedures. In cases of instability, ligament repair or reconstruction is indicated. In my practice, joint instability in these cases is often subtle, ligament and tendon repair following careful debridement can be effective. In cases of severe ligament injury with degenerative changes, ligament reconstruction may be necessary. The last type of atypical lateral epicondylitis involves symptoms caused by other diseases, such as chronic collateral ligament injury and a tight posterior lateral rotator instability, as described by Sean Driscoll. Despite having been published over 20 years ago, tight posterior lateral rotator instability due to cubitus virus is still frequently misdiagnosed. Symptoms can closely resemble those of lateral epicondylitis, especially in milder cases. For example, this is a 49-year-old male with over 40 years of post-traumatic cubitus virus deformity, presented with lateral elbow pain. Although MRI shows partial tear of the ligament and the ECRB, local hospital found no sign of elbow instability. Consequently, he was misdiagnosed with lateral epicondylitis and underwent osteoscopic debridement after four years of conservative treatment. His symptoms worsened immediately after surgery, leading to new issues such as mild instability and cysts around the lateral elbow. Without a proper understanding of the tight posterior rotator instability due to cubitus virus, the diagnosis could have continued to be lateral epicondylitis with cyst formation post-surgery. Treatment should address the cubitus virus deformity, ligament injury, and cysts with suspicious infection. Rather than solely focusing on the injured ECRB. Given the inflammatory changes and concern about infection, we performed osteoscopic debridement and ligament repair as the first stage surgery. This surgery was conducted by Shuangjiao School as a teaching surgery in Shanghai and was very successful. The cyst disappeared and the pain resolved and the elbow instability was elevated. We subsequently performed a corrective gastrointestinal osteotomy in the second stage. Ultimately, the cubitus virus deformity was corrected, resulting in good range of motion without pain with no sign of joint instability. In summary, it is essential to recognize concomitant pathological changes alongside the lateral epicondylitis, such as arthritis, placa, lateral elbow synovitis, and OCD. Misdiagnosis can lead to fairly failed treatments. When the diagnosis of lateral epicondylitis is confirmed, injections or surgical treatment should be performed by experienced physicians to avoid ligament injury or symptomatic synovitis. Lastly, we must always understand the true pathogenesis behind the symptoms to prevent itogenic injury to the joint and the surrounding tissue. Thank you so much for your attention. Thank you, Dr. Lu, for the shared cases of atypical lateral epicondylitis. Last but not least, I would like to welcome Dr. In-Ho Jeon from Seoul, Korea. Dr. Jeon is currently a professor at Asan Medical Center, serving as the first vice president of CCOT and with editorial roles in leading journals, such as the Journal of Shoulder and Elbow Surgery. Dr. Jeon has contributed over 220 publications, advancing knowledge in elbow arthroscopy, arthroplasty, and orthopedic science. His international training, including fellowships in the UK and the Mayo Clinic, underlines his dedication to advancing elbow surgery globally. Professor Jeon, your time is 15 minutes for the lateral epicondylitis with elbow instability. The time is yours. Please. Thank you, Erica. I'm very, very excited and pleased to join this AJSM webinar series. Today, my talk is lateral epicondylitis with elbow instability. I'd like to start with my case 56-year-old lady with a lateral elbow pain over nine months. She had a non-dominant arm pain and history of multiple steroid injections and had a tenderness over the common extensor origin and pain at registered wrist extension. We can assume that she's got the symptoms of tennis elbow. This is my routine exam in the clinic. I did various laxity tests and compared to the opposite side and it was very positive on the affected side. The people shift the test a lot state was not very positive. If you look at these x-rays, there's a little bit of opening on the radial capitella joint, but the MRI clearly shows that detachment of common extensor tendon together with the inner capsular layer. The osteoscopic finding shows this opening of a radial capitella joint with degenerative capsular tissue and the common extensor tendons there. What we did was a ligament reconstruction, osteoscopic guided, so that this palmar longus was placed behind the radial capitella joint so that it can be a mechanical block there. This is before graft tensioning and this is after graft tensioning so that we could provide additional stability to the joint. If you look at the literature about the posterolateral rotatory instability of elbow in lateral condylitis, it's not very, very uncommon. We have all these clues in a plain stress view. In the operating room, you can see the people shift positive, oftentimes in the MRI, complete detachment of common extensor tendon. Even the surgical observation can give you a clue. And many studies in the literature, you can find all these in a PubMed. There are a lot of papers published regarding this elbow instability in the lateral condylitis and tennis elbow. So here, I would like to raise one important question, what we know and what do we not know? So still, I have to confess, we do not have much confidence. So here, I listed five different questions, which is important for clinician for right diagnosis and treatment. What are the most common symptoms and risk factors? What is the definite instability diagnosis and how we can get the accurate imaging? What are the operative options and what are the clinical outcomes? I'm going to address all these important questions with my systemic review, which published in AJSM recently. So these are symptoms, what is published in the paper and also the clinical setting. We believe patients will complain more instability symptoms in this setting, but unfortunately, patients, majority, over 86%, they only present with the pain. They are not complaining any instability symptoms. Patients, they come to you with the lateral elbow pain. So what are the risk factors? If you look at this pie graph, over 74%, they had a steroid injection and majority had multiple steroid shots. This is a significant risk factor for instability. And also the heavy labor job, occupation-related, 43%, and also very little portion of patient had sports-related activities. So looking at the instability test, majority people prefer lateral pivot shift test in general anesthesia setting. But in the office setting, when the patient is fully alert, post-lateral drawer test is their preferred clinical examination. And over 70% of clinicians, they prefer MRI for diagnosis and plain x-ray and ultrasonograph was used in less than 30%. So here's important diagnostic signs I would like to share with you. If you take MRI, these four or five findings are very important to diagnose instability. Looking at this very carefully, radial collateral ligament and LUCL injury, rupture of a common extensor, this is a very important finding you should find in the MRI. So if you have MRI, the instability sign, majority they come with ligament injury, lesions. So what are the intraoperative findings? They describe the ligament pessilexity is a very obvious in their surgical observation, but how do we know this pessilexity? This can be a very subjective observation. So here, I would like to share with you how we do in astroscope. So now we are putting the astroscope post-lateral portal, the right elbow behind. So here, this is a capitellum, this is radial head. Now what we are doing is a dynamic test. Supination valgus is kind of pivot shift test. Now you see the opening of radial capitellar joint and the front rim of a radial head you can see here. This is what we called named a sunrise sign. You see the wide opening of a radial capitellar joint. If you can see the front rim of radial head, this means the lateral collateral ligament complex is insufficient in this elbow. So you may prepare for ligament reconstruction or repair in this setting. Another important sign I would like to share with you, same portal, now you rotate your right cable to the ulna side and this is a trochlear and this is your ulna. So by applying the same force, supination valgus axial load, now you see the opening of only humeral joint, you can go deep to the medial trochlear, means this patient had a complete disruption of a lateral collateral ligament. Elbow is actually subluxating in this setting. So if you see the medial trochlear from the posterior lateral portal, this is kind of drive-through sign in a shoulder, you should prepare for ligament reconstruction. So one thing you can do is you can take out this palmaris longus from the same limb and then reconstruct the LUCL. You know where the isometric point behind the radial head and base of epicondyle is your isometric point for humeral tunnel. Or alternatively, you can do a primary LUCL repair, putting an anchor at the base of a lateral epicondyle, you pass this sutures and then same as like your meniscus repair, I'm using spinal needle to do augmentation. So at least two matricious stitches, you know the orientation of a radial collateral ligament. So I'm putting four passages so that I can tighten up. This is before reduction, this is a trial reduction. So you actually can see the opening of a radial capitella joint before and after. This is how you can do the LUCL repair. Or alternatively, you can do a ligament reconstruction. But if you look at the literature, what people prefer is osteoscopic radial collateral ligament application. Almost 50% they prefer osteoscopic application. And then next one is a reconstruction. And then some people do repair and then capsule application procedure at the same time. Results, mostly good, excellent outcome. But some patients they have residual symptoms. What sort of residual symptoms? Limited range of motion. So once you look at the literature, open procedure has a less chance of residual symptoms. Interesting, if you do osteoscopic application, they have more residual symptoms, which is stiffness. So if I summarize, discussion number one, what is the most common symptoms and risk factors in this patient group? Instability with tennis elbow, pain is the most common. They are not complaining much instability symptoms. Number two, steroid injection and heavy labor job are two prominent obvious risk factors. So if your patient has a multiple steroid injection and heavy labor, you need high index of suspicion for instability. Because once you look at very carefully on the lateral structure, this inner capsular layer, radial collateral ligament, and common extensor, they are all merged together. Depending on where your needle is, you actually can, your steroid injection can degenerate, attenuate these structures, eventually can cause instability. What is the instability diagnosis? You actually need a clinical symptoms and history, MR imaging, examination under anesthesia, and intraoperative osteoscopic observation. All these are important for your definitive instability examination. However, systemic review does not support any one of these is any better than the others. How we do the accurate imaging? X-ray, unfortunately, is not very helpful and useful, but if you do a high resolution MRI, you can find instability sign, which I addressed before. Radial collateral ligament, LUCL, common extensor tendon is either detached or torn in the MRI. So clinical outcome is usually good if you do the surgery, and the most common residual symptom is more of a limitation of motion, but this is not permanent one. So if you do the osteoscopic radial collateral application, you may warn your patient, they have some limited range of motion for a while. So again, I'd like to address these, I'd like to highlight these two important osteoscopic observation. Once again, once you are not very confident, but a patient needs a ligament surgery or not, these two osteoscopic observation may give you additional idea for a definitive surgery. Take-home message instability, again, is oftentimes come together with the refractory lateral epicondylitis and risk factor, multiple steroid and heavy labor. You need a good diagnosis so that you can prepare for right surgery. If you need any further information, you can find our systemic review of elbow instability in lateral epicondylitis in AJSM. Thank you very much. Okay. Thank you, Dr. Jeon, for the talk about lateral epicondylitis with elbow instability. Now I would like to invite all the faculties to proceed with the Q&A sessions. And we have maybe 10 minutes to these sessions, and I have picked up some questions to discuss. I know we have to wait about six months, and it is very classically time setting for us to diagnose a failed conservative of lateral epicondylitis. So do you think this is too long to wait for, because several patients are very highly demand or especially those who are having a great career in athletic population, would anybody would like to? Dr. Joaquin, how is your practice in Mayo Clinic? Do you have any clear guideline or critical time of wait and see before you make any definitive decision? Thank you for the question. For us, it's a little bit tricky because many patients come to us when they have already tried treatment with another physician for several months. So I do not see the patients that have had pain for only one month or two months or three months. It's very rare. So most of the times the patient I see already have tried a really good program of treatment. And by the time I see them, they're almost ready for surgery. But there is a paper that Dr. Murthy Murray published a long time ago. It's actually in AJSM. And it showed that the six month number is because those patients that have symptoms for more than six months, more commonly ended up in surgery. But I do think that if a patient is high performance and is suffering, and as long as the diagnosis is very, very clear, and the patient understands the implications, I think it's okay to make the exception. On the other hand, it's a pity to operate on patients that eventually can be better on their own. How about for you? How do you how do you decide when to do surgery or not? Yes, I think Dr. Joaquin, your answer is very important because we are all biased. As Clara presented in her slide, there's been already report about the effect of a sham surgery and, you know, open procedure. So we are all biased. But I think we should be very specific to our patients because, number one, we do not know exactly when their symptoms started. Patients all have a different subjective pain scale. So in my mind, at least we should provide a good history, a good, you know, information about the natural history of lateral epicondylitis. But I do prefer to do surgery, more of a failed surgical treatment. If they had already tennis elbow surgery and persistent pain and instability, that is my, you know, very clear indication for the surgery. And how you do, Clara, in Hong Kong, you have any guideline for conservative treatment? We don't have guidelines for that, and every doctor, they practice differently. So for me, I think it's for standard tennis elbow without associated lesions, such as without any instability or any intra-articular problem, then the patient's only suffering is pain. So it depends on the pain severity of the patient, whether they can, how much they can tolerate, and also their occupation, and also how demanding. If they're a professional athlete, then ask them to stop playing for for a few months, then it is not practical. So it's really individualized, depending, I would discuss with the patients in details, and I let them know all the facts, and so that they can choose by themselves. So for me, indeed, even though I take care of quite a lot of professional athletes, but from my observation, maybe in Chinese, they are quite reluctant to go ahead for an operation. So when I observe them for a while, even though they're still playing, then the pain can go. So I still believe that, because myself also have tennis elbow, so I found that with time, then the pain can resolve. And I have, we have self-protection. Whenever we do any activity with pain, we will avoid that. And with that period of avoidance, then indeed, the tendon can heal. So I would discuss with the patient in details. How about you, Dr. Lu, in Shanghai, you see a lot of patients, and how do you deal with these things? Thank you, Erica. In my practice, I think the indication for surgery is not to depend on the time, maybe. But till now, I didn't do surgery for patients without a previous injection or surgery. Yeah, even there's one year, and I think sometimes it still works for conservative treatment. But if there's a previous injection, a continuous procedure, or other surgery, I will do surgery even less than six months. So let's come to the next topic. So for me, I work in the second referral hospital, smaller than yours. Most of my patients in Indonesia, we like injections. It's like a magic cure for everything. So I saw a lot of patients, lateral elbow pain with injections. And these are my red flags, a positive red flag for me to send the patient for further examination, or I will spend more time with the patients. And for your study, so could you clarify with us, what is your clinical red flag in the clinic for lateral epicondylitis, in which patient you send for further imaging? I usually send for a dynamic ultrasound because it saves time and money, because the MRI is quite expensive in my setting. So maybe Dr. Jeon, for the first. Well, Erica, that is very, very important question. But here we are here to share our information. I would like to get in how the ASES, American Shoulder Elbow Society, the members, they have any consensus regarding this. Number one, do they accept a steroid injection as for initial first treatment? That's the number one question. Number two is, how often you guys order MRI for lateral epicondylitis? Is it acceptable or, I mean, not advised? How are you practicing the members in ASES? Yeah, I don't think we have a consensus on any cell, but no one has tried to reach consensus because it's such a difficult entity to analyze through the Delphi method or otherwise. I can tell you that in our practice, the most important tool for evaluation is definitely the history and physical examination. And what I have seen in the past as a problem is patients that do not have tennis elbow, but are thought to have tennis elbow and they have instability or a plaica or something else. I only order an MRI in a patient where I think there is something else other than tennis elbow or if I'm thinking about surgery, not for the first evaluation. How about for you, Clara? How do you manage the workup of these patients? Yeah, I agree with what you said. A very detailed history and physical examination is very important. I offer MRI for those that I plan for operation on them. Otherwise, if there's any clinical features of not a standard tennis elbow, then I may think about MRI and discuss with the patient. Any thoughts, Dr. Lu? Same with Clara. Yeah, same. Okay. Right. I also found that whether the patient did an operation or not, I found it quite dependent on the MRI finding. If the MRI showing the gap is big, if the MRI showing that the tendon tissue is quite poor, then I think natural healing won't happen. Then we may put the threshold for going for operation lower. So I think MRI is quite important before the operation to let us to determine whether we really decide for an operation or not. And also to see whether any associated intra-articular pathology. Yeah, I think, Clara, you raised a very important issue about the MRI and lateral epicondylitis because we know from the history and from the literature that there's not much correlation between the symptom severity and the MRI observation. But now more and more people, they order MRI, they start to correlate their symptom severity and the MRI severity. Do you think there is any correlation or is that much related each other? What's your thought on that? Yeah, I know that people are saying that the MRI finding is not correlated with the patient's symptom. But for those, I'm not sure, how about your experience for those who are going to be operated? And the quality of MRI is very important. If the quality of MRI is not high resolution enough, we won't be able to see the nature and also the substance of the remnant. So for myself, I find it's very correlating, not only at the elbow region, but also at the wrist, at the TFCC, whether you repair it, then it can heal. Same for the elbow. But maybe my experience is not, it's a lot, but I find MRI, I rely a lot, quite a lot on the MRI. Okay. Shall we go to the question box? We have three questions. We'll pick the first one is from Dr. Claudia Santosa. So it's about the counterpressure braces that causes the PIN entrapment. How many of you still prescribe them and for how long? Maybe Dr. Sanchez-Sotelo, because you have that topic in your presentation. Yeah, so I don't know of any study that has confirmed that the counterpressure brace causes PIN compression, but I have seen patients on a daily where I am convinced that's the case. And if you think about where the counterpressure brace ends, it's right over the arcade of frost. So I myself do not use counterpressure braces. If anything, I use a wrist splint. I tell patients to use them on and off because I think that complete disuse is actually detrimental for tendon regeneration. So if someone uses a brace, I think it has to be occasionally when working, you know, on and off, but not 24 seven. How about for you, Erica, do you use counterpressure braces in your practice? I prescribe the patients, but everybody's not adherent. So they're actually healing themselves from me. Okay. So second question from Dr. Derek Guo. Can I do a quick poll to see how most of the faculty will treat isolated lateral epicondylitis that has failed conservative management for a year and open or percutaneous or arthroscopically, how will you do the surgery? And will you placate the capsule or tendons with a suture anchor after? So please have a vote on the first one. Failed conservative management for a year. How many of us will do a surgery? I will do. Okay. So open, percutaneous or arthroscopic, what is your preference? For me, I do an arthroscopic debridement without placation or suture anchor. Okay. That's my technique. How about you, Dr. Lu? Yeah, I do arthroscopic. Dr. Jeon and Dr. Wong, any thoughts? I think I do agree to Dr. Sanchez-Taylor, because you need to specify the lesion. If lesion is confined within the common extensive ECLB, then arthroscopic debridement, that's the standard. But you need to have a careful look whether they have any associated lesions as a plica or instability, then that's a different story. So you cannot generalize lateral elbow pain, arthroscopic placation, something like that. Thank you. I fully agree. So we have another question. It's anonymous. Is there any ever indication for cortisone injection for lateral epicondylitis for a non-op treatment in the panel's opinion? Maybe Dr. Wong, would you like to answer? I prefer not to have steroid injection unless the patient wants to have a fast relief. For example, they need to do something several weeks later, they won't be able to have enough time for them to wait the pain to go, then I'll go for a steroid injection. Otherwise, I prefer PRP injection instead of steroid injection. So the biologic injection, anybody has an opinion on the biologic injection for the lateral epicondylitis? I myself don't do very much, either steroid injection for a very incapacitated patient or very old or doesn't fit for surgery. I do everything in scope if I can or open. Dr. Joaquin, can you introduce what is happening in America? Should elbow surgeons practice it? Do they prefer any biologic injection, PRP or etc? Or is it very accepted? What I hear from the podium right now, so when you go to meetings and people talk, everyone says that they do not use partial injections anymore. But then I see patients that have received at least one injection very often. So I think that what people are saying they do versus what they do is slightly different. I bet you that many doctors that have seen a patient with tennis elbow three or four times eventually find the temptation to use an injection, maybe just one. Regarding PRP, there is some data I think that shows that it may be beneficial. In the United States, the patient has to pay for that service or there is some financial limitations. So for me, if I have a patient that is really struggling with pain, I will occasionally use a correctional injection, even though people say never, ever, ever. I do occasionally use them, but typically only one. And if that fails, I do try PRP. At least I offer it if the patient is interested. And then if not, then we go to arthroscopic surgery, but very, very rarely. How about for you, Inho? Do you use cortisone, PRP, nothing? Yeah, Dr. Joaquin, as you said, I mean, that's very, very realistic. In my practice, I do have more of the referral cases and I cannot do any steroid injection because they already had multiple shots somewhere. But if I'm a primary doctor somewhere for any tennis elbow, yes, maybe for initial treatment, I think it's acceptable because not every patient are living in very advanced countries. So in some countries, yes, I think we have to accept the steroid can you know, try first treatment option. But what we need to inform our patient is a multiple steroid can be very harmful in a sense. So maybe the brace or alternative conservative treatment should be advised. But I am very concerned on the biologic PRP or the other injections because I'm not sure whether we still have a good enough clinical evidence to support that. But this is a matter of debate. That's what I explain to my patients. Okay. So we will have one more question, a short case from an email. So we have a 34 year old male with a classic tennis elbow feature clinically. MRI show a common extensor tendon and RCL tear from the lateral epicondyle about 2.5 centimeter retraction. So the doctors was asking, what do you recommend for this case? And is this that much different from a common extensor release? Because this is a part of Dr. Wong lecture. May I have your first opinion on this case? Thank you for your question. And since the history is talking about an acute injury, am I right? Correct. It's a new and acute. So I need to understand whether the patient has a preexisting elbow pain before that injury. And also any bruising, significant bruising afterwards. And also it seems the patient has no symptoms afterwards. Am I right? So I need to know whether the patient had any injection of steroid before and also any medical diseases associated with tendinopathy. So if the patient has a preexisting tennis elbow symptom and with acute and chronic injury from that fall injury or that accident, then the tissue substance would not be good. And with that retraction for that large amount, even though the patient has no symptom now, but I think the patient should have some instability that he doesn't know. So I will put the patient for further investigation with a fluoroscopy scanning. We have the fluoroscopic scanning in the clinic. Then I can assess and compare with contralateral side when there's associated instability. If there's instability, despite the patient has no pain, I need to address to the patient that the subsequent without treatment for that instability. So if the patient agreed, then I think I'll go ahead for an operation to restore the instability. All right. Any opinion on this? This is very, very unusual. That's 34, 35 young guys have a complete rupture and retracted common extensor tendon. Then you need to ask whether this is a really acute traumatic or chronic degenerative. Any steroid injection longstanding, I think you should be very careful, just simply deep writing in this a young, active patients. So young, active patients with the retracted common extensor, I think it's not a matter of common extensor. The capsule is also torn. Then you may consider very seriously for ligament reconstruction rather than repair because in a chronic attenuated tendon and capsule, they have a less chance of healing in my mind. Thank you. All right. So Dr. Lu, do you want to say something about the case? Would you reconstruct as a augmentation to your repair or? So thank you, Eric. So how do you measure the defect of the tendon? You said it is I think the doctor measure it on the MRI. I think it's harder to give a correct size of the lesion because it depends on the different cut of the MRI. Sometimes I think in my patient, I see if you see the MRI in the computer, you can see in different layer, different size of the, so if the 2.5 centimeters, it's very large, but it's unusual, I think. All right. So the MRI section is usually not parallel to the LUCL projection. So it is very difficult to measure the defect. Yes, especially when there is severe sinusitis. All right. Okay. So any addition, Dr. Sanchez-Sotelo for the last quick Q&A? No, I have had that situation only once in my career. I had a patient who was a farmer and had an injury and you could actually feel a defect. So I think if there is a true tear of the whole common essential group, I think surgery is indicated because once the tendon retracts, it's more difficult to reattach it. So if this is a semi-acute situation, I would recommend surgery. All right, everybody. Thank you for all the panelists for sharing your insights and expertise with us this evening or this morning. It was both a pleasure and an honor to serve as your moderator for this collaborative webinar between AJSM and APCAS. Stay tuned for the upcoming AJSM webinar series, which will be held four times a year. You can currently access it through the AJSM website at www.ajsm.org or at the AOSSM Learning Zone website at www.education.sportsmeds.org.

lateral epicondylitis

tennis elbow

diagnostic approaches

surgical management

elbow pain

patient selection

conservative treatments

misdiagnosis

elbow instability

treatment strategies

medical practice

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