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Tendon, Nerves and Pain Master Class

In May 2017, the YSP team were fortunate to attend the two day Tendon, Nerves and Pain Master Class hosted by the prestigious Liverpool Upper Limb Unit. Speakers at this event included some of the country’s leading upper limb surgeons, physiotherapists, radiologists, and neurophysiologists. The program included an in depth debate on advances, techniques and controversies associated with tendinopathy of the shoulder and elbow, including areas of therapy, biologics and surgery. Additionally, lectures covered the modern management, diagnosis and difficulties associated with the neurological conditions of the shoulder and elbow, incorporating the surgeons’ and therapists’ roles in managing the outcomes of patients with chronic pain.

Modern medicine is constantly evolving as a result of new clinical research and advancements in technology. At YSP we ensure we keep up to date, through events like this masterclass, to make sure we are offering you the most up to date treatments and advise. This was an excellent conference which was both insightful and inspiring. It has undoubtedly influenced the YSP team members in regards to clinical decision making. Here are a few of the key learning points:

1) Treating Tennis Elbow - ‘There is no role for steroid injection in the management of tennis elbow’

2) Quadralateral Space syndrome - Are we missing this neurovascular compression syndrome?

3) Superior Capsule Reconstruction - Good initial results from clinical research

4) Improving outcomes from surgical repair of the rotator cuff

1) ​Treating Tennis Elbow - ‘There is no role for steroid injection in the management of tennis elbow’

This was the view of one of the speakers who gave a thought provoking presentation on the treatment of elbow tendinopathies. Steroid injections are used to treat both tennis and golfers elbow, however, this is somewhat controversial.

The slide above from the presentation shows a graph displaying the recovery rate for different treatments for tennis elbow. Treatments combined with a steroid injection actually had delayed and poorer recovery rates including physiotherapy; physiotherapy combined with a steroid injection had poorer outcomes than physiotherapy combined with a with a placebo injection.

Tennis elbow is an tricky condition to treat and it can be extremely painful and debilitating. A steroid injection can seem like the quick solution that so many people are looking for but there is increasing evidence to show that this may be damaging in the long term. This evidence comes in the form of clinical research assessing the results of treatments, as seen in the graph above, but also in histological studies which look under a microscope at the effect of steroid injections on the structure of tendons. Some histological research suggests that these injections can potentially cause degeneration of the tendon! This could explain why steroid injections may increase the risk of tennis elbow re-occurring even though they can reduce pain in the short term.

Clinical research into the treatment of tendinopathies, and specifically in tennis elbow, has shown that exercise targeting the tendon can be successful in reducing pain and improving strength and function - this often needs to be combined with rest and/or modification of certain painful activities. This is not a quick fix and takes time and dedication - which isn't always easy. It can become frustrating and if results aren't seen quickly its natural to look for another treatment option.

When considering treatment options its important to weigh up the risks and the benefits; a steroid injection comes with some potential risks and has potentially less benefit than exercise which comes with little or no risk. At YSP we do offer steroid injections but we strongly advise against this for tennis elbow, particularly as the first treatment.

If you would like to read more on this topic here are some interesting papers:

Dean, B. J. F., Lostis, E., Oakley, T., Rombach, I., Morrey, M. E. and Carr, A. J. (2014b) 'The risks and benefits of glucocorticoid treatment for tendinopathy: A systematic review of the effects of local glucocorticoid on tendon', Seminars in Arthritis and Rheumatism, 43(4), pp. 570-576.

Dean, B. J., Franklin, S. L., Murphy, R. J., Javaid, M. K. and Carr, A. J. (2014a) 'Glucocorticoids induce specific ion-channel-mediated toxicity in human rotator cuff tendon: a mechanism underpinning the ultimately deleterious effect of steroid injection in tendinopathy?', British Journal of Sports Medicine, 48(22), pp. 1620-6.

Gaujoux-Viala, C., Dougados, M. and Gossec, L., 2008. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: A meta-analysis of randomized controlled trials. Annals of the rheumatic diseases.

Hart, L., 2011. Corticosteroid and other injections in the management of tendinopathies: a review. Clinical journal of sport medicine, 21(6), pp.540-541.

Littlewood, C., Ashton, J., Chance-Larsen, K., May, S. and Sturrock, B. (2012a) 'Exercise for rotator cuff tendinopathy: a systematic review', Physiotherapy, 98(2), pp. 101-9.

Loppini, M. and Maffulli, N. (2011) 'Conservative management of tendinopathy: an evidence-based approach', Muscles Ligaments and Tendons Journal, 1(4), pp. 134-7.

2) Quadralateral Space syndrome – Are we missing this neurovascular compression syndrome?

Quadratlateral space syndrome (QSS) is a rare condition that occurs when the axillary nerve and the posterior humeral circumflex artery are compressed within the quadrilateral space. The quadrilateral space is located behind and below the shoulder ball and socket joint (glenohumeral joint). The space is bounded above by the teres minor muscle, below by the teres major muscle, medially by the long head of the triceps, and laterally by the humeral shaft.

QSS mainly affects young active adults, between the ages of 25-35 years, who participate in throwing sports or have an occupation involving a repetitive overhead action. Symptoms include a dull ache in the back and outside of the shoulder and numbness or tingling in the arm. These symptoms are typically produced when the arm is in a throwing position. Weakness of the teres minor and deltoid muscles may also be noted. This is usually treated with rest and functional strengthening. Sometimes, in severe cases, surgery may be required to decompress the structures.

This was a great lecture updating the YSP team on the latest clinical and anecdotal evidence relating to this syndrome. QSS is a rare syndrome with symptoms that are often vague and found in other conditions including shoulder impingement and thoracic outlet syndrome. This means diagnosis is challenging and the question of whether this is an under-diagnosed syndrome was raised. This presentation has really emphasised the importance of considering all possibilities for the cause of symptoms, including the weird and the wonderful!

3) Superior Capsule Reconstruction - Good initial results from clinical research

Mr Peter Brownson, an internationally renowned orthopaedic surgeon, gave an update on the superior capsule reconstruction. This is a relatively new surgical procedure and is an exciting development that could be the solution to a tricky problem; how to treat some people who have a large, irreparable rotator cuff tear. Different treatment options exist for irreparable cuff tears including physiotherapy, keyhole surgery to 'tidy up' the free edges of the tendons that have torn (this is called debridement) or tendon transfer procedure which is a much bigger operation. For some people these options are not appropriate or are not successful and they may go on to have a reverse shoulder replacement. This is, however, a major surgical procedure and current evidence suggests that this should be used with caution in younger patients (under 70).

Although large, irreparable cuff tears in younger people are not common, for the small number of people that fall into this category it can be painful and debilitating and managing this has been an orthopaedic challenge. With advancements in technology, the superior Capsule Reconstruction was developed by Dr Teruhisa Mihata in 2007 and offers hope to these patients.

The superior capsule is the upper part of the capsular lining of the shoulder joint. It has been shown to have a useful role in keeping the ball in the socket during movement of the arm. This is normally the job of the rotator cuff tendon. When the supraspinatus tendon of the rotator cuff is torn beyond repair, reconstructing the superior capsule has been shown to be a useful surgical procedure. The initial results from research is promising, showing improvements in strength, pain relief and function. This is great news and could really be life changing for some people.

4) Improving outcomes from surgical repair of the rotator cuff

This was an interesting talk from Adnan Saithna, a shoulder surgeon specialising in sports injuries. Surgical repair of the torn rotator cuff is a largely successful precedure but unfortunately some patients do get not get good results from surgery and continue to have pain and poor function of the shoulder. Mr Saithna presented evidence for some of the factors influencing this.

Two of important factors were found to be:

  • Poorly controlled diabetes

  • Smoking

Research has shown a higher re-tear rate in patients with poorly controlled diabetes and there is evidence that nicotine can delay the healing of the tendon increasing the risk of re-rupture of the rotator cuff.

So the key message is STOP SMOKING IF YOU ARE HAVING A CUFF REPAIR. But……..smoking increases the risk of many health conditions, including rotator cuff tears, so don’t wait until you need surgery to stop!

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