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Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

Posted by Sunny Jacob on 6/18/03 at 09:05 (122220)

We routinely treat the above since 1998, using ESWT/LILT combination therapy. Our success rate for tennis elbow is the same as for other joint tendonitis rate, i.e. approx. 86.2%. However, the success rate for golfer's elbow is approx. 70%.
As always, we use in-line ultrasound imaging during treatment. We cannot explain the difference in the outcome percentage. Of course, we make our golfer's elbow patients aware of this difference ahead of time. Most of them proceed with the treatment anyway because they prefer ESWT to surgery.

Some of the papers quoted are quite old. I can quote papers that have similar results as we are experiencing. Many are in German, for example Dr. Joachim Haisst, Orthopaedische Gemeinschafts-Praxis Woerrstadt, Germany, using Siemens low energy with in-line ultrasound treated 1,098 patients with radial epicondylitis (tennis) and 308 patients with ulnar (golfer's) from March 1990 to 1994. His results were as follows: Tennis elbow - unsatisfactory 14.6%; Golfer's elbow - unsatisfactory 19.2%

In conclusion, I agree with Dr. Davis. Instead of starting another major debate about difference in success rate (from the patient's stand point), let the patients make the final decision.
From a scientific standpoint, the differences are only worthwhile for someone who wishes to do research to find the reason for this difference in success rate.

Re: Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

Ed Davis, DPM on 6/18/03 at 10:54 (122231)

Sunny:
Thank you for your post. The percentages we are discussing are encouraging but even more encouraging when considering the limited risk of ESWT. Many surgeries and drugs have significantly lower success rates and significantly higher risks. When viewed from the risk to benefit ratio standpoint, I have a hard time seeing how one can make a good argument against the widespread use of ESWT.

The other issue to consider is the 'regionalization' of studies. A number of earlier researchers saw no need to look at this modality on a regional basis as it was a modality for treatment of tendinopathies. The focus on PF probably came about as it was one of the toughest 'tendinopathies.' Interestingly, I see this 'regionalization' in few areas of medicine. A sales rep approached me at the hospital last week with a new device for mending broken tendons. I asked him which tendons it was for and he answered 'all tendons, of course.' I replied that while all tendons have similar physiology the load characteristics and diameters are different. He repsonded, 'well, one may need to use two or three of the devices in the achilles tendon, while only one in a smaller tendon, the surgeon needs to make the choice.' There is a lot more risk and potential problems in the surgical repair of tendons than ESWT.

Ed

Re: Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

elliott on 6/18/03 at 11:16 (122233)

Dr. Ed:

And at what point does it become an insurer's 'responsibility' to cover the procedure? That's really the key question. For now, as Sonny says, let the patient decide. That's fair enough.

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Re: Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

Ed Davis, DPM on 6/18/03 at 13:57 (122251)

Elliott:

That is the 'million dollar question.' While there should be widespread use of ESWT in my opinion I could certainly envision insurers covering procedures selectively. We have some common criteria for PF coverage via ESWT. Other criteria would need be developed for use of ESWT in other areas of the body and that criteria may be tighter depending on outcomes experience and preliminary research data.

I don't want to get too deep into this aspect because there is a big political element to decision making. I am a fan of tiered coverage.
For example Regence Blue Shield either covers a drug or it does not in Washington State. They have actually shrunk their formulary. Blue Cross of WA has 3 coverage tiers -- generics and approved drugs being on the first tier with the highest coverage percentage , a second tier for less 'favored' drugs and finally a third tier which provides some reasonable coverage for drugs that Regence would not even consider. I would favor a tiered approach to coverage -- the insurer would then move treatments between the tiers as the evidence and experience changes. Even if a treatment is on the lowest tier, the existence of coverage leads to a pre-negotiated price so that the insured has a limited financial liability.

Ed

Re: Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

David L on 6/18/03 at 14:12 (122253)

Sunny:
Our experience at our clinics across Canada match yours....generally about 80% success across the 14 or so different indications that we treat; however, golfer's elbow is about 70% as well. I wonder why the difference?
David

Re: Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

Ed Davis, DPM on 6/18/03 at 14:30 (122256)

Sunny and David:

I can only speculate but if it was my elbow I would want to use Sonocur (or Sonocur Plus) on it. If the head of the machine is too big, in order to make sure that I avoid the ulnar nerve, I may aim wide and in doing so, may decrease the potential therapeutic effect. I don't want to start a machine vs. machine battle here as it has been my policy to support all of the companies producing ESWT machines but I think that the issue may simply be one of technique refinment. I do have feel that this is an area of the body that I would feel much more compfortable using a low energy machine with a relatively small shock head.

Ed

Re: Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

elliott on 6/18/03 at 14:36 (122257)

Can anyone answer--for either medial or lateral--what I asked in another post, namely, what is the typical progression of epicondylitis, in particular, around what percentage of cases resolve permanently (either by themselves or through minimal treatment) to a satisfactory degree and after how long? Certainly relevant in the discussion of success rates. Thanks.

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Re: Oops! Sunny (not Sonny). Sorry (not Surry :-)) (nm)

elliott on 6/18/03 at 14:40 (122259)

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Re: Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

Ed Davis, DPM on 6/18/03 at 17:10 (122277)

Elliott:

I don't have that information but would assume that ESWT would be reserved for the tough or 'intractable' cases.

Ed

Re: Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

Sunny Jacob on 6/18/03 at 20:17 (122294)

Why is there such a difference in the success rate? This has puzzled me for some time. Perhaps Siemens should take a lead role to do research in this area.

Re: Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

BGCPed on 6/18/03 at 20:37 (122297)

My advice is if you are right handed golfer with medialis epicondylitis the switch to south-paw, should clear ir up fast

Re: Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

Ed Davis, DPM on 6/18/03 at 20:40 (122300)

BG:

Sounds like that should work for tennis elbow too.

Ed

Re: Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

BGCPed on 6/18/03 at 23:02 (122313)

Dont be so sure Dr Ed,the study is still pending on that being used for tennis

Re: Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

Ed Davis, DPM on 6/19/03 at 15:53 (122379)

BG:

Okay, I don't think we can make a decision until the FDA tells us what to do ;)

Ed

Re: Epicondylitis medialis (Golfer's) and radialis (tennis) elbow

BGCPed on 6/19/03 at 17:15 (122388)

Dr Ed, I dont think you can post an assumption regarding what the FDA will or will not allow allow us to do, that is until they make a ruling on that