The management of tennis elbow
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The management of tennis elbow. BMJ Clinical Review John Orchard, Alex Kountouris. What and who?. Systematic review 2 Australians – Professor in School of Public Health at University of Sydney and the Australian cricket team physio. Cause, presentation.

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The management of tennis elbow

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The management of tennis elbow

The management of tennis elbow

BMJ Clinical Review

John Orchard, Alex Kountouris


What and who

What and who?

  • Systematic review

  • 2 Australians – Professor in School of Public Health at University of Sydney and the Australian cricket team physio


Cause presentation

Cause, presentation

Tendinopathy - not thought to be an inflammatory condition now, so “lateral epicondylitis” no longer favoured.

The clinical features are

  • tenderness at the lateral epicondyle,

  • normal elbow range of motion, and

  • pain on resisted movements (particularly resisted third finger extension).

    If the elbow’s range of motion is restricted, other diagnoses should be considered…


Treatment

Treatment

  • Eccentric exercises

  • NSAID

  • Steroid/local anaesthetic

  • GTN patch

  • Other injections

  • Surgery

  • Extracorporeal shockwave therapy

  • Wait and see


Treatment eccentric exercises

Treatment - Eccentric exercises

  • Needs to be accompanied by easing off overload - well studied, works well

  • What the physio’s are likely to recommend if you refer patients there


More treatments

More treatments

NSAIDs – topical or oral

  • no clear evidence, but anecdotally useful

    Injections (steroid +/- LA)

  • fine in short term, but harmful in longer term (recurrence more likely), so should generally be avoided


Even more treatments

Even more treatments

GTN patch

  • applied over the painful area act as a local and systemic vasodilator and improved outcomes in the first six months compared with placebo.

  • Longer term results have not shown benefit over placebo, although unlike cortisone injections no long term harm was seen

    Other injections

  • Autologous platelet-rich plasma injections – uncertain results, expensive

  • Hyaluronan gel injections – promising results from one study vs placebo

  • Botulinum toxin A injections (into extensor digitorum longus muscles of 3rd/4th fingers) – paralyses finger extensors for months, so inconvenient


And more

and more…

Surgery

  • very little evidence to support its use

    Extracorporeal shockwave therapy

  • only potentially useful if there’s calcification in the common extensor tendon

    …and finally…

    Wait and see


Key messages

Key messages

  • Tennis elbow is a tendinopathy of the common extensor origin of the lateral elbow

  • Cortisone injections are harmful in the longer term and are no longer recommended in most cases

  • Rehabilitation (exercise) based treatment is helpful, but to be effective patients must usually remove tendon overload

  • Further research is needed on newer (minimally invasive) treatments, such as platelet-rich plasma injections, hyaluronan gel injections, and nitrate patches

  • Reserve surgery and botulinum toxin injections for the worst cases because patients can take six months to return to full function

  • Many cases of tennis elbow cases will naturally resolve in 6-12 months


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