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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

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…

  • Eccentric exercises
  • 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…


  • 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