Treatment options for tennis elbowPete Kissel
Tennis elbow is a tendinopathy involving the tendons of the lateral elbow. Not surprisingly, most who experience this clinical condition are not tennis players at all. This injury is seen most commonly in individuals who suddenly overuse a relatively deconditioned and possibly degenerated tendon for the task at hand. A sudden return to vigorous exercise at the gym, unusual work around the house or heavy lifting are common presentations of lateral elbow overuse.
Although this condition is relatively easy to diagnose (disclaimer there are several important differential diagnosis to consider so please don’t just assume lateral elbow pain is tennis elbow) it is much more difficult to fix over the long term. A recent clinical review from the British Medical Journal (BMJ) called “The Management of Tennis Elbow” nicely summarized the efficacy of some commonly sought after treatment strategies that I will summarize below.
If you go to a baker, they will sell you bread…if you go to an orthopedic surgeon, they will sell you surgery…and if you go to a physio or chiro they will probably sell you, as part of their program of care, rehabilitation exercises. And while this may be true, the evidence is rapidly mounting for the efficacy of carefully prescribed exercises that challenge the tissue as close to its limits as possible without exceeding them for many musculoskeletal conditions. Eccentric exercise has become the focal point of rehabilitation programs for most tendinopathies (see Achilles tendinopathy post). Patients must also be willing to modify their activity level of the elbow during a rehabilitation program for optimal results. Continued participation in sports or heavy upper limb exercise routines, for example, will inhibit the effectiveness of rehabilitation.
Non-steroidal anti-inflammatory drugs (aspirin, ibuprofen, naproxen etc.)
NSAIDs can be helpful to cope with the pain of tennis elbow in the short term. However these drugs do not improve the long term outcome. Theoretically NSAIDs may even have deleterious effects on tendon healing (similar to cortisone injections). Further research is required to demonstrate the long term detrimental effects of NSAIDs on tissue healing.
Much like NSAIDs, cortisone injections may provide much needed short term relief (especially the first 6 weeks). However, patients treated with cortisone injections are more likely to have a recurrence. Therefore in most cases, especially where the long term outcome is more important than the short term outcome, cortisone injections should not be used.
Platelet-Rich Plasma (PRP) Injections
PRP has experienced a rapid rise to fame, especially in the sports medicine community. Pro Athletes such as Tiger Woods, Hines Ward and Troy Polamalu have all been reported to have benefited from PRP for post surgical healing, ligament and muscle healing respectively. Recent high quality RCT’s that compared PRP injections with cortisone injections for lateral elbow pain found superior cure rates and pain scores for PRP injections up to two years after injections. Two conclusions are possible, either PRP is helpful for tennis elbow or cortisone injections are detrimental for tennis elbow. Considering the known negative long term outcome from cortisone injections, our confidence in PRP with current evidence is weak. PRP has not been tested against other similar treatments that penetrate the skin (ie. acupuncture or other types of injections such as prolotherapy, hyaluronan or botulinum toxin). PRP is a relatively new treatment and is expensive. Evidence for superiority in efficacy is necessary, compared to similar forms of treatment, to warrant the increased costs.
A 2004 systematic review published out of McMaster University stated that there is strong evidence suggesting that acupuncture is effective in the short-term relief of lateral elbow pain. There are a few small studies that also claim that electro-acupuncture is more effective than manual acupuncture in chronic tennis elbow (more research needed). Clinically I believe acupuncture is an extremely powerful therapeutic option that should be a primary intervention for everyone suffering from tennis elbow.
Shockwave treatment may be effective in tennis elbow cases that involve calcifications of the tendon (usually confirmed via imaging). However, a 2009 Cochrane review concluded that there is strong evidence that shockwave therapy provides little or no benefit in terms of improving pain or function in the majority of tennis elbow cases. The treatment itself may be quite painful causing irritation of the skin and possibly nausea.
Like many other conditions, as a general guide, surgery has a role in cases of tennis elbow that do not respond to a sustained period of conservative treatment. Considering tennis elbow usually resolves within 12 months, a surgical intervention should not explored within this time period. Although there are several techniques (such as releasing, lengthening, excising and repairing the common extensor origin) described to surgically treat tennis elbow, the success of surgeries is likely due to forcing an initial rest period with gradual rehabilitation as the pain from surgery diminishes.
A conservative program of care to consider:
From clinical experience, soft tissue releasing techniques such as Active Release Technique (ART) are effective in the early intervention and long term maintenance for tennis elbow; especially in chronic, recurrent cases. Generally after an ART treatment patients will state that their elbow and forearm feels immediately “looser” with greater pain free range of motion. The combination of ART, electro-acupuncture and activity modification improves the intensity of symptoms and functional limitation in the majority of cases (in as little as 3 visits for some patients). When clinical symptoms become more manageable, the next phase of care involves more intense rehabilitation (including eccentric exercise) which will determine long term success of the treatment.
Orchard J and Kountouris A. The management of tennis elbow. BMJ. 2011;342:d2687.
Trinh KV et al. Acupunture for the alleviation of lateral elbow pain: a systematic review. Rheumatology. 2004;43(9):1085-90.