The information - tennis elbow
Consultant orthopaedic surgeon Mr Mike Hayton continues our series of evidence-based lowdowns on common presentations using PUNs and DENs
The patient's unmet needs (PUNs)
A 35-year-old plumber attends with a two-month history of elbow pain, which is now starting to affect his work. He hasn't injured it and he's tried NSAIDs without any benefit.
Examination reveals tenderness over the lateral epicondyle and pain on resisted extension of the wrist. You diagnose tennis elbow and start to explain the condition to him, but he interrupts by saying that he just wants some treatment to get him back to work as soon as possible.
The doctor's educational needs (DENs)
What is the natural history of tennis elbow? Does a period of rest speed up recovery?
Tennis elbow is very common, with a general population prevalence of about 2%. The usual age range in presentation is between 35 and 55 years, and it affects men and women equally. The cause of the pain is uncertain and likely to be multifactorial. Despite the term epicondylitis, there is no histological evidence of inflammation at biopsy.
Most cases of tennis elbow resolve with time, and in approximately 80% of cases symptoms will have significantly improved after one year. But patients do often want a quick fix rather than waiting for the natural history to provide relief. Avoiding the provoking activity does help recovery – but, of course, may not be possible.
Do occupational factors often play a part? Is there any simple advice we can give which might enable someone to continue at work in this situation?
Activities that cause excessive overload of the common wrist and finger extensors may cause tennis elbow, particularly if these activities are repetitive – manual workers are often affected. Patients can be advised that simple analgesia may help, and to avoid the provoking activity where possible. The use of forearm clasps and braces may give temporary benefit by off-loading the lateral epicondyle, and this can enable the patient to return to work.
What are the relative merits of strapping or braces, physiotherapy and anti-inflammatory drugs?
Forearm braces that act as counter-force devices aim to reduce the extensor muscle pull on the lateral epicondyle. But studies have failed to show any benefit for these over physiotherapy or a brace combined with physiotherapy.1 Physiotherapy has been shown to give benefit over no treatment in the first six weeks, and over steroid injection after six weeks.2 NSAIDs are useful as analgesia, but because tennis elbow doesn't involve inflammation their anti-inflammatory properties aren't useful.
A Cochrane database systematic review in 2005 gave platinum evidence showing no benefit from the use of shock-wave therapy in tennis elbow.
One of my own publications considered the use of botulinum toxin, the theory being to relax the common extensor muscles while the natural healing process takes place. But we found no benefit in the use of botulinum toxin injection over a placebo injection – patients reported no improvement in elbow pain.3
Recently there has been some excitement about platelet-rich plasma injections. The patient's own blood is placed in a centrifuge and spun down, separating the platelet-rich plasma – which is then injected into the tennis elbow area. The growth factors present in platelets are thought to enhance healing.
Recent prospective randomised trials have supported the use of platelet-rich plasma injections.4 The endpoint for success in this paper was defined as a 25% reduction in visual analogue score for pain or a similar reduction in the Disabilities of the Arm, Shoulder and Hand (DASH) score, but many of my patients just want to be pain free, and this would equate to a visual analogue score closer to zero out of 10.
My opinion is that the beneficial effect of injections may be the actual needle trauma rather than the injected substance.
Tennis elbow is a chronic condition with no active healing. It may be that the body heals this noxious stimulus and secondarily resolves the chronic tennis elbow.
There seems to have been a move away from cortisone injections for this condition in recent years. Why is this? Do they still have a role in some cases?
The use of steroid injections does seem to give temporary benefit. But there has been a slow move away from them because when studied beyond 12 months, patients who received the steroid injection appear to be worse off than patients who received nothing.2
Steroid injections still remain the first-line treatment for many clinicians in primary and secondary care. I always warn patients about adverse reactions and – in particular – lipodystrophy, which may manifest as fat necrosis with changes in skin pigmentation.
To minimise this risk you should inject deep to the extensor forearm fascia and use a concentration of no more than 10mg of triamcinolone (or equivalent).
Who should be referred for specialist assessment? What secondary care interventions are effective?
Patients who have failed conservative treatment and want the pain to be eradicated may be considered for surgery after three to six months.
There are many different operations – the most common is release of the common extensor origin from the lateral epicondyle and decortication of the underlying bone. The mechanism by which this works is not known.
The technique I use for classic extra articular tennis elbow is performed under local anaesthetic which is very well tolerated, and without a tourniquet. Around 10% of patients with tennis elbow have co-existing intra-articular pathology, and this explains the occasional tennis elbow release performed arthroscopically.
A Cochrane review in 20115 found no definitive conclusion as to the outcome of one surgical technique over another due to a lack of randomised controlled trials comparing techniques.
- Caused by repetitive excessive load on the wrist and hand extensor muscles
- Tennis elbow has a prevalence of 2%
- Men and women are equally affected
- Age range between 35 and 55 years
- Very localised pain over the lateral epicodyle of the elbow
- Pain is made worse with resisted wrist extension (Mill's test)
- There are very few differential diagnoses
- Some 10% of cases are associated with intra-articular pathology – such as locking – and radial tunnel syndrome
Unfortunately there is no evidence-based guidance on the appropriate treatments. But this may be a useful pathway:
- Rest and analgesia
- Steroid injection (low dose to avoid skin bleaching and fat necrosis)
- Consider platelet-rich plasma injections
- Surgery as a last resort
- Lipodystrophy and skin pigmentation changes with steroid injections
- Steroids may make the situation worse at
- 12 months
The prognosis for tennis elbow is good – most cases settle within 12 months and the rest usually respond well to treatment
Mr Mike Hayton is a consultant orthopaedic surgeon at Wrightington, Wigan and Leigh NHS Foundation Trust
Go to mikehayton.com for further information on a wide range of hand conditions and videos of several hand operations.
1 Struijs P, Korthals-de Bos C, van Tulder M et al. Cost-effectiveness of brace, physiotherapy or both for treatment of tennis elbow. Br J Sports Med 2006;40:637-43
2 Bisset L, Bellwe E, Jull G et al. Mobilisation with movement and exercise, steroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;333:939
3 Hayton M, Santini A, Hughes S et al. The treatment of tennis elbow with botulinum toxin A: a double-blind placebo-controlled trial. J Bone Joint Surg Am 2005;87:503-7
4 Gosens T, Peerbooms J, van Laar W and den Oudsten B. Ongoing positive effect of platelet-rich plasma versus steroid injection in lateral epicondylitis: a double-blind randomised controlled trial with two-year follow-up. Am J Sports Med 2011;39:1200-8
5 Buchbinder R, Johnson R, Barnsley L et al. Surgery for lateral elbow pain. Cochrane Database Syst Rev 2011;16:CD003525