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Try my simple tennis elbow remedy

From Dr Michael Blackmore

Ringwood, Hants

I suspect that the conclusion drawn from the results of the Australian trial comparing the long-term outcome of treating tennis elbow with steroid injections and physiotherapy is not as clear cut as it may seem (News, 5 October).

In my experience of treating very many cases over the past 30 years (including my own), very few GPs advise patients about the use of their hand as part of the treatment. This is especially important after injections have been used.

I suspect physiotherapists will concentrate much more on the need for correction of the provoking factors and that this has strongly influenced the findings in this trial.

In order to achieve good long-term results (and indeed short-term relief of symptoms) it is vital that the patient is taught to modify the way they use their hand on the affected side. In practical terms tennis elbow can be regarded as an injury to the common extensor insertion. An essential part of the treatment is resting the injured part and sparing it from any further injury.

This is achieved by advising the patient to use the hand 'palm up' (or in the case of golfer's elbow – palm down) for several months. In most cases this is sufficient to effect resolution. Steroid injections add nothing to the healing process but they do provide effective short-term pain relief. That is all that can be expected from them.

Since, in most cases, the pain is a response to loading the extensor insertion, it is a useful training aid in establishing the use of the 'palm up' position. If it is reduced substantially or abolished by a steroid injection and the previous pattern of use is not changed, it is not surprising that the problem recurs once the effect of the steroid injection has waned after three to six weeks.

It has long been my practice to advise against steroid injections for these enthesiopathies unless there is sufficient pain at rest to interfere with sleep. In the vast majority of cases retraining in the use of the hand is effective in achieving short-term relief of the pain (usually within a day or two).

It is vital that the patient is warned that the pain will inevitably recur if the changed position of the hand is not maintained for at least six to eight weeks and that in many, if not most cases, the pain is likely to recur from time to time in the future, perhaps for several years.

Prompt return to the 'palm up' position will give almost immediate relief.

I urge colleagues to try this simple remedy which can be taught in a few minutes. Steroid injections are rarely required but in the case of severe pain not relieved by retraining they can provide very effective pain relief. In milder cases the use of non-steroidal gel applied frequently to the affected tendon insertion can be sufficient to avoid the need for injection.

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