Tennis Elbow - What's the Best Approach?

Tennis elbow, lateral epicondylitis, lateral epicondylalgia or whatever you wish to call that pain on the outside of the forearm, is not easy to treat. Assuming that “tennis elbow” is not referred pain from the cervical spine, there are many treatment techniques I have encountered that aim to reduce the pain of the condition, and increase the hand and elbow function of those afflicted by it.

Some of the techniques commonly used include, but are not limited to: prolotherapy, steroid shots, lidocaine shots, Platelet Rich Plasma (PRP) shots, oral NSAIDs, oral analgesics, oral steroids, topical NSAIDS (Voltaren, Penssaid), elbow braces, immobilization of the elbow, compression bandages, ultrasound, phonophoresis, electrophoresis, trigger point release of forearm muscles, trigger point injections, cold-laser therapy, stretching, transverse frictions, joint mobilization, mobilizations with movement, mill’s manipulations, rest, postural re-education, eccentric forearm exercises, tendon transfer surgery….etc. No management strategy has had exceptional results with treating tennis elbow, even though numerous randomized trials have been performed

Bisset et al (2006) investigated whether Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow[1] had the best short and long-term results. The results of this study were not surprising, but rather, give further credence to the field of physical therapy.

The authors found that cortisone injections had the best effect at 6 weeks, even over physical therapy (except on the global improvement outcome scale), and significantly better than “wait and see.” At 6 weeks, mobilisation with movement (MWM) and exercise had a clear advantage over “wait and see.” The NNT (number needed to treat) in this example was 3, ie for every 3 patients treated with MWM and exercise, the PT would have had one more successful outcome than if they “waited to see.” At 52 weeks, physical therapy was superior to both corticosteroid shot and “wait and see.” Interestingly, those subjects that had injections had the highest reoccurrence rates of tennis elbow.

Numerous studies have shown the absence of inflammatory cells[2] histologically in tennis elbow, so why use anti-inflammatories or cortisone shots at all? I can see the benefit in the first 6 weeks of injury when inflammatory markers may be present, but I see no additional benefit for chronic cases of tennis elbow. This brings up another interesting question. Why do anti-inflammatories or NSAIDs work at all (albeit short term) in chronic cases of tennis elbow? Perhaps they work on inhibiting the pain element of the cyclooxygenase pathway (COX pathway), rather than the inflammatory element? I welcome responses regarding this phenomenon.

Some evidence suggests that tennis elbow may be related to changes in the common extensor origin, more specifically:

•neurogenic chemical mediators of pain (substance P and calcitonin gene-related peptide).[3]
•Increased level of glutamate (an amino acid)[4]
•neovascularization[5]
•muscle fiber morphology changes (ie fiber necrosis, higher percentage of fast twitch oxidative fibers, and moth eaten fibers)[6]
•Changes to sympathetic nervous system (no vasomotor response)[7]
•Presence of mechanical, but not thermal hyperalgesia[8]

With regard to manual therapy, there have been numerous studies purporting its benefit to treating tennis elbow, and proposing varied reasons why it works. In reality, there are probably many varied reasons (explained and unexplained) as to why manual therapy works on various different systems. Interestingly, Abbot et al (2001) proved that a MWM performed on the elbow in patients with tennis elbow resulted in improved external rotation ROM immediately after the procedure.[9] This certainly baffles me!

Vicenzino et al (2009) are following in the footsteps of the Childs and Cleland (2006) clinical prediction rule for treating lower back pain, in that they provided a Level IV evidence of a clinical prediction rule to treat tennis elbow[10]. Their analyses looked at age, and pain-free grip strength on the affected and unaffected sides. I will reserve judgement on this article until a further validation study has been performed.

Coombes et al (2009) in an exciting and prospective trial are following on from the work of Bisset et al (2006). In this trial, they have gathered 132 tennis elbow patients. They intend to randomize the subjects into one of four treatment groups:[11]
1) Corticosteroid injection
2) Saline injection
3) Corticosteroid injection with physiotherapy
4) Saline injection with physiotherapy.
PT will comprise 8 sessions (like in the Bisset et al trial), with follow –up assessments at 4, 8, 12, 26, 52 weeks.
I look forward to the results of this trial, especially since the authors are including cost effectiveness and cost-benefit analyses. After all, treatments must be cost-effective and have therapeutic value to be considered for use in the wider community.
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[1] Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939
[2] Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow): Clinical features and findings of histological. immunohistochemical, and electron microscopy studies.Bone Joint Surg Am. 1999; 81:259-278.
[3] Ljung BO, Alfredson H, Forsgren S. Neurokinin 1-receptors and sensory neuropeptides in tendon insertions at the medial and lateral epicondyies of the humerus: Studies on tennis elbow and medial epicondylalgia. J Orthop Res 2004;22:321-327.
[4] Alfredson H. Ljung BO, Thorsen K, Lorentzon R. In vivo investigation of ECRB tendons with microdialysis technique: No signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop. 2000;71:475-479.
[5] Zeisig E, Ohberg L, Alfredson H. Extensor origin vascularity related to pain in patients with tennis elbow. Knee Surg Sports Traumatol Arthroscopy. 2006;14:659-663.
[6] Ljung BO. Lieber RL, Friden J. Wrist extensor muscle pathology in lateral epicondylitis. J Hand Surg. 1999;24:177-183.
[7] Smith RW, Papadopolous E. Mani R, Cawley ML Abnormal microvascular responses in a lateral epicondylitis. Br J Rheumatol. 1994;33:1161-1168.
[8] Wright A, Thurnwaid P, Smith J. An evaluation of mechanical and thermal hyperalgesia in patients with lateral epicondylalgia. Pain Clinic. 1992;5:221-227.
[9] Abbott JH. Mobilization with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylalgia. Manual Therapy. 2001;6:170-177.
[10] Vicenzino B, Smith D, Cleland J, Bisset L. Development of a clinical prediction rule to identify initial responders to mobilisation with movement and exercise for lateral epicondylalgia. Manual Therapy. 2009;14(5):550-554.
[11] Coombes B, Bisset L, Connelly L. et al. Optimising corticosteroid injection for lateral epicondylalgia with the addition of physiotherapy: A protocol for a randomised control trial with placebo comparison. BMC Musculoskeletal Disorders. 2009; 10:76.