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WHAT IS IT?

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Tennis Elbow has been known as a number of other names including tendonosis, lateral epicondylitis and angiofibroblastic hyperplasia. It’s common name of Tennis Elbow is descriptive of the tendency of regular tennis players succumbing to the injury due to the high occurrence of late back hand and forced wrist extension. Tendons that are often involved in ballistic performance movements under load are regarded as being susceptible to an injury of this kind.
Pain can often radiate down through your forearm to your wrist or up towards your shoulder. This pain is from tiny tears in the tendons that connect forearm muscles to the elbow. This pain can hinder a persons grip making it hard for them to perform simple tasks such as opening a door or holding a glass.

 

SIGNS & SYMPTOMS

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Patients who have Tennis Elbow will often complain of tenderness and pain over the bony prominence of the lateral epicondyle (elbow). The underlying pathology of the injury is demonstrated by a degenerative change in the long extensor tendons for the forearm and the hand.
There is a large range of severity ranging from slight pain to severe and continuous pain and it is characteristically exacerbated by resisted extension of the middle finger and extension of the wrist. Tendons that have poor blood supply and straddle two joints such as those within the forearm are more sensitive to damage such as that shown in Tennis Elbow injuries.
Although this injury can be severely painful in some patients, the injury itself is not generally indicative of inflammatory changes. Physical signs such as altered signal around the lateral epicondyle on MRI scanning are often used to diagnose the injury. Furthermore, those with Tennis Elbow will often demonstrate a level of compromised grip strength.

 

WHO DOES IT OCCUR IN?

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Tennis Elbow has its largest occurrence in the 40-50 years old group with prevalence being as high as 19% (up from 1-3% in all ages). Furthermore, research has shown it is in 40-50% of regular tennis players. There is no correlation with gender although there is a clear-cut association with those who use repetitive forearm and hand movements in their occupation.
Arm movements that can lead to this injury include overuse of tools like screwdrivers (construction workers), painting (painters) or chopping food continuously (chefs). Office workers who do a lot of work with a computer mouse can also be susceptible.

 

TREATMENTS

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Tennis Elbow is an injury that has MANY forms of treatment (there have been approximately 40 different kinds developed!). This means that the optimum treatment has been hard to define over the years as what works for one patient doesn’t necessarily mean it works for another.

Initial treatment suggestions are using pharmalogical and physical modalities to settle pain and inflammation including exercise, NSAIDS, analgesics, ice and rest followed by exercise and electrotherapies such as ultrasounds, laser and high frequency galvanic stimulation, massage and trigger point injections.

However, there are many other forms of treatment available and it can become confusing as to what may be appropriate for the individual. We have taken some of the guess work out of it all for you by breaking up some of the common treatments into the most useful and beneficial down to the ones that the jury is still out on:

 

LONG TERM & EFFECTIVE TREATMENTS

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Exercise Physiology & Physiotherapy

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Especially in recent times, there have been many proposed treatments for Tennis Elbow utilising exercise as the main form of medicine. Croisier et al (2007) determined that a program involving iso-kinetic strength exercises was much more effective in controlling the symptoms of Tennis Elbow than a program that did not involve any strength work.
Your Exercise Physiologist will work with you to develop the right exercises for your case which may involve some stretching and strengthening of the forearm muscles and mobility of the wrist. Eccentric exercises (those that lengthen the muscle under load) such as the bicep curl will often help strengthen the wrist and build the forearm.

 

SHORT TERM & EFFECTIVE TREATMENTS

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Local Steroid Injections

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The most common treatment suggested for Tennis Elbow is the injection of corticosteroid with local anaesthetic. The physician will feel for the point of most tenderness and then injects the corticosteroid into here. Although this treatment has been deemed safe and effective at 4 weeks post injection for example, as with the treatment of many musculoskeletal complaints, the correlation between initial response and longer term follow up is poor (ie. The effectiveness is often only short term with pain returning again).

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NSAIDs

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Often, both topical and oral NSAIDs are offered to patients with Tennis Elbow. Green (2007) found some evidence to suggest that topical NSAIDs may relieve pain in the elbow for a short period of time however the evidence on the successful use of oral NSAIDs is much more ambiguous. In saying this, it is quite common for patients to claim oral NSAIDs are effective from their own practice so it can come down to individual preference.

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Wrist Extension Splints

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The most functional position of the hand is one in which there is slight extension and pronation. As this position requires the muscle to be active, any kind of activity using the hand may be painful in the lateral elbow. Due to this, workers will often attempt to use a splint that holds the wrist in extension. This then moves the need for the muscles to work to hold the wrist in this position.
Although some research has shown that the brace can cause some marginal pain relief for some patients, for many it is too uncomfortable or hard to wear (Altan et al., 2008).

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Acupuncture

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A review by Trinh et al (2004) indicated that whilst acupuncture may be effective in the short term and provide some relief from pain, it is not of much use for long-term control of the injury.

 

QUESTIONABLE & INDIVIDUAL PREFERANCE TREATMENTS (LAST RESORT!)

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Autologous Blood Injection (ABI)

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Autologous injections are thought to stimulate an inflammatory response and promote the necessary nutrients for healing. However, no benefit in the long term follow up has been found using ABI for treatment and it is only recommended for those severe cases where other modalities of treatment have failed.

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Orthotics (Braces & Clamps)

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The lateral epicondylar brace or elbow clamp is a popular treatment for Tennis Elbow yet the research supporting their use is still ambiguous. A brace alone may prove useful as an initial therapy but Struijs et al (2004) suggested that a combination therapy is much more successful than the brace alone.

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Platelet Rich Plasma Injections (PRP)

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This technique requires blood to be extracted from the patient, put through the centrifuge and then the plasma re-injected into the lateral epicondyle.
Current research on PRP and lateral epicondylitis is promising however more is needed to determine the full effectiveness of its use.

 

Ice

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Ice is a popular treatment method among patients with Tennis Elbow. Local application of ice on the injury site has been a common household method for years however the research does not necessarily support it. Manias et al (2006) concluded that there was no advantage over using a combination of ice and exercise when compared to using exercise alone.

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Extracorporeal Shock Wave Treatment (ECSWT)

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Although ECSWT has been shown to be a safe and effective treatment of Tennis Elbow by some, other studies have struggled to replicate its success and therefore, it is still in question (Radwan et al, 2007; Pettrone & McCall, 2005). Haake et al (2002) for example, reported that ECSWT was ineffective and that previous positive results of the therapy may have been shown to be effective due to poor research design as opposed to actual treatment success.

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Botox

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Botox is often used as a treatment to induce a period of temporary paralysis that gives time for the soft tissue at the injured site to recover. Again, the literature has drawn no real conclusion as to whether this treatment gives any real benefit. Wong et al (2005) concluded that although botox may  result in some improvement in elbow pain, many patients experience finger weakness in extension following its use.

 

Lasers

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When compared to a brace or ultrasound treatment, laser therapy offered no long-term advantage (Oken et al, 2008).

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Surgery/ Open Surgery Technique

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Encouragingly, most patients respond to some form of conservative treatment with Tennis Elbow and do not require surgical intervention. However, should the pain not subside with these less invasive treatments, surgery may be required. Most variations of surgical intervention require removal of the diseased tissue with decortication (removal of the outside layer) of the lateral epicondyle. This procedure can be done several ways including through open, percutaneous and arthroscopic approaches.

The Open Surgery technique involves the excision of an identifiable lesion in the origin of the extensor carpi radialis brevis and has been found to be successful in up to 97.7% successful (Dunn, 2008 & Nirschl, 1979).

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Percutaneous Release

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This procedure involves using local anaesthesia to release the extensor carpi radialis brevis at the point of origin at the epicondyle. Although it is a relatively simple procedure that can be just a day case, research has shown that can have good results in relieving pain and has minimal scarring (Nazar et al, 2012).

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Arthroscopic Treatment

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Arthroscopic surgery has been attempted on tennis elbow but with mixed results and has been suggested to provide the option of addressing other pathologies at the same time although specialist instruments and skills are required (Jerosch et al, 2005).

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Surgical Lengthening

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Roughly 50% of patients have responded to surgery involving lengthening of the ECRB tendon at the level of the wrist (Leppilahti et al, 2001). Though it is suggested that about half of these positive cases also noted a similar response to decompression of PIN which have been linked here previously.

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MISDIAGNOSIS

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Often patients who have Tennis Elbow have been diagnosed due to their high use of repetitive manual tasks. However, these tasks also put them at risk of radial tunnel compression. As the signs and symptoms of the two injuries are so similar, it can be difficult to differentiate the difference between them and misdiagnosis can occur.
Radial tunnel compression is associated with pain on resisted supination and resisted extension of the middle finger so can be misinterpreted as Tennis Elbow.
Jalovaara (1989) has suggested that around 30% of cases of Tennis Elbow are in fact from radial tunnel syndrome and some researchers openly acknowledge that it is virtually impossible to distinguish between the two conditions.
The surgical technique of Wilhelm is commonly used to release the nerve involved with radial tunnel syndrome. Similarly, procedures for Tennis Elbow relax the ECRB tendon but also indirectly decompresses the radial nerve which then poses the question as to whether the patient was actually suffering from radial tunnel syndrome instead. Research has then suggested that perhaps Posterior Interosseous Nerve (PIN) release should be performed on those suffering from Tennis Elbow who have proved resistant to all other forms of treatment.

 

 

CONCLUSIONS

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When comparing all the different types of treatments for Tennis Elbow, it is important to remember that the order in which they often occur, may differ between the individuals depending on their situation. In addition, most surgeons (and patients!) would often leave more invasive treatments such as surgery as a last resort and only if all other forms of treatment have been exhausted.
Research has concluded that neither Botox nor ECSWT represent definitive cures for this injury. They may provide relief in some patients that have proven resistant to other treatments

Tennis Elbow is also one of those injuries that requires PATIENCE! Recovery will not happen overnight and some assistance from the patient is often needed to ensure the treatment is done correctly. In the case of using exercise as treatment, it is important for the individual to follow their rehabilitation program as instructed by their practitioner and be patient with it.
It may be a long road but as always, short cutting will not provide the answers!