Management of tennis elbow

Clinical question: What is the best treatment for tennis elbow?

Results: Despite a wealth of research, there is no true consensus on the most efficacious management of tennis elbow especially for effective long-term outcomes. Corticosteroid injections do show large pain-relieving effects in the short term but are associated with risks of adverse events and long-term reoccurrence. Advice with a “wait and see” approach is recommended as the first-line treatment in primary care for most cases. In the medium term physiotherapy and or low-level laser therapy may be effective.

Implementation: Rule out alternative diagnosis. Onward referral may be indicated if the condition does not resolve after 12 months.

Tennis elbow

Definition: Tennis elbow, also known as lateral epicondylalgia (LE) and often referred to as epicondylitis or tendinopathy clinically,¹ has a complex underlying pathophysiology which is not well understood but is characterized by uncomplicated signs of localized pain over the lateral epicondyle which is made worse with resisted wrist extension and grip.² The term epicondylitis has recently been considered a misnomer because a lack of inflammatory signs.

Etiology: The annual incidence of tennis elbow is 4 to 7 cases per 1000 patients, predominantly in patients aged 35 to 55 years.^3,4 The condition affects between 1% and 3% of the population,^5,6 is usually self-limiting, and lasts between 6 and 24 months.⁴ Twenty percent of cases persist for more than a year.⁷

Risk factors: Repetitive manual tasks, or handling of heavy loads (.20 kg) or heavy tools (.1 kg).⁸ Risk is increased by a working posture of arms raised in front of the body, coupled with repetitive forearm twisting or rotating motions. The risk is further increased by high gripping force.⁹ LE is also associated with computer use of more than 20 hours per week, a risk that increases in line with years of use.¹⁰

Economics: Up to 30% of patients report work absenteeism.

Level of evidence: Systematic reviews, meta-analyses, general reviews, and randomized controlled trials (RCTs).

Search sources: MEDLINE (PubMed), CINHAL, EMBASE, AMED, Web of Knowledge, SPORTDiscus, Cochrane Library, DARE, DHdata, PEDro.

Chesterton et al
Outcomes: From a patient perspective the main outcomes are:

• Pain relief at rest and on activity.

• Improved function.

• Reduced sick leave.

• Avoidance of adverse events.

These are frequently measured in the short (0 to 12 weeks), intermediate (13 to 26 weeks), and long term ($52 weeks).

Consumer summary: Tennis elbow is a common, painful condition that generally occurs in middle-aged people and often prevents them from working or participating in their usual daily activities. Despite a large number of studies investigating an array of interventions, there is no favored evidence-based treatment for tennis elbow that gives anything beyond short-term pain relief. Corticosteroid injections do show large benefits in the short term, but can be painful and are associated with an increased risk of long-term recurrence, especially if more than one injection is given. There is some evidence that low-level laser therapy (LLLT) may be beneficial in the short term, although this is controversial and not always available as a tretament. Combined physiotherapy treatments give some medium-term relief slightly superior to advice and analgesics alone and show significantly better outcomes than steroid injections in the long term. For those patients who do not recover or respond to treatment in the long term, there is limited low-level support for injecting blood plasma, or for persistent and severe cases to undergo surgery. Advice with prescribed over-the-counter pain medication is recommended as the first-line treatment for most cases.

Are injection therapies beneficial?

(a)Corticosteroid agents

Steroid injections are the most thoroughly investigated intervention. There are 4 systematic reviews,^12–15 the most recent reporting 18 separate analyses from 12 trials (n = 1171 patients).¹⁴ Coombes et al¹⁴ concluded that there was strong evidence for the short-term benefit of corticosteroid injections across all outcome measures. Despite heterogeneity within the included trials which prevented pooling of some data for meta-analysis, consistent large effect sizes were seen in favor of corticosteroid injections compared with no intervention (“wait and see”), non-steroidal anti-inflammatory drugs (NSAIDs), physiotherapy, orthotic devices, and platelet-rich plasma (PRP) injections (reported in a separate review).¹⁶ These findings are in agreement with previous meta-analyses of the same subject^12,13 and with a recent systematic review restricted to comparing corticosteroid injections with various (individual as opposed to combined) physiotherapy interventions.¹⁵ One exception to this was the comparison with NSAIDS, in which Gaujoux-Viala et al¹³ reported that corticosteroids were not better in the short term (n = 1113).

In the intermediate and longer term, Coombes et al¹⁴ reported strong evidence that corticosteroid injections are less beneficial and show more adverse responses than all other interventions. This is also in agreement with a previous analysis.⁷ The authors report a subanalysis, which included the variable quality of trials, and this did not alter their conclusions. Different doses and suspensions of corticosteroid did not alter outcomes, although repeated injections (average 4.3, range 3 to 6 over 18 months) were associated with poorer outcomes.¹⁴ Gaujoux-Viala et al¹³ also reported a sensitivity analysis for disease duration which suggested that steroid injections are more effective in acute and subacute tendonitis (duration ,12 weeks) than in chronic disease, although the authors did suggest publication bias in favor of positive trials.

In the Coombes et al review,¹⁴ 82% of trials using corticosteroid injections reported adverse events which affected 17% of patients (n = 72/416; atrophy 38, pain 31, depigmentation 2, rupture 1). Another trial also reported high reoccurrence rates.¹⁷ A number needed to harm (NNH) of 26 for corticosteroid injections versus other commonly used treatments was reported.¹³ (The NNH is the number of patients who, if they received treatment, would lead to one additional person being harmed compared with patients who receive control treatments.¹⁸) (b) Noncorticosteroid agents

Three systematic reviews have investigated the injection of noncorticosteroid agents, although the number of relevant studies included in each is very small.^14,19,20 Coombes et al¹⁴ report the following results: sodium hyaluronate provided better pain relief at all outcome points than placebo injection (1 study,²¹ n = 165 intervention group). However the review authors noted that the placebo group (n = 166) in this study showed no improvement over 12 months, which is inconsistent with most other trials. No significant short-, intermediate-, or long-term effects were seen in

34 patients injected with glycosaminoglycan polysulfate (NSAID),²² or in the use of a sclerosing polidocanol versus a local anesthetic (lidocaine + epinephrine) (n = 32).²³

Rabago et al¹⁹ reviewed prospective case studies and controlled trials in respect of prolotherapy, polidocanol, whole blood, and PRP injections. They concluded that for LE which is refractory to conservative treatment, there is some limited pilot level evidence for the effectiveness of these therapies. For botulinum toxin a meta-analysis of 4 RCTs showed beneficial effects in the short term in pain reduction, but no effect on grip strength.²⁰ No high quality studies have investigated long-term outcomes for any of these interventions.

No adverse effects were observed for sodium hyaluronate, lauromacrogol, prolotherapy, or PRP. Aprotinin was associated with itching and burning and botulinum toxin with weakness and paresis¹⁴ and pain at the injection site.²⁰ Table 1 shows relevant randomized controlled trials published after the  latest systematic review.