Tennis elbow (lateral epicondylitis)

OK I mentioned in my previous post that I had bilateral tennis elbow… Well it’s only getting worse. I saw an osteopath last week (my first time!) and he did some hard core massage, mobilisation and cracked my elbow (which at the time gave me such a shock I nearly punched him in the face with my good arm). Poor Mr Osteopath…

So today I was thinking: is osteopathy going to work? Should I be taking meds? Should I just get a steroid injection? Should I amputate both upper limbs and attempt my activities of daily living with stumps instead?

So many questions…

What is tennis elbow?

Tennis elbow (lateral epicondylitis) is a common degenerative disorder of the extensor origin at the lateral humeral epicondyle first described in 1873.

A tear is just one of the pathologies...

A tear is just one of the possible pathologies…

I laughed at the title of one paper: “Lateral epicondylalgia: midlife crisis of a tendon”. Trust me, with all this sleep deprivation it’s not only my tendons that feel a bit over-the-hill. I have pancorporalgia…

What causes tennis elbow?

Physical exposures that are implicated are repetitive and extensive/prolonged wrist bending/twisting and forearm movements.

(Er hello? Unscrewing containers and jars, twisting bottle tops, shaking milk bottles, lifting and carrying infant, lifting and holding saucepans and fry pans, single-handedly hold squirming baby’s legs while changing nappy… Sigh… the list goes on)

Randomly found this 'realistic' new baby card. All potential/ new parents should be given this instead of the mushy crap that's out there.

Randomly found this ‘realistic’ new baby card. All potential/ new parents should be given this instead of the mushy crap that’s out there.

The first step in treating tennis elbow is avoiding the activities that cause it. Unfortunately we don’t always live in an ideal world.

Are there any physical therapies that work for tennis elbow?

  • Muscle strengthening: one study found a patient’s tennis elbow improved when muscle strengthening of the trapezius was done;
  • Taping was found to reduce pain and increase wrist extension force and grip strength in one study, however a Cochrane review could not draw definitive conclusions about the effectiveness of taping and other orthotic devices;
  • DTFM (deep transverse friction massage) combined with other physiotherapy modalities did not show consistent benefit for pain control, grip strength or functional status in tendonitis;
  • Osteopathy: limited evidence-based studies however some find that there is a favourable initial response to manual therapy (including MWM – mobilisation with movement) shown by increased pain-free and maximum grip strength.

Is there anything I can apply that will help my tennis elbow?

  • The administration of topical glyceryl trinitrate directly over the area of tennis elbow reduces pain (starting from 3 weeks, lasting until 6 months);
  • Topical NSAID gel may improve treatment success however may cause a skin rash;
  • The addition of TENS (transcutaneous electrical nerve stimulation) to GP advice and analgesia did not result in any additional benefit in the management of tennis elbow;
  • Acupuncture has been shown to provide short term pain relief however no benefit lasting more than 24 hours has been demonstrated.

What about oral medications?

It is unsure whether oral NSAIDs improve pain or function (because of the low quality of the evidence) however they possibly also increase stomach pain and diarrhoea.

Do steroid injections work for tennis elbow?

One study compared the effectiveness, after 3 months, of platelet-rich plasma (PRP – I’ll discuss more later) single injection vs steroid injection vs saline injection, in reducing tennis elbow pain. It had a high dropout rate of 58% which messed with the results a bit, but found that:

  • At one month, results favoured the steroid injection (no difference at 3 months) however tendon thickness reduction was greater in the steroid group;
  • PRP injections were more painful than both saline and steroid injections.

A Cochrane Protocol has been established to look at the effectiveness of corticosteroid injections for tennis elbow… stay tuned.

Other than amputating both my arms, are there any surgeries that work?*

  • Due to the small number of heterogeneous, poorly reported trials, a Cochrane review found insufficient evidence to support or refute the effectiveness of surgery for tennis elbow;
  • We also need to bear in mind that any surgery carries risks – pain, infection, bleeding, damage to surrounding structures, etc etc etc.

* Obviously I wouldn’t consider amputating both arms for tennis elbow… The pain of tennis elbow would only be replaced with phantom limb pain, which would be a billion times worse.

Any up-and-coming therapies that can help tennis elbow?

PRP (platelet rich plasma): platelets form part of blood and produce growth factors that assist in tissue regeneration and repair. It has been thought that if a high concentration of platelets is applied to an injury that faster healing will occur.

The current studies with PRP are few and mostly poor quality, which means that their results may not be reliable:

  • Once study found decreased pain at 6 months after treatment with 84% of patients expressing a high level of satisfaction;
  • A Cochrane review pooled the limited data and found very weak (very low quality) evidence for a slight benefit of PRP in the short-term (up to 3 months) management of pain;
  • One study compared PRP and AWB (autologous whole blood) in the treatment of tennis elbow and found both to be useful (reduced pain and improved function lasting up to 1 year). In this study PRP was not superior to AWB in long term follow up.

Bottom line

As you can see, a lot of the evidence for the treatment of tennis elbow is a bit iffy (not to say that these don’t work, but that the QUALITY of the evidence is so poor that it’s hard to draw reliable conclusions).

I’ll give my osteopath some more time (after all even I know that maximal benefits aren’t going to be seen after only one session) and if there still isn’t any improvement… amputation it is.

REFERENCES
Abbott JH, Patla CE, Jensen RH. The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia. Manual Therapy 2001 Aug;6(3):163-169.
Bhatt JB, Glaser R, Chavez A, Yung E. Middle and lower trapezius strengthening for the management of lateral epicondylalgia: a case report. J Orthop Sports Phys Ther. 2013 Nov;43(11):841-7. doi: 10.2519/jospt.2013.4659. Epub 2013 Sep 9
Brosseau L, Casimiro L, Milne S, Welch V, Shea B, Tugwell P, Wells GA. Deep transverse friction massage for treating tendinitis. Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD003528. DOI: 10.1002/14651858.CD003528
Buchbinder R, Johnston RV, Barnsley L, Assendelft WJJ, Bell SN, Smidt N. Surgery for lateral elbow pain. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD003525. DOI: 10.1002/14651858.CD003525.pub2
Chesterton LS, Lewis AM, Sim J, Mallen CD, Mason EE, Hay EM, van der Windt DA. Transcutaneous electrical nerve stimulation as adjunct to primary care management for tennis elbow: pragmatic randomised controlled trial (TATE trial). BMJ. 2013 Sep 2;347:f5160. doi: 10.1136/bmj.f5160.
Descatha A, Dale AM, Jaegers L, Herquelot E, Evanoff B. Self-reported physical exposure association with medial and lateral epicondylitis incidence in a large longitudinal study. Occup Environ Med. 2013 Sep;70(9):670-3. doi: 10.1136/oemed-2012-101341. Epub 2013 Jul 3.
Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft WJJ. Acupuncture for lateral elbow pain. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD003527. DOI: 10.1002/14651858.CD003527
Karimi Mobarakeh M, Nemati A, Fazli A, Fallahi A, Safari S. Autologous blood injection for treatment of tennis elbow. Trauma Mon. 2013 Winter;17(4):393-5. doi: 10.5812/traumamon.5095. Epub 2013 Jan 15.
Luk JK, Tsang RC, Leung HB. Lateral epicondylalgia: midlife crisis of a tendon. Hong Kong Med J. 2014 Apr;20(2):145-51. doi: 10.12809/hkmj134110. Epub 2014 Feb 28.
Moraes VY, Lenza M, Tamaoki M, Faloppa F, Belloti J. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD010071. DOI: 10.1002/14651858.CD010071.pub3
Ozden R, Uruç V, Doğramaci Y, Kalaci A, Yengil E. Management of tennis elbow with topical glyceryl trinitrate. Acta Orthop Traumatol Turc. 2014;48(2):175-80.
Pattanittum P, Turner T, Green S, Buchbinder R. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD003686. DOI: 10.1002/14651858.CD003686.pub2
Raeissadat SA, Rayegani SM, Hassanabadi H, Rahimi R, Sedighipour L, Rostami K. Is Platelet-rich plasma superior to whole blood in themanagement of chronic tennis elbow: one year randomized clinical trial. BMC Sports Sci Med Rehabil. 2014 Mar 18;6(1):12.
Shamsoddini A, Hollisaz MT. Effects of taping on pain, grip strength and wrist extension force in patients with tennis elbow. Trauma Mon. 2013 Sep;18(2):71-4. doi: 10.5812/traumamon.12450. Epub 2013 Aug 13.
Shiple BJ. How effective are injection treatments for lateral epicondylitis? Clin J Sport Med. 2013 Nov;23(6):502-3. doi: 10.1097/JSM.0000000000000042.
Struijs PAA, Smidt N, Arola H, van Dijk CN, Buchbinder R, Assendelft WJJ. Orthotic devices for the treatment of tennis elbow. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD001821. DOI: 10.1002/14651858.CD001821

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