The management of tennis elbow BMJ Clinical Review John Orchard, Alex Kountouris

What and who? Systematic review 2 Australians – Professor in School of Public Health at University of Sydney and the Australian cricket team physio

Cause, presentation Tendinopathy - not thought to be an inflammatory condition now, so “lateral epicondylitis” no longer favoured. The clinical features are tenderness at the lateral epicondyle, normal elbow range of motion, and pain on resisted movements (particularly resisted third finger extension). If the elbow’s range of motion is restricted, other diagnoses should be considered…

Treatment Eccentric exercises NSAID Steroid/local anaesthetic GTN patch Other injections Surgery Extracorporeal shockwave therapy Wait and see

Treatment - Eccentric exercises Needs to be accompanied by easing off overload - well studied, works well What the physio’s are likely to recommend if you refer patients there

More treatments NSAIDs – topical or oral no clear evidence, but anecdotally useful Injections (steroid +/- LA) fine in short term, but harmful in longer term (recurrence more likely), so should generally be avoided

Even more treatments GTN patch Other injections applied over the painful area act as a local and systemic vasodilator and improved outcomes in the first six months compared with placebo. Longer term results have not shown benefit over placebo, although unlike cortisone injections no long term harm was seen Other injections Autologous platelet-rich plasma injections – uncertain results, expensive Hyaluronan gel injections – promising results from one study vs placebo Botulinum toxin A injections (into extensor digitorum longus muscles of 3rd/4th fingers) – paralyses finger extensors for months, so inconvenient

and more… Surgery very little evidence to support its use Extracorporeal shockwave therapy only potentially useful if there’s calcification in the common extensor tendon …and finally… Wait and see

Key messages Tennis elbow is a tendinopathy of the common extensor origin of the lateral elbow Cortisone injections are harmful in the longer term and are no longer recommended in most cases Rehabilitation (exercise) based treatment is helpful, but to be effective patients must usually remove tendon overload Further research is needed on newer (minimally invasive) treatments, such as platelet-rich plasma injections, hyaluronan gel injections, and nitrate patches Reserve surgery and botulinum toxin injections for the worst cases because patients can take six months to return to full function Many cases of tennis elbow cases will naturally resolve in 6-12 months