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

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

3. 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…

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

5. 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

6. 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

7. 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

8. 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

9. 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