What is supported by evidence regarding tennis elbow?
Charles Lascano, MD, CAQSM. Sports Medicine Specialist. Sanitas Medical Centers.
Lateral epicondylitis, commonly known as “tennis elbow,” is a painful condition involving the tendons that attach to the bone on the outside (lateral) part of the elbow. With the tennis elbow, there is degeneration of the tendon’s attachment, weakening the anchor site and placing greater stress on the area. This can lead to pain associated with activities in which this muscle is active, such as lifting, gripping, and/or grasping.
Potential causes of tennis elbow include overuse and trauma. Overuse can be both non-work and work-related. Overuse can happen from repetitive gripping and grasping activities such as meat cutting, plumbing, painting, auto-mechanic work, etc. Trauma, although less common, can be due to a direct blow to the elbow which may result in swelling of the tendon that can lead to degeneration. This can make the elbow more susceptible to an overuse injury.
Tennis elbow symptoms include pain in the elbow that spreads into the upper arm or down to the forearm, or weakness of the forearm. The pain can begin suddenly or can develop gradually over time. Also, you might have a harder time with activities that require arm strength, including sports that require you to hit a backhand or throw a ball.
This condition is usually diagnosed based on an exam and your description of pain. Therefore, there is no need to order MRI, ultrasound, or another test to make the diagnosis. However, your health care provider could order x-rays of the elbow to check for other causes of pain like osteoarthritis and to check of tendon calcifications.
There is a wide range of treatment options, but little high-quality evidence supporting any particular approach which creates confusion and controversy among patients and even healthcare providers. I am going to discuss recommended treatment options based on supporting scientific evidence.
If left untreated, symptoms associated with tennis elbow persist between six months and two years. Patients should try to avoid activities that exacerbate symptoms. For athletes, correction of faulty mechanics must be part of their activity modification.
As part of the initial management of tennis elbow, you can apply a counterforce brace. Counterforce braces may provide benefits during the first six weeks following injury and are easy to use and inexpensive. These braces are placed on the forearm approximately six to ten centimeters distal to the elbow joint.
Well-designed physical therapy programs are an effective initial treatment for many patients with tennis elbow. It is very important to be compliant with the primary care provider’s indication of going to physical therapy and with the home exercise program provider. The therapy and the home exercises are important not only as treatment but also as prevention of further damage of the degenerated tendon. Your primary care provider can give you the needed physical therapy prescription and the appropriate home exercises. Therefore, there is no need to wait to be seen by a specialist to obtain these and start taking care of this condition.
Anti-inflammatories have been a mainstay of the treatment of tennis elbow for many years. As the scientific understanding of this condition has developed, and now we know tennis elbow is a degeneration rather than inflammation, the controversy surrounding the role of anti-inflammatory medications in the treatment of this condition.
Multiple trials and systematic reviews have found that glucocorticoid injection for lateral epicondylitis improves many short-term (six weeks) outcome measures but does not prevent recurrence and may lead to worse long-term outcomes.
Platelet-rich plasma (PRP) is purported to contain growth factors that stimulate tissue repair, and percutaneous injection of PRP is used by some clinicians to treat epicondylitis with good results. However, this procedure is not typically covered by health insurance plans, which can be expensive for the patient needing repetitive PRP injections.
Acoustic waves have been used to treat chronic lateral elbow tendinosis. Overall, evidence supporting extracorporeal shock wave therapy (ESWT), and other “electrophysical” modalities, is unconvincing. Also, procedure is generally uncomfortable.
Surgery is only considered when the pain is incapacitating and has not responded to other treatments, and when symptoms have lasted six to twelve months. Surgery involves removing the diseased, degenerated tendon tissue.