The basics - Tennis elbow

Sometimes a 'wait and see' policy is best for this common and painful condition. By Dr Alison Glenesk

Corticosteroid injection should be used cautiously and only after discussion with the patient about relapse (Photograph: SPL)
Corticosteroid injection should be used cautiously and only after discussion with the patient about relapse (Photograph: SPL)

This is a common and painful condition, with an incidence of 4-7 per 1,000 people per year, meaning a full-time GP will see about one new patient per month.

Tennis elbow is not confined to players of racquet sports, but can occur after any activity which puts strain on the forearm extensor insertion - even DIY or housework. The cause is thought to be trauma to the muscle fibres at the insertion itself.

Most patients are aged from mid-thirties to mid-fifties with the peak incidence being between 40 and 50 years.

1. Making the diagnosis
Diagnosis is usually simple. The patient will complain of pain in the region of the lateral epicondyle, usually on the dominant side, with severe pain on lifting objects - classically the teapot - and activities such as shaking hands.

This pain can be reproduced by asking the patient to extend the wrist with the forearm pronated. On examination, there is usually no swelling. Severe tenderness on the anterior aspect of the epicondyle clinches the diagnosis.

Other painful elbow conditions to consider are olecranon bursitis, arthritis of the elbow and referred pain from cervical root compression or from shoulder or wrist conditions. However, these will not present with the specific clinical features of tennis elbow.

2. Initial treatment
The natural history of the condition is encouraging: at one year, 89 per cent of patients will have recovered without treatment, but most will have had to give up the activity which originally caused the problem.

This can cause occupational difficulties for manual workers and/or problems with recreational activities. Almost certainly, the presenting patient will expect something to be done to help. Simple, common sense treatments, such as rest and ice application after activity may be helpful, as may anti-inflammatory medication, either orally or topically.

Some patients find an epicondylitis clasp helpful. This is a rigid pad which is held tightly to the arm, just distal to the epicondyle, by an elastic strap.

These measures may provide some relief in the short term, but do not appear to influence the long-term outcome.

3. Evidence-based management
The three management strategies for which there is most evidence are: corticosteroid injection, physiotherapy and 'wait and see'.

In a Dutch study in 2002, 185 patients were randomly assigned to one of the above groups, and followed up several times for up to one year.1 At six weeks, the injection group had the best outcome, with 92 per cent improved, compared with 47 per cent of the physiotherapy group and 32 per cent of the 'wait and see' group.

However, relapse rates were high in the injection group. At one year, 91 per cent of the physiotherapy group had improved compared with 83 per cent of the 'wait and see' group and 69 per cent of the injection group.

A similar study carried out in 2006 in Australia gave comparable results.2 The conclusion was that corticosteroid injection should be used with caution, and only after a full discussion with the patient about the possibility of relapse and the probable eventual favourable outcome if no specific treatment is offered.

As physiotherapy gives a similar end result to doing nothing, the point is made that we should consider the latter approach on economic grounds.

Corticosteroid injections are frequently offered and patients are grateful for the respite they offer. The injection may be repeated after a period of two months. The preferred preparation is hydrocortisone acetate (a short-acting steroid) mixed with a small quantity of local anaesthetic injected into the point of maximum tenderness. This preparation is preferred at the elbow as long-acting steroids are more likely to cause subcutaneous atrophy.

Another treatment is the daily application of a glyceryl trinitrate (GTN) patch over the epicondyle.3 In a trial in 2003, 86 patients received standard tendon rehabilitation plus the application of a placebo or GTN patch.

The treatment group achieved better results, with 81 per cent asymptomatic at six months compared with 60 per cent of the placebo group. At five-year follow-up in 2009, no difference was found between the groups.

4. Surgery
For some patients in whom the condition has become chronic, surgery can be performed as a last resort. This takes the form of an 'extensor release' or division of the extensor tendons at the epicondyle, and can now be done arthroscopically. The procedure can be done as a day case. Full healing takes about three months.

Most studies suggest success rates are about 80 per cent at one year, however, some state that there is no good evidence that surgery is better than expectant treatment.

There are some references to 'high energy orthopaedic lithotripsy' in the treatment of tennis elbow. Perhaps this will be the treatment of the future.

  • Dr Glenesk is a GP trainer in Aberdeen
Key points
  • Peak age is 40-50 years.
  • Pain on lifting, tenderness at lateral epicondyle.
  • 89 per cent of patients are better at one year with no treatment.
  • Steroid injection helps in the short term.
  • Surgery is a last resort and is not supported by evidence.

References
1. Smidt N, van der Windt DA, Assendelft WJ et al. Corticosteroid injections, physiotherapy or a wait and see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002; 359(9307): 657-62.

2. Paoloni JA, Appleyard RC, Nelson J, Murrell GA. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med 2003; 31(6): 915-20.

3. Bisset L, Beller E, Jull G et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow:randomised trial. BMJ 2006; 333: 939.

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