Tennis Elbow 2

Updated: Jun 10

In part 1, I wrote about the prevalence and etiology of Lateral epicondylitis, if you haven’t read it yet, feel free to check it out to have a background on the topic. That said, in part 2, I intend on reviewing the most common treatment modalities used to manage Tennis elbow.



The current literature regarding treatment modalities in Tennis elbow has yielded mixed results, although most of the modalities used did produce an improvement in symptoms and function, it is yet to be determined which modality is the best, and so it ends up boiling down to expert opinion and what is readily available for use to the clinician.


Normally, patients complaining of tennis elbow have to go through the primary care physician who would prescribe NSAIDs and rest, other patients have direct access to a pain management clinic where the patient is offered anything from shockwave therapy to different types of injections. All of which depend on how qualified the center is. I’ve seen this practice in Germany and is not uncommon.


Lastly, if the patient is sent to an orthopaedic, the patient is offered a cortisone injection/NSAIDs and perhaps a referral to a physiotherapist clinic, and when all else fails, surgery is offered as a last-line treatment.

And so, I’ll quickly go over the most common modalities used and then talk about my modality of choice starting off with Platelet rich plasma (PRP) which is the newest kid around the block. It has been pushed around as a miracle treatment for tendon injuries. But a recent systemic review showed that it is no different than normal saline injection in terms of clinical improvement[1], so it may be just an overpriced modality with limited use.


That said, since tendon injuries are mostly degenerative in nature, the degenerative is irreversible so the notion that PRP can heal the damage doesn’t seem to make sense, unless the PRP is given when the tendon tissue is in the reactive phase instead of the degenerative phase, but that's just a speculation on my end. And as far as I recall, its impossible to tell the difference between reactive vs. degenerative tissue without a histological analysis.

However, I do have to mention that normal saline injections also produce clinically significant improvements compared to no intervention[2], so that may mask the effectiveness of the PRP, and we have yet to determine what is the mechanism by which normal saline actually produces an improvement.


It has been proposed that it has psychological and physiological effects. Psychological effects can be explained by placebo and the expectant theory. Physiological effects however are yet to be studied as there is no research on the effect of Normal saline on muscular and tendon tissue. Still if NS is just as good as the PRP, why use it in the first place? It has the same effect minus the cost.


Corticosteroids on the other hand have been used for no short time, and is usually the first-line injection Orthopedics use in hospitals and clinics; its relatively cheap and produces great effects. The short-term outcome of corticosteroids is amazing, it shows the best clinical improvement within the first 8 weeks compared to PRP, however, its long-term outcome is worse than PRP[3], and in some cases it may become worse than baseline[4][5].


So the question is when do we use this modality? Personally when I’m dealing with athletes, or the young population, I always recommend against taking Corticosteroids injections, as they may increase the degenerative change in tendon tissue which is counterproductive to our goal. There are other ways to get around inflammation and pain.


With the less active population, my recommendations may be different as it would depend on the patient’s current health status, and how willing the patient is to commit to treating his tendinopathy without using any invasive modalities.


Which brings us to the less invasive treatment modalities such as extra-corporal shockwave therapy, acupuncture, stretching and exercise. There are other non-invasive modalities, but they’re less commonly used and the research on them is quite primitive, and to be honest the article is long enough already, thus I’ll only focus on the modalities stated above.


Acupuncture seems to provide short-term pain relief, usually within the first 4-6 weeks compared to no intervention or to pulsed ultrasound[6], unfortunately there are no papers contrasting acupuncture to corticosteroid injections, at least not that I know of, and there are no papers on the long-term outcome of acupuncture for lateral epicondylitis.

I do want to note that the meta-analysis cited here wasn’t very convincing due to the large heterogeneity between the studies. So, if you want to give this a shot, it may at least help in the short-term and it does look quite cool…no?


Extra-corporal Shockwave therapy (ECSWT) on the other hand has some longer term studies, at least up to 6 months as it did show better clinical improvement compared to ultrasound therapy, but I do have to mention that both produced the same effect in terms of return to function, but ECSWT produced better pain scores (VAS) and better grip strength post treatment[7].


Although I’m not a fan of this treatment modality, it is usually available at physiotherapy centers. Thus, this is also an option for those who previously have used it and are comfortable with it, or those willing to try. Bare in mind, it can be quite annoying or painful as it feels quite odd like some sort of vibration.


This concludes part 2 of the Tennis Elbow series, see you soon in part 3.

Reference:


1. Simental-Mendía M, e. (2020). Clinical efficacy of platelet-rich plasma in the treatment of lateral epicondylitis: a systematic review and meta-analysis of randomized placebo-co... - PubMed - NCBI . Retrieved 7 March 2020, from https://www.ncbi.nlm.nih.gov/pubmed/32103373


2. Acosta-Olivo, C. A., Millán-Alanís, J. M., Simental-Mendía, L. E., Álvarez-Villalobos, N., Vilchez-Cavazos, F., Peña-Martínez, V. M., & Simental-Mendía, M. (2020). Effect of Normal Saline Injections on Lateral Epicondylitis Symptoms: A Systematic Review and Meta-analysis of Randomized Clinical Trials. The American Journal of Sports Medicine. https://doi.org/10.1177/0363546519899644


3. Li, A., Wang, H., Yu, Z., Zhang, G., Feng, S., Liu, L., & Gao, Y. (2019). Platelet-rich plasma vs corticosteroids for elbow epicondylitis. Medicine, 98(51), e18358. doi: 10.1097/md.0000000000018358


4. Olaussen, M., Holmedal, Ø., Mdala, I., Brage, S., & Lindbæk, M. (2015). Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial. BMC Musculoskeletal Disorders, 16(1). doi: 10.1186/s12891-015-0582-6


5. Bisset, L., Beller, E., Jull, G., Brooks, P., Darnell, R., & Vicenzino, B. (2006). Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ, 333(7575), 939. doi: 10.1136/bmj.38961.584653.ae


6. Trinh KV, e. (2020). Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. - PubMed - NCBI . Retrieved 7 March 2020, from https://www.ncbi.nlm.nih.gov/pubmed/15213328


7. Yan, C., Xiong, Y., Chen, L., Endo, Y., Hu, L., & Liu, M. et al. (2019). A comparative study of the efficacy of ultrasonics and extracorporeal shock wave in the treatment of tennis elbow: a meta-analysis of randomized controlled trials. Journal Of Orthopaedic Surgery And Research, 14(1). doi: 10.1186/s13018-019-1290-y

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