Treatment Options for Tennis Elbow

The mainstay of treatment for tennis elbow is non-surgical treatment. Very few patients who suffer with tennis elbow require a surgical procedure. The numbers requiring surgery are less than 5%. It is recommended that surgery should not be considered unless the symptoms of tennis elbow persist for more than six months.

Non-surgical treatments of tennis elbow:

  1. Rest and non-steroidal anti-inflammatory drugs
  2. Physical therapy
  3. Corticosteroid injection
  4. Orthosis
  5. Shockwave therapy
  6. Other modalities

1. Rest and non-steroidal anti-inflammatory drugs

This has been the mainstay of treatment for tennis elbow. In a recent article in the British Medical Journal published October 2007 the recommendation for non-surgical treatment of tennis elbow has solely been non-steroidal anti-inflammatory creams and tablets. There is no evidence that non-steroidal anti-inflammatory drugs change the tendon pathology. The non-steroidal anti-inflammatory drugs simply treat the pain of tennis elbow. Non-steroidal anti-inflammatory drugs carry risk, although the risk is small. The risks from non-steroidal anti-inflammatories include gastric irritation and in very rare cases, the risk of peptic ulceration resulting in bleeding and death.

There has been published data on the efficacy of non-steroidal anti-inflammatory drugs in the treatment of tennis elbow. One such paper is a multicentre double blind randomised trial carried out by Labelle and Guibert. This study compared 28 days of oral non-steroidal anti-inflammatories with placebo in 129 patients. Both groups were temporarily immobilised. The treatment group reported less subjective pain. However, a lack of improved grip and functional ability, coupled with gastro-intestinal side effects from the non-steroidals, prevented the Authors from endorsing oral non-steroidals for lateral epicondylitis

In a second randomised trial published by Hay Et Al, published in the BMJ in 1999. This study looked at a two week course of Naproxen versus placebo. It failed to show a treatment effect at four weeks, six months and twelve months.

2. Physical therapy

Physical therapy is often prescribed for lateral epicondylitis. The most effective mode of therapy and treatment are still matters of debate. There is no conclusive research evidence that shows that physical therapy is a cure for lateral epicondylitis

3. Injections

Corticosteroid injections have been used to treat the acute pain of tennis elbow. There have been several investigations which have evaluated the efficacy of steroid injection versus non-steroidal anti-inflammatories and placebo. These papers include one by Smidt et al, published in the Lancet in 2002, also Hay et al, published in the BMJ 1999 and Lewis et al, published in the Clinical Journal of Pain 2005.

These investigations show that there is pain relief early after the injections. This pain relief usually lasts somewhere from five to six weeks. However, at longer follow up, between twelve weeks and twelve months, the results of those who received steroid injections were the same as, or worse than, those of other treatment groups. Potential explanations are that the injections may have weakened the tendon itself or that patients may have further aggravated the tendon during the relatively painless period early after the injection.

A paper by Altay et al, published in 2002, showed no differences in outcomes at a year when the tennis elbow was injected with local anaesthetic versus local anaesthetic and corticosteroid injections.

Recent research has highlighted the risks associated with corticosteroid injections.

In addition to the common side effects of skin de-pigmentation and fat atrophy, steroids have been shown to decrease collagen production, as well as tenosite replication. Common extensor tendon rupture has also been reported following local corticosteroid injection.

4. Orthosis

Orthosis devices have been prescribed for patients with lateral epicondylitis. These include a proximal forearm band, otherwise known as a Tennis Elbow Clasp, or a cock up wrist splint. There have been conflicting studies regarding the efficacy of splinting for lateral epicondylitis. Some clinicians feel that splinting may even hinder recovery.

To date there have been no adequately powered studies to determine their efficacy.

5. Shockwave therapy

Extra corporeal shockwaves are single pulsed sonic waves that dissipate energy at the interface of two substances with differences in acoustic impedance. The mechanism by which these waves produce symptomatic relief is well understood. These shockwaves have been used in the treatment of tennis elbow.

6. Other Modalities

Other modalities have been used for the treatment of tennis elbow. These include laser light therapy and low intensity ultrasound therapy. Studies on these modalities have shown limited clinical usefulness.

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