The latest evidence on treating the troublesome ‘Tennis Elbow’
by Dr Rick Seah
MBBS MSc (Hons) MAcadMEd MRCGP FFSEM(UK) DCH DipSEM(GB&I) Dip FootballMed
Consultant in Sport, Exercise & Musculoskeletal Medicine
Lateral elbow pain (pain on the outside of the elbow) is a common symptom. It is estimated to affect between 1-3% of the adult population each year! There are several possible causes for this but one of the most frequent is lateral epicondylopathy or ‘tennis elbow’ (TE).
Diagnosis & treatment
The diagnosis of TE is made by a combination of history taking and clinical examination, often followed by some imaging (ultrasound or MRI scan).
There are many treatment options for TE. These include physiotherapy rehabilitation, injections therapy options (e.g. cortisone, platelet-rich plasma (PRP), prolotherapy), non-injection therapy options (shockwave therapy (ESWT)) and surgery (open vs arthroscopic). Often a combination is utilised of treatment options can be considered.
TE can give rise to a spectrum of symptoms and range from the mildly uncomfortable and persistent to severe and debilitating, with major impact on a patient’s ability to work or participate in physical activity or sport. It’s not just tennis players who suffer with this!
TE is more common in the dominant arm and can be regarded as an overuse injury involving repeated wrist extension against resistance, although it can also occur as an acute injury (trauma to the lateral elbow).
Amateur tennis players can develop symptoms due to various factors, including poor swing technique and the use of heavy racquets. TE is also seen in labourers who utilise heavy tools or engage in repetitive gripping or lifting tasks.
What's New Doc?
I thought it would be helpful to carry out an overview of the current methods of lateral elbow injury management, considering what’s topical and novel in the recent research literature.
I did this by performing a PubMed literature search (similar to a Google search, but focussing main on medical and scientific articles) with the phrase’ tennis elbow’.
I concentrated on recent high-level studies- Meta-analysis (MA), Systematic reviews (SR) and Randomised controlled trials (RCT)- from the years 2019 and 2020. The results were interesting!
1. Cortisone injections against Platelet-rich injections
The first study (a SR and MA) by Li and colleagues that compares traditional cortisone injections (CSI) against platelet-rich injections (PRP). PRP injections are a non-cortisone alternative which became popular around 15 ago as it was used by elite level athletes to treat their longstanding tendon and ligament injuries.
In the short term, cortisone injections demonstrated favourable outcomes (up to 2 months after injection) but in the medium term, PRP injections were better at improving pain and function by the 6 month mark.
These findings were backed up by a paper (MA) by Xu and colleagues earlier on in the year.
2. Prolotherapy against Cortisone injections
The next study (a RCT) by Bayat and colleagues compared prolotherapy against cortisone injections.
Prolotherapy injections typically work by encouraging the body to lay down new collagen fibres within the substance of the injured tissue, thickening and strengthening them. In practice, this involves a series of injections of irritant solution into ligament and soft tissue insertions to relieve pain, promote tissue healing and address tissue laxity (often presenting as joint instability).
They found both methods to be effective in the short-term treatment of TE, but dextrose prolotherapy seems to be slightly more effective than cortisone injection over a longer period.
3. Acupuncture against Cortisone injection
A cohort study by Peng and colleagues compared acupuncture against cortisone injection for the treatment of TE.
They noted that both treatments could be used for treating TE but after 6 months of treatment, the acupuncture group achieved better pain relief and elbow function, compared to the cortisone injection group of patients.
4. PRP injections against Surgical treatment
Watts and colleagues compared PRP injections against surgical treatment in a prospective randomised trial.
Patients with ongoing symptoms after non-operative treatment of TE have been trialled are often treated with surgical release of the injured area. Platelet-rich plasma injection is an alternative treatment option.
They found that PRP injections and surgery produce equivalent functional outcome but surgery resulted in lower pain scores at 12 months. 70% of the patients treated with platelet-rich plasma were able to avoid surgical intervention.
5. Keyhole surgery vs Open surgery
Wang and colleagues carried out a study (SR and MA) comparing keyhole surgery vs open surgery for releasing one of the elbow extensor tendons involved in painful TE.
Both arthroscopic debridement (keyhole surgery) and open debridement (open surgery) of the extensor carpi radialis brevis (ECRB) tendon are recognised to be effective in the treatment of TE.
They found there was no significant difference between either with regards to failure rate, function and complication rate. They noted that keyhole surgery for TE was associated with a longer surgical time, possibly because it is more technically challenging.
6. Stem Cell Injections (SCI) for TE
Stem Cell Injections (SCI) for TE are topical and it is not uncommon for patients to ask about these treatment options after reading about them in the press. I was not able to locate any RCT/ SR/ MA papers in 2019 & 2020 relating to SCI for TE.
A Pubmed search with search terms ‘tennis elbow stem cell’ yielded 9 articles in 2019 and 1 case report in 2020 on this topic. Most of these 10 articles were pilot studies describing the challenges & theoretical solutions. There currently does not appear to be enough high level evidence to recommend the use of SCI in treating TE.
- Cortisone injections can be useful for pain management, but only in the short term. It's not a cure for tennis elbow (TE)!
- PRP & prolotherapy injections appear to have better results in the longer term (more so than cortisone).
- Acupuncture has a role in management.
- Stem cell injections– it’s too early to tell, there are not enough level 1 studies to recommend its use at present. As with everything in healthcare, patients’ safety must be foremost when considering any non-approved treatments.
- Surgery - Keyhole & open debridement for TE are both effective.
- Rehabilitation plays a vital role. Although I have not cited specific papers, there is a good body of scientific evidence to suggest that physiotherapy treatment is highly effective in treating TE and should be considered one of the first line treatments, ahead of the more invasive treatments such as injections and surgery.
- The same can also be said for extracorporeal shockwave therapy (ESWT)which has the advantage of being less invasive than injections (and therefore often more acceptable to patients who might be needle phobic).
- Cutts S, Gangoo S, Modi N, Pasapula C. Tennis elbow: A clinical reviewarticle. J Orthop. 2019 Aug 10;17:203-207.
- Li A, Wang H, Yu Z, Zhang G, Feng S, Liu L, Gao Y. Platelet-rich plasma vs corticosteroids for elbow epicondylitis: A systematic review and meta-analysis. Medicine (Baltimore). 2019 Dec;98(51):e18358.
- Xu Q, Chen J, Cheng L. Comparison of platelet rich plasma and corticosteroids in the management of lateral epicondylitis: A meta-analysis of randomized controlled trials.Int J Surg. 2019 Jul;67:37-46.
- Bayat M, Raeissadat SA, Mortazavian Babaki M, Rahimi-Dehgolan S. Is DextroseProlotherapy Superior To Corticosteroid Injection In Patients With ChronicLateral Epicondylitis?: A Randomized Clinical Trial.Orthop Res Rev. 2019 Nov 5;11:167-175.
- Peng Z, Zhang M, Li Y, Feng Z. Treatment of lateral epicondylitis with acupuncture and glucocorticoid: A retrospective cohort study.Medicine (Baltimore). 2020;99(8):e19227.
- Tang S, Wang X, Wu P, Wu P, Yang J, Du Z, Liu S, Wei F. Platelet-rich plasmavs autologous blood versus corticosteroid injections in the treatment oflateral epicondylitis: a systematic review, pairwise and network meta-analysis of randomized controlled trials. PM R. 2019 Nov 17.
- Watts A, Morgan B, Birch A, Nuttall D, Trail I. Comparing leukocyte-rich platelet-rich plasma injection with surgical intervention for the management of refractory tennis elbow. A prospective randomised trial.Shoulder & Elbow. 2020;12(1):46-53.
- Wang W, Chen J, Lou J, Shentu G, Xu G. Comparison of arthroscopic debridement and open debridement in the management of lateral epicondylitis: A systematicreview and meta-analysis.Medicine (Baltimore). 2019 Nov;98(44):e17668.
- Vuvan V, Vicenzino B, Mellor R, Heales LJ, Coombes BK. Unsupervised Isometric Exercise versus Wait-and-See for Lateral Elbow Tendinopathy.Medicine and Science in Sports and Exercise. 2020 Feb;52(2):287-295.