treatment

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Lateral epicondylitis is usually a self limiting condition with a typical episode lasting on average about six months to two years (but most (89%) recover within one year) (1). General treatment guidance include (2):

Non operative procedures:

rest, application of ice
- the treatment of tennis elbow primarily involves rest

the activity that precipitates pain must be avoided so to allow the lesion to heal

NSAID’s
- both topical and oral NSAID’s provides short term pain relief, topical preparation may be associated with fewer side effects

physical therapy
- stretching and strengthening exercise - specially eccentric (lengthening only) exercises

ultrasound therapy - provides modest pain reduction over one to three month (8)

corticosteroid injections
- has very good results in short term use (six weeks) but the benefits do not persist beyond six weeks (6)

hydrocortisone acetate mixed with local anaesthetic may be used, and of note long acting steroids should be avoided as there is a risk of skin atrophy
long term effectiveness when compared to other conservative methods are uncertain and recurrences are more common with long term use
repeating and repeated corticosteroid injections
- has been reported that repeated injections (average 4.3, range 3 to 6 over 18 months) were associated with poorer outcomes - the suggestion is that steroid injections are more effective in acute and subacute tendonitis (duration <12 weeks) (10)
- if considering repeating corticosteroid injections then "..injections may be repeated 2-3 times at the same site at 3-6 month intervals, if the previous response was positive (11)

orthotic devices
- although commonly used, there is insufficient evidence regarding the effectiveness of orthotic devices

extracorporeal shock wave therapy (ESWT)
- except for rare occasions with ectopic calcification in the tendon, randomised trials have not found any benefit of ESWT in regular cases of tennis elbow (6)

Surgery

useful in resistant cases to conservative treatment
surgery is still an unproven treatment modality for tennis elbow due to lack of high quality evidence to either support or discourage its use (7)
should be considered after 1 year of conservative therapy since the condition resolves in around 12 months in most patients (6)
less than 10% of people undergo surgery (7)
surgical procedures can be broadly grouped into open, percutaneous and arthroscopic
majority procedures involves exposure of the extensor carpi radialis brevis tendon and excision of any fibrous mass which is present or release the tendon altogether (8)

Newer treatments

autologous platelet-rich plasma injections

recent high quality randomised controlled trials have shown superior cure rates and pain scores for platelet-rich-plasma (PRP) injections up to two years after treatment when compared to cortisone injections

hyaluronan gel injection
topical glyceryl trinitrate patches
- when applied over the painful area, it improves outcomes in the first six months compared to placebo
botulinum toxin A injection

Notes:

a study compared the efficacy of wait and see policy, physiotherapy or corticosteroid injections (3)
- concluded that physiotherapy or a wait and see policy were the best long term treatment options
- a subsequent study comparing these treatment options concluded that (4):
  - corticosteroid injection was the most effective strategy in the short term, but symptoms often recurred and long term relief was poorer than with physiotherapy or wait and see
  - physiotherapy provided faster relief from pain than wait and see, but long term results were similar
a systematic review and metaanalysis of randomised controlled trials (RCTs) examining the effectiveness and safety of novel treatments for tennis elbow as compared with steroid injections (9)
- data from 10 RCTs confirmed the lack of effectiveness of steroid injections after 8 weeks
- data from 4 trials of botulinum toxin showed marginal effectiveness but this was accompanied by temporary weakness of finger extension
- autologous blood (3 RCTs) and platelet-rich plasma (2 RCTs) were, statistically, more effective than placebo
- other injections with 1 RCT each were prolotherapy, hyaluronan, glycoaminoglycan and polidocanol
- in all, 17 RCTs were included in the study
- only 4 were found to have a low risk of bias. Of these only one (prolotherapy) showed evidence of effectiveness compared with placebo

Reference:

Last edited 05/2018 and last reviewed 05/2018

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