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Tennis Elbow, new treatments

Tennis elbow is the most common overuse injury of the elbow and is caused usually by repetitive contraction of the extensor muscles of the wrist. Only 5% of tennis elbows occur as a result of racquet sports. Most elbow pains of this type are occupational or due to acute trauma.

The underlying pathology is that of a repetitive microtrauma to the tendon of the forearm muscle called extensor carpi radialis brevis (ECRB). The poor repair process results in development of angiofibroblastic hyperplasia and neovascularisation which some people would say is a normal part of ageing which has been accelerated by overuse. The repetitive microtrauma leads to degeneration of the collagen matrix in the tendon and formation of micro tears. Sometimes calcification is also present.

tennis-elbow-sore

On examination the most predictive sign is that of point tenderness over the teno-osseous junction of the lateral epicondyle of the humerus.

There is often pain on resisted wrist extension or extension of the fingers.

Ultrasound or MRI scan examination can demonstrate degenerative changes and inflammation in and around the tendon.

It is thought that if left alone this condition can resolve in 6-24 months. Rest and activity modification are very important adjuncts to treatment. Non-steroidal anti-inflammatory drugs can be tried. Manual therapy from a physiotherapist, osteopath or chiropractor can improve the function of the forearm muscles along with any adverse neural tension which can sensitise the enthesis. The patient should be advised regarding gripping technique and on stretching before playing sport. There are also braces that can be used while playing tennis to offload the muscle insertion.

Corticosteroid injections are a well-known form of treatment but there is a 30-40% chance that the immediate improvement is followed by recurrence within a year.

One of the new approaches to treatment for tennis elbow is that of ‘autologous blood’ or ‘platelet-rich plasma’ injections where the patient’s own blood is taken from a vein and injected around the area of tendon insertion. The autologous blood injection carries with it growth factors from platelets and these growth factors act as mediators to induce the healing ‘cascade’. This promotes new tissue formation and has a 70-80% success rate in most clinical trials. Interestingly the success of this injection seems to persist without further injections being needed.

Other types of treatment can include an eccentric training programme along with stretching exercises and different types of myofascial soft tissue techniques. These are normally carried out by physiotherapists, osteopaths or chiropractors.

Dry needling or acupuncture-type treatments are often used with varying success.

Extracorporeal shockwave therapy (ECSWT) is sometimes used and has shown to be effective in certain trials.

Topical glyceryl trinitrate (GTN) patches have recently been shown to be effective in alleviating the symptoms of tennis elbow but the treatment can be over several months.

Some trials have used botulinum toxin which reduces stress on the muscle insertion.

Another emerging treatment option is monophasic microcurrent therapy (MCT). For example, Poltawski et al have recently shown that MCT of 50μA is highly effective in ameliorating the symptoms of chronic lateral epicondylosis.

Radial pressure wave therapy is also rapidly emerging as an alternative therapeutic option. This is a different type of extracorporeal shockwave therapy.

Interestingly local application of leeches has also recently been shown to decrease the pain associated with tennis elbow.

References:

Poltawski L, Johnson M, Watson T. Microcurrent therapy in the management of chronic tennis elbow. Physiother Res Int 2001 (In press).

Storheim K et al. Extracorporeal shockwave therapy (ESWT) in chronic musculoskeletal pain. Tidsskr Nor Laegeforen 2010.

Thanasas et al. Platelet-rich plasma versus autologous blood for treatment of chronic lateral elbow epicondylitis: A randomised controlled clinical trial. Am J Sports Med 2001.

Paoloni J A et al. Five year prospective comparison study of topical glyceryl trinitrate treatment of chronic lateral epicondylosis at the elbow. Br J Sports Med 2011

Dr Simon Petrides MB BS DM-S Med Dip Sports Med DO FFSEM (UK&I)