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Tennis Elbow
- ANDREW D LAWSON (3 November 2006)
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Tennis elbow and physiotherapy
- Rod N Mitchell (4 November 2006)
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Tennis Elbow:- Basic assumptive errors
- Dr A Breck McKay (4 November 2006)
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Re: Tennis Elbow
- usamah jannoun (4 November 2006)
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Tennis Elbow treated by Medical Acupuncture
- Tim W Robinson (6 November 2006)
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Joint & Soft tissue Injection - Tennis Elbow
- Trevor Silver (6 November 2006)
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Tennis Elbow: Treating the Non-responders
- Christopher J Blakeley, Kambiz Hashemi (10 November 2006)
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Tendinopathies - myths and troublesome corticosteroid injections
- Jan M Bjordal, Rodrigo A.B.Lopes-Martins, Jon Joensen, Mark I Johnson, Vegard V. Iversen (12 November 2006)
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Why make "Tennis elbow" complicated???
- Soubhagya R Nayak, Ashwin Krishnamurthy, Latha V. Prabhu (17 November 2006)
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ANDREW D LAWSON, Consultant in Pain medicine OX107DA
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How reasonable is to to take the poor evidence of efficacy of injections of iml triamcinalone and 1ml of lidocaine1% to mean that " corticosteroid injections provide only short term relief" ? Granted it may be true but what about the effect of the local anaesthetic? I know of practitioners who use larger volumes of longer acting local anaesthetics and who use different steroids .The injection techniqes also vary ( I speak from personal experience ). Can we reasonably infer that all steroid and local injections provide only short term relief - or merely that this combination does? Competing interests: None declared |
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Rod N Mitchell, Physiotherapist 105-877 Goldstream Ave Victoria BC Canada V9B 2X8
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As corticosteroids reduce any healing response it is not surprising that their long term results are not as good as the other approaches. Combining the wait and see approach with exercise advice is a good compromise. Treating the pattern of weakness from the shoulder and upper back is my preferred approach. As the condition improves then the exercises can focus on the specific weakness with wrist curls, a routine which in my experience is counterproductive in the early stages as it provokes pain and does not improve the overall strength of the upper quadrant. From a therapist's point of view it is important to keep in mind that there will be a pattern of weakness that can be improved. Competing interests: None declared |
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Dr A Breck McKay, Musculoskeltal/Family Physician Brisbane
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The topic of Tennis Elbow has been debated for decades, with little advancement in understanding or management. The editorial covers the statistics of three trials which show no significant difference in final outcomes over time. This should force a total rethink on the whole issue. Are there flaws in the hypotheses? Yes. Tennis Elbow involves a whole body response (1), because pain is the final central brain perception to many afferent pathways with ascending modulation, that also evoke midbrain efferent autonomic vascular changes and reflex protective muscle functions, prior to conscious recognition of pain and dysfunction. They also change the Tennis Elbow severity and functional whole arm use. It is the awareness and management of this whole body response that must be addressed and not merely the localised epicondylalgia, which lacks any demonstrable inflammatory criteria. Similarly, the use of corticosteroid injections without follow-up towel wringing anhd similar exercises also fails to understand or manage the problem correctly. The needle effect on the periosteum has now been demonstrated to be an important component of the injection, because it reduces the volume of receptor activation of the A-delta and C fibre input to the dorsal horn, thereby reducing wind-up and central pain perception.(2)(3) Basic research is when an assumption is made and it is proved right or wrong. Applied research (as described for Tennis Elbow) create hypotheses (often reductive in nature), which are then tested ad nauseum, too often without reassessing the initial assumptions, leaving a wealth of statistics that advance medicine sideways! Surely it is time to review the assumptions underlying applied research hypotheses, to prevent further waste of research time and dollars and to genuinely advance medical managements? Reference: 1. McKay AB, Tennis Elbow Everywhere, Australasina Musculoskeletal Med, Nov 2005, 10(2) 127-130 2. McKay AB, Pain and Chronic Low Back Pain: A New Model? Part 1 The Hypothesis and Model and Part 2 Observations and Clinical Material Australasian Muculoskeletal Med. May 2004 9(1:14-25 3. Bogduk N, Mechansims of Musculoskeletal Pain, Australasian Musculoskeletal Med. May 2006, 10(1)7-19 References available: mckayabATbigpond.net.au Competing interests: None declared |
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usamah jannoun, Musculoskeletal & Sports Physician EC3N 2JY
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This paper has many flaws and is misguiding to practitioners that are looking for the best management of tennis elbow. First of all,the diagnosis requires diagnostic ultrasound to be confirmed. Differtial diagnosis could be amongst others forearm supinator strain or elbow joint capsulitis with a similar clinical picture on clinical assessment. Secondly, I have seen many patients treated by injection up to 5-8 times, unfortunately injected inaccurately and in the wrong place. These two important factors (correct diagnosis and injection site/technique)need to be taken into account in order to take this paper seriously. But most important of all is the misconception that patients should have one form of treatment only in order to get better.Patients should never be treated with only injections but require functional rehabilitation at the same time to prevent recurrence. Also looking at ergonomics and leisure activiy (eg tennis,golf)technique is required to correct any inappropriate recurring repetitive biomechanical mistakes. Last but not least, if you leave anything long enough, be it with or without treatment, most will get better in the long run regardless of what treatment option was chosen. Competing interests: None declared |
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Tim W Robinson, General Practitioner Barton House, Beaminster, Dorset DT8 3NE
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The conclusions drawn from the randomised trial by Bisset et al on the treatment of Tennis Elbow are as follows: in the short term, physiotherapy was better more effective than 'wait and see' policy and worse than steroid injection. In the long term physiotherapy was more effective than injection and the same as 'wait and see'. From these conculsions we would be correct in treating tennis elbow with physiotherapy. However, this does not address the significant pain of tennis elbow in the short term. A treatment strategy worth considering for relief of pain in the short term is Medical or Western acupuncture. Medical acupuncture is the proceedure of acupuncture needle insertion in areas of musculoskeletal discomfort. In tennis elbow needles are inserted in the lateral humeral epicondyle, extensor carpi radialis brevis and surrounding tender tissues. Medical acupuncture is a skill that can be taught to medical health professionals through attendance at an approved British Medical Acupuncture Society 4 day course. Acupuncture treatment is administered within a 10 minute GP consultation; needles are inplace for 3 -5 minutes. 2-4 further treatments are usually needed at weekly intervals. The advantages are that this is immediate treatment (avoiding the delay in referral and waiting time for physiotherapy appointment), brief treatment appointment (within 10 minute GP consultation), inexpnesive proceedure(needles cost 6.4 pence each). I have been practicing medical acupuncture within my GP consultations since training last year. Over the twelve months prior to my training I performed steroid injection in 6 cases of tennis elbow. In the twelve months after medical acupuncture training I have treated 18 patients with acupuncture, 3 of which were unsuccessful and in whom I proceeded to steroid injection. I would suggest that a further trial to compare medical acupuncture with physiotherapy, 'wait and see' and steroid injection would be informative in the management of tennis elbow. This would demonstrate its effeciveness in the treatment of tennis elboew in the short term , which the Bisset trial has shown to be ineffectively treated by physiotherapy. Competing interests: None declared |
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Trevor Silver, Senior Lecturer St George's Hospital Medical School
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The randomised trial of corticosteroid injection for tennis Elbow and your Editorial are conspicuous by ommission.The technique of injection must be comprehensive stated and uniformly demonstrated in any controlled trial to ensure accuracy and confidence in interpretation. A significant deficit in the past research studies has been a lack of uniformity of techniques of injection.Infiltration of the whole lesion is paramount and to do this it is only possible if local anaesthetic is omitted so that every part of the lesion can be detected [and not suppressed by Local Anaesthetic]. There is no place for the common technique of "stab" and "run" before the patient complains!All the tender points of a lesion need to be infiltrated with corticosteroid for success. Perhaps a controlled trial using both techniques would provide the answer. Ref: Joint & Soft tissue Injection "Injecting with Confidence" Radcliffe Medical Press 2002 (4th Edition in press). Competing interests: None declared |
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Christopher J Blakeley, A&E Consultant Mayday University Hospital, CR7 7YE, Kambiz Hashemi
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It is certainly our experience that steroid injection when combined with rest, physiotherapy and non-steroidal anti-inflammatory medication has a response rate of around 90%. The steroid injection may need to be repeated up to a maximum of three injections. Accurate injection of the steroid is essential. The problem of how to treat the remaining 10% of patients is an ongoing debate. Further steroid injections are unlikely to be beneficial and the traditional approach has then been to advocate surgery. It has been our practice over the last 15 years to perform a manipulation under anaesthetic instead of surgery. This has a similar success rate (85 - 90%) to surgery, may be repeated up to three times and has none of the potential complications of open release. In this way we have avoided surgery in the vast majority of patients with tennis elbow with our data soon to be published in the Journal of One Day surgery. Competing interests: None declared |
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Jan M Bjordal, Associate Professor Bergen University College, 5020 Bergen, Norway, Rodrigo A.B.Lopes-Martins, Jon Joensen, Mark I Johnson, Vegard V. Iversen
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Dear editor The editorial about tennis elbow by Smidt and van der Windt is a timely and important one. However, two vital issues regarding corticosteroid (CS) injections in tendinopathies remain unaddressed in the editorial. Firstly, the primary effects of CSs are modulation inflammatory processes (reduce inflammation) and immunosupression, and CS is one of the most potent modulators of the inflammatory process. The data from three trials show a highly significant and consistent effect from steroid injections at 3 and 6 weeks. In view of the subacute/chronic conditions with mean symptom durations of 12, 18 and 26 weeks respectively, this effect is surprising as it partly contradicts the current paradigm of tendinopathy management. Tendinopathy researchers have recently been forwarding strong recommendations to abandon the tendinitis myth [1]. Their recommendation has been supported by the lack of inflammatory cells and cytokines in chronic tendinopathies[2, 3]. In this perspective we would not have expected any positive effects from CS injections. However, the reported lack of inflammation may have been transient and confounded by prior activity. Recent findings of increased inflammatory cytokines levels in chronic tendinopathies challenge this view[4, 5]. Tendinopathy patients at our clinic report that bouts of vigorous tendon loading cause a short-lived increase in pain and reduced function for 0.5 - 2 days [6]. The temporary increase in pain intensity for symptomatic patients fits well with the time course of a transient inflammatory and pathological response to tendon loading. A relationship has been established between increased levels of inflammatory cytokines and increased release of degenerative substances such as stromelysin and collagenase [7]. The complexity of tendinopathy pathogenesis include degeneration, local nerve sprouting and peripheral sensitisation in the nervous system, but the contribution of inflammation cannot be ruled out. The second important issue is that the three CS injection trials represent the final confirmation that CS injections cause negative effects in tendons in the intermediate and long term (6-12 months). From a pharmacological perspective this is not surprising and studies have shown that CS injections can cause tendon degeneration[8], impair tenocyte proliferation [9] and delay healing of tendon matrix injuries [10]. In clinical settings, CS injections have been associated with higher prevalence of partial tendon ruptures [11], and CS injection has caused complete rupture of the common extensor tendon at the lateral elbow [12]. Particularly in middle-aged patients with lateral elbow tendinopathy, structural tendon matrix defiencies may be the underlying pathology [13]. Initiation of CS injections in these patients seems counter-productive to us. Another intriguing consequence of the CS injection trial results, is that negative results in trials with physical interventions may have been confounded by previous CS injections. Trials with oral or topical non- steroidal ant-inflammatory drugs (NSAID) have consistently excluded patients with previous CS injections, but most trials with physical treatments have not used this exclusion criterion. While steady improvement is the natural course of lateral elbow tendinopathy, the three CS injection trials show a consistent detoriation of symptoms at 6 to 26 weeks from baseline. Imbalance in numbers and timing of prior steroid injections between active therapy groups and control groups may have confounded results. For instance, 9 out of 11 trials with low level laser therapy (LLLT) in LET did not exclude patients who had prior steroid injections. Another point is that downregulation of cortisol receptors by cortisol-antagonists or CS actually block the anti-inflammatory effect of LLLT[14]. In our opinion, there is still room for optimising the elements of physiotherapy package, and future trials in LET should exclude patients who have had CS injections within 26 weeks prior to randomisation. References 1. Khan, K.M., Cook, J.L., Kannus, P., Maffulli, N., and Bonar, S.F., Time to abandon the "tendinitis" myth. BMJ, 2002. 324(7338): p. 626-7. 2. Astrom, M. and Rausing, A., Chronic Achilles tendinopathy. A survey of surgical and histopathologic findings. Clin Orthop, 1995(316): p. 151-64. 3. Alfredson, H., Ljung, B.O., Thorsen, K., and Lorentzon, R., In vivo investigation of ECRB tendons with microdialysis technique--no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop Scand, 2000. 71(5): p. 475-9. 4. Fu, S.C., Wang, W., Pau, H.M., Wong, Y.P., Chan, K.M., and Rolf, C.G., Increased expression of transforming growth factor-beta1 in patellar tendinosis. Clin Orthop, 2002(400): p. 174-83. 5. Kim, Y.S., Bigliani, L.U., Fujisawa, M., Murakami, K., Chang, S.S., Lee, H.J., Lee, F.Y., and Blaine, T.A., Stromal cell-derived factor 1 (SDF-1, CXCL12) is increased in subacromial bursitis and downregulated by steroid and nonsteroidal anti-inflammatory agents. J Orthop Res, 2006. 24(8): p. 1756-64. 6. Bjordal, J.M., Lopes-Martins, R.A., and Iversen, V.V., A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2 concentrations. Br J Sports Med, 2006. 40(1): p. 76-80; discussion 76-80. 7. Archambault, J., Tsuzaki, M., Herzog, W., and Banes, A.J., Stretch and interleukin-1beta induce matrix metalloproteinases in rabbit tendon cells in vitro. J Orthop Res, 2002. 20(1): p. 36-9. 8. Tillander, B., Franzen, L.E., Karlsson, M.H., and Norlin, R., Effect of steroid injections on the rotator cuff: an experimental study in rats. J Shoulder Elbow Surg, 1999. 8(3): p. 271-4. 9. Scutt, N., Rolf, C.G., and Scutt, A., Glucocorticoids inhibit tenocyte proliferation and Tendon progenitor cell recruitment. J Orthop Res, 2006. 24(2): p. 173-82. 10. Tsai, W.C., Tang, F.T., Wong, M.K., and Pang, J.H., Inhibition of tendon cell migration by dexamethasone is correlated with reduced alpha- smooth muscle actin gene expression: a potential mechanism of delayed tendon healing. J Orthop Res, 2003. 21(2): p. 265-71. 11. Paavola, M., Kannus, P., Jarvinen, T.A., Jarvinen, T.L., Jozsa, L., and Jarvinen, M., Treatment of tendon disorders. Is there a role for corticosteroid injection? Foot Ankle Clin, 2002. 7(3): p. 501-13. 12. Smith, A.G., Kosygan, K., Williams, H., and Newman, R.J., Common extensor tendon rupture following corticosteroid injection for lateral tendinosis of the elbow. Br J Sports Med, 1999. 33(6): p. 423-4; discussion 424-5. 13. Connell, D., Burke, F., Coombes, P., Mcnealy, S., Freeman, D., Pryde, D., and Hoy, G., Sonographic examination of lateral epicondylitis. AJR Am J Roentgenol, 2001. 176(3): p. 777-82. 14. Lopes-Martins, R.A., Albertini, R., Lopes-Martins, P.S., De Carvalho, F.A., Neto, H.C., Iversen, V.V., and Bjordal, J.M., Steroid Receptor Antagonist Mifepristone Inhibits the Anti-inflammatory Effects of Photoradiation. Photomed Laser Surg, 2006. 24(2): p. 197-201. Competing interests: None declared |
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Soubhagya R Nayak, Anatomist Kasturba Medical College, Bejai, Mangalore, India-575004, Ashwin Krishnamurthy, Latha V. Prabhu
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Tennis elbow or (lateral epicondylitis) is a disease diagnosed a century ago, but till date the exact region of the disease is unknown to medical community. The main reason of the tennis elbow is extra work load to the extensor tendons that take origin from the lateral epicondyle of humerus. The micro tear in the tendon of extensor carpi radialis muscle is a major cause in the formation of the tennis elbow, i.e. decreasing the activity done by the radial wrist extensor can minimize the chances of the diseases itself. How ever Tennis elbow also mimic the symptoms arises in Golfer's elbow and bursitis. The modern life style and thrive for successes pushing the human physical limits. Sport persons and individuals engaged in activities where the radial wrist extensor are used often should restrain themselves to a certain degree. The most effective treatments for tennis elbow is rest the arm until the pain disappears, then massage to relieve stress and tension in the muscles, and exercise to strengthen the area and prevent re -injury. Majority of cases the problem arises in the Tennis elbow due to the professional hazards, in our view physiotherapy treatment and rest is always preferable than surgery or administration of drugs. Competing interests: None declared |
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