Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Injections for all?
- Fred Kavalier (9 September 2009)
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Differential diagnosis of tennis elbow
- Madhavan Chikkapapanna Papanna (27 September 2009)
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Injecting steroids is not good for Tennis Elbow
- Ray F O'Connor (8 October 2009)
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Treating and Diagnosing Tennis Elbow
- Adrian F Peall (28 October 2009)
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Family practice & specialism - the difference
- peter mahaffey (23 November 2009)
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decorator's elbow
- Geraldine R lindley (23 November 2009)
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Exorcise your tennis elbow
- Gary Stack (27 November 2009)
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Tennis Elbow and the glint of gold
- John Challenor (30 November 2009)
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Lateral Epicondylitis treatment has moved on
- Patricia Jane Ann Dunbar (3 December 2009)
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No emphasis on elbow clasp?
- Sidha S Sambandan (5 December 2009)
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Tennis Elbow
- Christian Mallen, Professor Elaine Hay (14 December 2009)
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Outcome of cell therapy in lateral epicondylitis
- Dr Kaushik Sanyal (16 January 2010)
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Tennis elbow
- Katherine H Greenwood (23 January 2010)
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Pre-warn patients of cosmetic side effect of steroid injection for Tennis elbow
- Bo Povlsen (28 January 2010)
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Fred Kavalier, GP London N7 0AL
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Dr Mallen and colleagues seem to suggest that everyone who presents with tennis elbow symptoms should be given a local injection of steroid and local anaesthetic. They give the impression that any steroid will do (triamcinolone, methylprednisolone, and hydrocortisone are mentioned). Most of the evidence they cite shows similarly good responses from other forms of treatment: analgesia, physiotherapy, wait-and-see. They do not mention the common problem of recurrent tennis elbow. Would they suggest recurrent injections, despite the well known risks associated with this practice? It would have been useful to know if there are any reliable criteria available to help distinguish between patients who will genuinely benefit from injections, and those who will do just as well with non- invasive treatments. Competing interests: None declared |
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Madhavan Chikkapapanna Papanna, Doctor Luton and Dunstable Hospital NHS Trust, LU32LL
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I read this article with interest and I note that the authors have pointed out that patients presenting with symptoms of tennis elbow would not require any further investigation apart from history and clinical examination. The most common differential diagnosis for tennis elbow are osteoarthritis,olectronon bursitis and radial tunnel syndrome.Very rarely tumor. I was wondering if only hisory and clinical examination is sufficent without further investigation ? Competing interests: None declared |
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Ray F O'Connor, General Practitioner/ Asst Programme Director Mid-West Specialist GP Gtaining Scheme, University of Limerick, Limerick City, Ireland.
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Dear Editor, In their recent paper on Tennis Elbow, Mallen et al seem to advocate routine local injection for the condition. I believe that this advice is incorrect. I had long been struck by the significant recurrence rates of the condition in my own practice following corticosteroid injection. Indeed this was shown very comprehensively in a paper published in the BMJ in 2006 (1). This paper concluded that "the significant short term benefits of corticosteroid injection are paradoxically reversed after 6 weeks, with high recurrence rates, implying that this treatment should be used with caution in the management of tennis elbow". I have changed my own clinical practice as a result and no longer inject tennis elbow at all. Alternative management policies are wait and see in the first instance or physiotherapy combining elbow manipulation and exercise in the case of persistent pain. References: 1. Bisset L et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006 doi: 10.1136/bmj.38961.584653AE (published 29/09/2006) Competing interests: None declared |
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Adrian F Peall, SpR Rheumatology Royal Glamorgan Hospital, CF72 8XR
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Dear Editor, I read with interest the recent article on tennis elbow by Mallen et al. Their early use of steroids has to be questioned from a fundamental view point as tennis elbow is not an inflammatory process rather one of "angiofibroblastic tendinosis" as described by Nirschl(1). The best approach to treating tendinopathy remains elusive although a conservative approach would seem more appropriate in this patient particularly in the primary care setting. Increasingly ultrasound scanning with doppler is being used in diagnosing tennis elbow and is highly sensitive and specific according to a recent paper by du Toit et al.(2) Potentially steroid injections should be reserved as a pain relieving measure in patients with confirmed tennis elbow resistant to other forms of treatment, at least until we have better and more pathology specific treatments available. Alternatives for example autologous blood injections show promise (3) and aim to promote healing rather than suppress a non- existant inflammatory response. References 1) Elbow tendinopathy: tennis elbow. Nirschl RP, Ashman ES. Clin Sports Med. 2003 Oct;22(4):813-36. 2) Diagnostic accuracy of power Doppler ultrasound in patients with chronic tennis elbow. du Toit C, Stieler M, Saunders R, Bisset L, Vicenzino B. Br J Sports Med. 2008 Nov;42(11):572-6. 3) Autologous blood injections for refractory lateral epicondylitis. Edwards SG, Calandruccio JH. J Hand Surg Am. 2003 Mar;28(2):272-8. Competing interests: None declared |
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peter mahaffey, consultant (plastic & hand surgery) bedford hospital mk42 9dj
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We in the hospital service are constantly told that its more efficient to retain patients in primary care, but honestly, most of that 'consultation' was flannel. And what did the patient get out of it at the end......nothing really. Tennis elbow is diagnosed following a complaint of persistent pain at the lateral epicondyle and is confirmed by focal tenderness 1 cm distal to the bony prominence. There is no proven treatment and the condition settles after about 1 year. Usually its fatuous to tell patients to "avoid" certain actions because they have to get on with their lives and pain will dictate what they can and cant do. Steroids achieve nothing (Stahl, S., Journal of Bone and Joint Surgery 79:1648-52 (1997). Indeed if one believes the microtrauma theory, then to subject patients to "pepperpot" injections at the site is nonsense because anyone who's done appreciable amounts of minor surgery will be well familiar with the degree of bruising and bleeding one gets in local tissues from injections. Competing interests: None declared |
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Geraldine R lindley, retired homoeopath N/a
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The grip tension may be the source of the problem if no other cause is obvious. Has your patient tried increasing the circumference of his brush handles with the use of padding( or changing the make of his brushes)? This will frquently give some relief as it may help relax his habitual grip and thus help resolve the problem Competing interests: None declared |
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Gary Stack, GP Park Medical Practice, Killarney, Co Kerry
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I totally agree with Dr O'Connor, I have been extremely disappointed with the results of injection. I advise the patient of same and suggest the following exercises learnt from a sports physician many years ago: 1. WRIST ON WRIST, FLEX & EXTEND x 25 (Place the wrist of the painful forearm on top of the other wrist & move it up & down 25 times) 2. = 1. UPSIDE DOWN x 25 (Turn turn "bad" wrist in the opposite direction and again move it up & down 25 times) 3. = 1. and 2. HOLDING CAN OF BEANS x 25 (Do 1 & 2 holding a weight) 4. WRING A TEA TOWEL x 25 5. SQUEEZE A TENNIS BALL x 25 6. APPLY AN ANTI-INFLAMMATORY GEL (May well be the massage of the area rather than the medication that helps!) Do all of the above 3 times a day until resolution To my financial detriment I have had excellent results. Competing interests: None declared |
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John Challenor, Consultant Occupational Physician Yealmpton, Devon, PL8 2NU
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Arguably, Mallen et al have compressed a much researched and complex topic into ten minute consultation format. However, this does not excuse the illogical inclusion of keyboard use in their list of occupations that may be associated with the onset of pain in the lateral humeral epicondyle. From the occupational point of view it is likely that wrist actions that involve extension and rotation against resistance are the most usual suspects. But it is not possible to argue that they are causal as the debate regarding microtrauma and degenerative change may not be over. Importantly it is wrong to implicate keyboard use as causal. This is because keyboard use lacks the important component of force, being a relatively neutral activity at the wrist. In my experience those who most commonly complain of lateral humeral epicondyle pain associated with work are those who have undertaken unremitting activity requiring forceful rotatory actions of the wrist such as fabricators and nut runners. To suggest that keyboard work is in any way causal will prompt another flood of litigious complainants who see the glint of gold in what is likely to be a condition not caused by their work. Dr John Challenor FRCP FFOM. Competing interests: None declared |
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Patricia Jane Ann Dunbar, self employed sport and exercise medicine physician Framework Clinic, Bridge of Allan, FK9 4HH
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As a specialist in Sport and Exercise Medicine I would like to draw attention to some of the more recent advances in the treatment of common extensor tendonopathy. In the history and examination we would put more emphasis on function; resisted wrist and digital extension and, undertake neural tension tests. We would also check the cervical spine for referred pain. Eccentric exercises (1,2) are now considered an integral part of treating tendonopathy (easy to teach and demonstrate in a 10 minute consultation). Lastly the article suggests steroid injection treatment (for which there is little evidence (3,4)) without any confirmation of diagnosis or guidance by musculoskeletal ultrasound (admittedly not always accessible in general practice), but routine in Sport and Exercise Medicine. In addition other injection therapies are increasingly used e.g.autologous blood and platelet-rich plasma (5,6). I have concerns that GPs should still be encouraged to perform blind injections of common extensor tendonopathy without consideration of all the safer better treatments available with evidence(1). For the latest in current management of musculoskeletal medicine, I would recommend consultation with The British Journal of Sports medicine and the full speciality involved in musculoskeletal medicine – Sport and Exercise Medicine. yours sincerely Dr P Jane A Dunbar MBChB, FFSEM , Dip Sports Med, DRCOG DTM&H 1. Brukner P, Khan K, “Elbow and arm pain “ Clin Sports Med. 2007 289 -307 2. Malliaras P, Maffuli N,”Eccentric Training programmes in management of lateral elbow tendonopathy” DisabilRehabil. 2008;30(20-22) 1590-6 3. Szabo RM. “Steroid injection for lateral epicondylitis” J Hand Surg Am. 2009 Feb;34(2):326-30 4. Xu B, Goldman H, “Steroid injection in lateral epicondylar pain” Aust Fam Physician 2008 Nov;37(11):925-6. 5. Hall M P, Band P A Platelet rich plasma: current concepts and applications in sports medicine. Jm Acad OrthopSurg 2009 Oct;17 (10):602-8 6. Mishra A Am J Sports Med 2006 Nov;34(11):1774-8 Plasma-rich platelet treatment Competing interests: none |
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Sidha S Sambandan, GP/GPwSI in Orthopaedics YareValley Medical Practice, 202 Thorpe Rd, Norwich NR1 1TJ
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The case described here is a classic example of tennis elbow caused by overuse activity. Roller painting on ceiling is well known to cause tennis elbow. A significant proportion of patients do not have a history suggestive of triggering factors and the origin of symptoms is more insidious. The crucial points from a primary care perspective is to be sure of the diagnosis, bearing in mind the 2nd commonest cause of pain in that region being radial tunnel syndrome (about one in five tennis elbows referred to me for injection by GPs, where the tenderness is about 2 to 2.5 cm beyond the lateral epicondyle, and middle finger extension test is very useful too. Early synovitis should also be borne in mind. If there is significant sympom improvement by the "clasp test" (gripping the forearm one inch below the extended elbow with forearm pronated and making the patient pick up a book or wad of papers)compared to lifting the book without clasping the forearm, one could predict that an appropriate tennis elbow clasp with a proper velcro or other tightening facility will work well. The clasp should be applied about an inch below the lateral epicondyle. It is important to counsel the patient about tightening it just before any lifting or painting in this case, and then loosening it thereafter. By wearing the clasp one removes the forces acting on the epicondylar enthesis of the ECRB, thereby reducuing the severity of pain. The "pepper pot" technique (also called "crack pot" technique by the cynics)of steroid and lidocaine injection has absolutely no evidence, but is religiously followed by physiotherapists and some GPs. It is more important to counsel the patient to enable them to have a realistic expectation from steroid injections. I use the "Rule of thirds" - One third would have almost permanent relief, one third will have significant symptom relief and one third will have no benefit. I also inform the patient that I cannot say which group he/she belongs to! Always review your diagnosis if there is no response at all. Iam aware of one patient who even had surgical release after two years of symptoms, with no relief, and had to have a second surgery to explore the radial tunnel, with immediate postoperative relief, after 3yrs! Its also important to warn the patient about possible lipodystrophy and dyspigmentation and document it in the notes.Verbal consent is adequate. Competing interests: None declared |
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Christian Mallen, Senior Lecturer in General Practice Keele University, ST5 3RH, Professor Elaine Hay
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Dear Editor We are pleased that our 10-minute consultation for tennis elbow [1] has produced so much discussion. These short (600 word) pieces aim to provide a brief overview of how to manage a common problem during the initial general practice consultation and are not intended to replace more extensive clinical reviews. We completely agree with readers who comment that corticosteroid injection should not be routinely used. Evidence from both primary care studies and a systematic review suggest that corticosteroid injection provide short-term improvement in pain [2-4]. Longer-term outcomes (>6 weeks) are less clear. At one year, seven out of ten people who received an injection will be pain free, compared with eight out of ten people who did not receive an injection. Whilst this message was clear in our original submission, 10-minute consultations are reviewed and edited to meet the necessary word count and format. We apologise if our final version suggests ‘injections for all’ as we certainly do not advocate this and regret this error. In the minority of patients who might benefit from corticosteroid injection, we are not aware of any evidence supporting one injection technique over another. Ultrasound guided injection may in the future be the gold standard for all joint injections in primary care but to date evidence is not available to support the superiority of ultrasound guided tennis elbow injection in primary care settings. Furthermore, ultrasound is rarely available for use during a general practice consultation. Other treatments, such as autologous blood injections, may show early promise but their inclusion in a 10-minute consultation would be premature before primary care based RCTs have demonstrated there potential in this setting. We agree with Dr Sambandan that an accurate diagnosis is important. Diagnosis in primary care is usually straight forward so long as clinicians are alert to well known mimics like referred neck pain or fibromyalgia. The majority of patients with tennis elbow in primary care have a good outcome at one year [2]. Physiotherapy, exercise and analgesics will form the backbone of core treatment for most, especially during their initial consultation. Further investigation and treatment (including corticosteroid injection) should be limited to the minority of patients. 1. Mallen C, Chesterton L, Hay E. Tennis elbow. BMJ. 2009 Sep 2;339:b3180. doi: 10.1136/bmj.b3180. 2. Hay E, Paterson S, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis in primary care. BMJ 1999; 319: 94-968 3. Smidt N Smidt N, Assendelft P, van der Windt D, Hay E, Buchbinder R, Bouter L. Corticosteroid injections for lateral epicondylitis: a systematic review Pain 2002; 96: 23-40 4. Bisset L Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006 Nov 4;333(7575):939. Epub 2006 Sep 29. Competing interests: None declared |
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Dr Kaushik Sanyal, Specialist Registrar Rheumatology KT2 7QB
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This common overuse syndrome of the extensor tendon of the forearm can occur with many activities. Other options are topical NSAID, elbow brace and corticosteroid injection. Refractory cases benefit from surgical intervention. Ultrasound guided autologous blood technique has shown some promising results. principle of autologous blood injection is to trigger a few steps of the inflammatory cascade (1). This leads to healing of degenerative tissue via mediaters in blood or by the localised trauma from the injection itself. There is an increase in the concentration of transforming-factor beta and fibroblast growth factor. However one should be aware that the procedure is considered experimental due to the lack of published literature. There have been few pilot studies done on the efficacy and safety of this procedure and further expansion is essential. Reference: 1. Connell D A et al. Ultrasound–guided autologous blood injection for tennis elbow. Skeletal Radiology 2006 Jun; 35(6):371-7 Competing interests: None declared |
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Katherine H Greenwood, Salaried GP St James Medical Practice, County Court Road, Kings Lynn Norfolk PE30 5SY
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Thank you for the article on Tennis Elbow published in the BMJ on 23/01/2010. This article seems to be identical however to the article on Tennis Elbow published in the BMJ on 21/11/2009. I wonder what the intended article for 23/01/2010 was? My husband who is an orthopaedic hand surgeon was disappointed for a second time because there was no mention of compression of the posterior interosseous nerve as a differential diagnosis. Competing interests: None declared |
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Bo Povlsen, Consultant Orthopaedic Surgeon Dept. Orthop.; Guy's Hospital, SE1, London, UK
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I want to congratulate Mallen et al for an informative and useful article aimed at general practice doctors on the enigma known as Tennis elbow. I agree with most of the content of the paper both as an upper limb surgeon who have treated Tennis elbow patients for more than 20 years but also as a personal sufferer of 2 years. However, the paper fail to emphasise that doctors should always inform/warn the patients prior to steroid injection that significant fat/muscle atrophy can develop after injection that in some cases can be severe (mine is still there more than 1 year later) and that in patients with darker skin types temporary de- pigmentation often develop which may last for up to a year. Both of these side effects can be perceived to be cosmetically unpleasing and failure to pre-warn can at best generate unhappy patients and at worst lead to formal complaints. Competing interests: None declared |
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