Treatment of tennis elbow: the evidence
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7410.330 (Published 07 August 2003) Cite this as: BMJ 2003;327:330
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I have started a prospective double blind randomised control trial
looking at dry needling therapy for lateral epicondylitis. This is a
relatively new treatment which involves the passage of a hollow needle
into the abnormal tendon substance under ultrasound guidance. The
area needled is one of angiofibrobalstic degeneration of the tendon
substance and creates an area of bleeding. This is thought to reset the
inflammatory response and allow fibroblastic proliferation and collagen
formation leading to tendon healing. We have had excellent results using
this technique.
Competing interests:
None declared
Competing interests: No competing interests
sir,are there any studies regarding 1.the usage of a local injection
of hyaluronidase? and 2.usefullness of oral therapy with a combination of
glucosamine and chondroitin?for chronic tennis elbow.
Competing interests:
None declared
Competing interests: No competing interests
My investigations of the literature and experiences with self treatment of a chronic tennis elbow (tendiosis - not tenditis) lead one way. Treatment, which if performed on a daily basis is preventive in future damaging the tendons.
The treatment is based on eccentric muscle work of the long extensors of the fingers done with hand weights or the order arm pressing down on the hand. This active treatment of tendinosis is well-investigated by:
Svernlov B, Adolfsson L., Scand J Med Sci Sports. 2001 Dec;11(6):328-34 --- and --- Alfredson et al. 1998. THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 26, No. 3.
Competing interests:
None declared
Competing interests: No competing interests
The articles by Meller, and by Assendelft et al. are
excellent short reviews on the evidence based treatment of tennis elbow.
However, the rather disappointing treatment outcomes are annoying
especially taking the common occurrence of this diagnosis into
consideration.
One can speculate whether the term tennis elbow which is commonly used in
the clinical setting represents a pathology which is the same in all cases
and invariably located at the extensor insertions laterally at the elbow.
If this is not the case, i.e., if we are dealing with
several disorders with several locations we may have a problem in studying
the effect of various treatments.
If all cases of what we call tennis elbow are in fact either inflammatory
disorders of the tendons/insertions at the lateral elbow or disorders of
other character located in the same region, e.g., compression of the
posterior interosseous nerve secondary to pathology in the adjacent
structures such as muscles or fascia(radial tunnel syndrome), it would be
reasonable to expect some effect of topical or systemic non-steroid anti-
inflammatory drugs (NSAID). This in fact appears to be the case - but only
on a short term basis. Why does NSAID not provide long term pain relief?
Could a proportion of lateral elbow pain of longer duration be a non-
nociceptive pain? Could the pain be neuropathic? This in fact may be
suggested by the
inability of NSAID to reduce chronic pain and by the common complaints of
weakness and numbness/tingling in these patients. Could such pain derive
from the afflictions of nervous structures located proximally to the elbow
such as the radial nerve or the lateral portion of the infraclavicular
brachial plexus?
To me the chronic work-related lateral elbow pain which is mostly
diagnosed as tennis elbow in fact seems to share the characteristics of a
neuropathic pain. Symptoms are mostly not restricted to the lateral elbow,
although they often tend to concentrate there. With a detailed examination
of these patients, patterns of mild neurological deviation from normal are
common. These patterns of slight pareses, sensory changes including
vibratory threshold, and
mechanical allodynia along nerves are in accordance with anatomy and
suggest a pathology involving the upper limb peripheral nerves. Such
pathology can be localised from the patterns. Treatment modalities should
address the responsible pathology where it is localized. Consequently, if
my observations are correct, the pathology should not
necessarily be assumed to be tendinous and inevitably located where pain
dominate, e.g. at the elbow. It may also potentially be neurogenous and
localized elsewhere as suggested from the physical examination. These
considerations appear not to have been addressed in the quoted studies.
Subgroups of patients with lateral elbow pain (so-called epicondylitis)
may need various treatments depending on the pathology and its location.
Competing interests:
None declared
Competing interests: No competing interests
I would like to congratulate Simon Mellor for drawing attention in
his article to that illuminating work, Vulvoginal Candidiasis,
Interpreting the evidence,(Spence D)one of the few references freely
accessed beyond the labyrinth of subscription.
Too often evidence based medicine is hampered by restriction and
inconsequential abstracts which bypass the readers attention.(1)
The weight of numbers at the end of a paper appear to lend gravitas
to it's content. Well it might, if we all had opportunity to read the
papers and got past the abstracts to make a truly critical evaluation of
it's worth.
(1)
http://www.improbable.com/airchives/classical/articles/referential_ethic...
Competing interests:
None declared
Competing interests: No competing interests
It has been suggested to me by an orthopaedic colleague that some
cases of tennis elbow can be relieved by simply thickening the handle of
the racquet.This would obviously reduce the tension on the long extensors
of the fingers. Is there any published work on this point?
Competing interests:
None declared
Competing interests: No competing interests
Polarised polychromatic non-coherent light (Bioptron light) and tennis elbow/lateral epicondylitis. Letter
Tennis elbow (TE) or lateral epicondylitis (LE) is one of the most
common lesions of the arm with a well defined clinical presentation, which
significantly impacts on the community 1. The terms TE and LE are not the
appropriate to describe this condition, since firstly the term TE is
referred in just one cause of this condition, the tennis, whereas the
condition is likewise common among people who carry out some occupational
activities and secondly in the term LE is referred as the site of
pathology the lateral epicondyle with the pathology to be inflammatory,
whereas the site of pathology of this condition is just below the lateral
epicondyle, on the facet of it, where is the origin of the extensor carpi
radialis brevis (ECRB) tendon and the primary pathology is degenerative or
failed healing tendon response 2. However, these two terms will be used to
describe this condition in this letter, because these two terms usually
cross physicians' lips for clinical diagnosis, so people know this
condition with one of these two terms 2.
Although the diagnosis of this condition is simple and can be
confirmed by tests that reproduce the pain, such as palpation over the
facet of the lateral epicondyle, Tomsen test, Handgrip dynamometer
testing, coffee-cup test and etc, the management of this condition is a
difficult task for the clinician. Conservative treatment is the primary
choice of treatment for TE and physiotherapy has a significant role in the
management of this condition 3.
Many available physiotherapeutic interventions have been recommended
in the management of this condition, but the ideal treatment is still
unknown. Light therapy is one of these and research with Low Power Laser
Light (LPLL) has been conducted. Even though, many authors had concluded
that LPLL could not be offered beneficial effects for musculoskeletal
disorders such as TE 4,5,6 a recently review supported its effectiveness
in tendinopathies such as LE if the right parameters are used 7.
However, research with other lights in the management of LE has not
been conducted. One of the rest lights is the polarised polychromatic non-
coherent light (Bioptron light) and the manufacturer’s explanation of how
it works is given in the following Table.
Therefore future well-designed studies to investigate its
effectiveness, absolute and relative, in the LE condition are required.
Dimitrios Stasinopoulos Physiotherapist, M.Sc, research student,
Cert. Clin Ed., PGCRM, Cert Orth Med (Cyriax) /Rheumatolory and
Rehabilitation Centre, Athens Greece/ School of Health and Human Sciences,
Leeds Metropolitan University, Leeds, U.K.
Prof. Mark I. Johnson B.Sc, PhD, PGCHE, Principal Lecturer in Learning,
Teaching and Assessment (Human Physiology), School of Health and Human
Sciences, Leeds Metropolitan University, Leeds, U.K.
References
1. Stasinopoulos D, Johnson MI. (2004). Cyriax physiotherapy for
tennis elbow/lateral epicondylitis. BJSM in press December 2004
2. Stasinopoulos D, Johnson MI. A review of existing literature in
nomenclature, epidemiology, etiology, pathophysiology and diagnosis of
Tennis elbow/lateral epicondylitis. Submitted article in Physical therapy
in Sport
3. Stasinopoulos D, Johnson MI (2004). Physiotherapy and tennis
elbow/lateral epicondylitis. Letter. BMJ rapid response to Assendelft et
al. (2003) article Tennis elbow.
4. Krasheninnikoff, M., Ellitsgaard, B., Rogvi-Hansen, B., Zeuthen, A.,
Harder, K., Larsen, R. and Gaardlo, H. (1994). No effect of low power
laser in lateral epicondylitis. Scand J Rheumatol 20. 260-63.
5. Mulcahy, D., McCormack, D., McElwain, J., Wagstaff, S. and Conroy, C.
(1995). Low level laser therapy: A prospective double blind trial of its
use in an orthopaedic population. Injury. 26. 315-317.
6. Gam AN, Thorsen H, Lonnberg F. (1993). The effects of low-level laser
therapy on musculoskeletal pain: a meta analysis. Pain, 52 63-66.
7. Bjordal JM, Couppe C, Ljunggren AE (2001). Low level laser therapy for
tendinopathy. Evidense of a dose response pattern. Physical therapy
Reviews; 6: 91-99
Competing interests:
None declared
Competing interests: Table: Manufacturer’s explanation of how Bioptron’s light worksPolarisedIts waves move on parallel planes. In this device polarization reaches a degree of approximately 95%PolychromyPolychromatic light contains not just one wavelength (like laser light), but also a wide range, including visible light and a part of infrared range. The wavelength of this device’s light ranges from 480nm to 3400nm. This electromagnetic spectrum does not contain ultraviolet radiationIncoherencyIn contrast to laser light, this device’s light is incoherent or out of phase light. This means the light waves are not synchronisedLow energy This device light has a low energy density (Fluence), which has biostimulative effects. This means the light can simulate various biological processes in the body in a positive way.Source: www.bioptron.com/characteristics/index.php