Tennis elbow
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3180 (Published 02 September 2009) Cite this as: BMJ 2009;339:b3180
All rapid responses
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Pre-warn patients of cosmetic side effect of steroid injection for Tennis elbow
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
Competing interests: No competing interests