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Treating Lateral Epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review
Morten Olaussen, Oeystein Holmedal, Morten Lindbaek, Soeren Brage, Hiroko Solvang
Lateral Epicondylitis is otherwise known as “Tennis Elbow” is an overuse injury of the extensor tendons that join the forearm muscles to the lateral epicondyle of the humerus. This overuse injury is thought to affect the extensor carpi radialis brevis (ECRB) specifically. This injury is seen in patients with either excessive repetitive flexion with subsequent extension of their wrist such as in tennis players, improper form and/or improper equipment or even with a daily profession that requires manual labour with their hands.
Lateral Epicondylitis is generally thought to be a self-limiting injury but can take a long time to resolve. Common treatments used by family physicians and doctors who deal with sports injuries include rest, NSAIDS, physical therapy, deep friction massage, braces, acupuncture, extracorporeal shockwave therapy, cortisone injections, surgery as well as more recently platelet-rich plasma injections.
This article looked at the benefits of two of these treatment modalities: lateral elbow cortisone injection and non-electrotherapeutic physiotherapy. The authors did a systematic review, which included 11 randomized controlled trials, representing 1161 patients of both sexes and all ages. All of these studies looked at least at one treatment group and one control group which included receiving anything from no treatment, to common treatments such as counselling, rest, or NSAIDS. Some of the measures used to evaluate the efficacy of the treatments were pain, grip strength and overall improvement effect at 4, 12, 26 and 52 weeks of follow-up.
Overall, the results showed that corticosteroid injection provided patients with a short-term reduction in pain versus control groups. However, more notably corticosteroid injections resulted in an increase in pain, reduction in grip strength and negative effect on the overall improvement at the intermediate stage of follow-up. Manipulation and exercise in comparison to control showed improvement at short-term follow-up, but no significant difference at intermediate or long-term follow-up.
In all, this study reveals that corticosteroid injections may have a significant negative effect on the intermediate follow-up likely outweighs any of the short-term benefits. Manipulation and exercise and exercise and stretching have a short-term effect, with some evidence of longer-term effect.
Dr. Mickey Moroz M.D.C.M. CCFP
Sport and Exercise Medicine Fellow, University of Ottawa
Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (CAC SEM), Dip Sport & Exercise Med
Lateral epicondylitis, commonly known as tennis elbow, can affect up to 13% of elite tennis and up to 50% of non-elite tennis players.¹ As any primary care physician knows, this syndrome isn’t confined to just tennis players and can leave patients in significant and debilitating pain for up to two years.
What is lateral epicondylitis?
Lateral epicondylitis is actually a tendinopathy of the common extensor-supinator tendon rather than an epicondylitis. It is most commonly an overuse injury which demonstrates micro tears in the common extensor supinators with the origin of extensor carpi radialis brevis most commonly affected.¹ The term epicondylitis, as with “tendinitis”, has been challenged as studies fail to show inflammatory cells in affected tissues. To be correct, this syndrome should actually be coined “lateral elbow tendinosis”.
Who does it affect?
The condition primarily affects ages 45-54 with equal distribution among men and women.¹ People with current or prior tobacco use were found to have an increased risk of developing tennis elbow. It generally presents as an overuse injury in patients who perform repetitive wrist extension movements. In fact, tennis players make up only 10% of the patient population.¹ In tennis, the predominant activity of wrist extensors in all strokes may explain it’s predisposition for this condition. It can affect both elite and non-elite and tends to affect those who active their extensors more frequently, with poor form as an underlying risk factor.
Signs and Symptoms
The primary symptom is pain. Patients will often complain of pain around the lateral elbow which can become diffuse with maximal tenderness over or near the lateral epicondyle. They will have diminished extension strength of the forearm as well as diminished grasp function. On physical exam, there will often be pain with resisted extension of the wrist. These symptoms can be quite debilitating and can significantly impact activities of daily living. Be cautious of conditions which can mimic tennis elbow such as cervical radiculopathy, nerve entrapment, and osteochondritis dissecans for example.
The diagnosis can be made clinically however in cases resistant to conservative treatment one could consider ultrasound, X-ray, MRI and electromyophysiological testing to rule out alternate causes of elbow pain.
The primary goal in treating tennis elbow is to reduce pain and return function. A watch and wait approach is acceptable however, the following is a list of conservative treatment measures.
- Ergonomic assessments and modifications, early involvement of an occupational therapist is important.
- Athletes – proper stroke biomechanics and proper equipment.
- Cessation of offending activity but not immobility.
- Ice for vasoconstriction and analgesic effects.
- Anti-inflammatories including both naproxen and cortisone injection which have similar long term outcomes. Voltaren gel can be applied if oral NSAIDs are contraindicated.
- Physiotherapy – ultrasound, phonophoresis, stimulation, manipulation, active release therapy, neural tension, stretching and strengthening, including home strengthening routines are very important in conservative treatment of tennis elbow. There is also some evidence for acupuncture and dry needling.
- Bracing – may improve daily function. Ensure appropriate use of the brace as patients will often apply to elbow instead of forearm.
Treatment of Chronic Tennis Elbow
Treating chronic tennis elbow not responding to traditional conservative methods can be a challenge for a primary care physician. There are several promising treatment methods currently being applied by specialists. Botulinum toxin has been shown to improve symptoms as early as 2 weeks post injection.² Platelet rich plasma or autologous growth factors is also showing excellent benefit in patients with little complications and should be considered if all other conservative measures have failed. Other options include ultrasound guided injections of sclerosing agents or glyceric-trinitrate patches.
Surgery is indicated in cases of proven tennis elbow which have not responded to conservative measures. Roughly 8% of patients with tennis elbow may require surgery which can demonstrate an improvement in 85-95% of patients.²
In summary, tennis elbow is a common condition which primary care physicians will encounter frequently. It presents as pain and weakness with extension of the forearm. Diagnoses is a clinical one and initially a wait and see approach is appropriate. Commonly, the condition can persist for up to 1-2 years but with involvement of a multidisciplinary approach, the symptoms can be managed to improve daily function.
For more information please refer to: Review: Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment
Article written by: H. Henry, Sports Medicine Fellow
1) MacAuley, D. Oxford Handbook of Sport and Exercise Medicine. Lateral Epicondylitis. 2nd Edition. Oxford. 510-511. 2013.
2) De Smedt, T. de Jong, A et al. Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment. BJSportMed. 6 July 2007; 41:816-819.