Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment

Thomas De Smedt; Andy de Jong; Wim Van Leemput; Dossche Lieven; Francis Van Glabbeek

doi:10.1136/bjsm.2007.036723

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Tennis injuries

Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment

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Re:Lateral epicondylitis surgery complications
Joseph A Smith
Published on: 11 October 2022
Lateral epicondylitis surgery complications
Erica L. Williams
Published on: 11 October 2022
Learning from the lower extremity?
Karsten Knobloch
Published on: 11 October 2022
Poor play on Centre Court
Jan M Bjordal
Published on: 11 October 2022

Published on: 11 October 2022
Re:Lateral epicondylitis surgery complications
- Joseph A Smith, Lube Tech
I had lateral epicondylitis surgery in 2010. It has been five months and im still in alot of pain. I had to go back to work and I'm finding it hard to make it through the day because of the pain. I called the doctor and they told me to find somewhere to go for pain management. I did and they said they could not do anything because of the acher pin in my arm, what should I do?
Conflict of Interest:
...
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I had lateral epicondylitis surgery in 2010. It has been five months and im still in alot of pain. I had to go back to work and I'm finding it hard to make it through the day because of the pain. I called the doctor and they told me to find somewhere to go for pain management. I did and they said they could not do anything because of the acher pin in my arm, what should I do?
Conflict of Interest:
i had lateral epicondylitis surgeon
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Conflict of Interest:
None declared.
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Published on: 11 October 2022
Lateral epicondylitis surgery complications
- Erica L. Williams, City Carrier for United states Postal service
I had lateral epicondylitis surgery in January 3, 2008, wore a cast for two weeks then about three weeks of physical therapy and sent back to work on light duty and first of March 2008 I was put back to full work duty and physical therapy was stopped also. I am still in pain and my doctor has closed my case even though he informed me that injury would only get worse as long as I continue to perform my job as a city lette...
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I had lateral epicondylitis surgery in January 3, 2008, wore a cast for two weeks then about three weeks of physical therapy and sent back to work on light duty and first of March 2008 I was put back to full work duty and physical therapy was stopped also. I am still in pain and my doctor has closed my case even though he informed me that injury would only get worse as long as I continue to perform my job as a city letter carrier and that I needed to quit my job if I wanted my arm to get better. He did do another MRI or x-ray to see what is going on with my arm. Please help!
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Conflict of Interest:
None declared.
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Published on: 11 October 2022
Learning from the lower extremity?
- Karsten Knobloch, Hannover Medical School
- Other Contributors:
  Peter M. Vogt
Dear editor,
I read with great interest the recent review focussing the pathophysiology, the diagnosis and the treatment of tennis elbow. However, based on this report I would appreciate having the chance to comment on some issues raised by the authors shortly.
Diagnosis: The role of neovascularisation determined by colour or even better by Power Doppler sonography has been mentioned for several sites...
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Dear editor,
I read with great interest the recent review focussing the pathophysiology, the diagnosis and the treatment of tennis elbow. However, based on this report I would appreciate having the chance to comment on some issues raised by the authors shortly.
Diagnosis: The role of neovascularisation determined by colour or even better by Power Doppler sonography has been mentioned for several sites with painful tendons. Besides both, mid-portion and insertional Achilles tendinopathy [8], patellar tendinopathy [6], supraspinatus tendinopathy [1] as well as tennis elbow and wrist tendinopathy [7] have been reported to be associated with neovascularisation which is closely related to pain. Therefore the role of colour and Power Doppler sonography can currently not be overestimated based on these reports, which is not reflected in the review.
The effect of elbow position on grip strength as an easy measure in the evaluation of tennis elbow should be mentioned here [4]. The grip strength was tested in full extension of the elbow and in 90° flexion. Strength was no different in flexion and extension for the healthy extremity and 29% stronger in flexion than in extension for the affected extremity. The affected arm averaged 50% of the strength of the healthy arm in extension and 69% of the strength of the healthy arm in flexion. These differences were statistically significant. An 8% difference in grip strength between flexion and extension was found to be 83% accurate in distinguishing the affected from the unaffected extremities.
Conservative treatment: A recent analysis of 383 patients suffering tennis elbow from two randomized trials investigated wait-and-see policy, corticosteroid injections and physiotherapy [2]. Based on individual patient data from both trials, they found that corticosteroid injections were statistically and clinically superior at 6 weeks, but significantly worse at 52 weeks compared with both wait-and-see and physiotherapy.
I agree with the authors of the review that further randomized- controlled trials are warranted focussing for example the use of eccentric training in tennis elbow. However, given the results at the Achilles and the patellar tendon level, one could speculate that an appropriate painful eccentric training at the elbow and forearm level ameliorates recovery in tennis elbow, but studies are pending.
Surgery: Recently a ten- to 14-year follow-up has been published among 139 consecutive patients suffering tennis elbow which were operated on by a single surgeon between 1991 and 1994 [5]. The overall improvement rate was 97%. Patient satisfaction averaged 8.9 of 10. Ninety-three percent of those available at a minimum of 10-year follow-up reported returning to their sports.
Evidence-based medicine: Bottom line should be the recent reference by Dr. Cowan and coworkers. They analysed the quality of prospective controlled randomized trials [3]. The use of the gold-standard trial design, the prospective randomized therapeutic study (Level-I or II evidence), does not ensure quality research or reporting. Critical analysis of scientific work is important regardless of the study design. Clinical scientists should be familiar with the CONSORT criteria and adhere to them when reporting clinical trials.
References
[1] Alfredson H, Harstad H, Haugen S, Ohberg L, Sclerosing polidocanol injections to treat chronic painful shoulder impingement syndrome-results of a two-centre collaborative pilot study. Knee Surg Sports Traumatol Arthrosc. 2006;14(12):1321-6
[2] Bisset L, Smidt N, Van der Windt DA, Bouter LM, Jull G, Brooks P, Vincenzino B. Conservative treatments for tennis elbow do subgroups of patients respond differently? Rheumatology (Oxford) 2007;46(10):1601-5.
[3] Cowan J, Lozano-Calderon S, Ring D. Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example. J Bone Joint Surg Am 2007;89:1693-9.
[4] Dorf ER, Chhabra AB, Golish SR, McGinty JL, Pannunzio ME. Effect of elbow position on grip strength in the evaluation of lateral epicondylitis. J Hand Surg [Am] 2007;32:882-6.
[5] Dunn JH, Kim JJ, Davis L, Nirschl RP. Ten- to 14-year follow-up of the Nirschl surgical technique for lateral epicondylitis. Am J Sports Med 2007 Nov 30 [Epub ahead of print].
[6] Gisslen K, Alfredson H. Neovascularisation and pain in jumper`s knee: a prospective clinical and sonographic study in elite junior volleyball players. Br J Sports Med 2005;39:423-8.
[7] Knobloch K, Spies M, Busch KH, Vogt PM. Sclerosing therapy and eccentric training in flexor carpi ulnaris tendinopathy in a tennis player. Br J Sports Med 2007;41:920-1.
[8] deVos RJ, Weir A, Cobben LP, Tol JL. The value of power Doppler ultrasonography in Achilles tendinopathy: a prospective study. Am J Sports Med 2007;35:1696-701.
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Conflict of Interest:
None declared.
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Published on: 11 October 2022
Poor play on Centre Court
- Jan M Bjordal, PT/PhD
- Other Contributors:
  Christian Couppe
Dear editor
In the last issue of the journal, a review of tennis elbow and its management in tennis players appears. It is disappointing to see that the journal publishes a review with misleading treatment recommendations. The review article suffers from the inherent weaknesses of the narrative review form with an unjustified favourisation of "promising" pharmacological and surgical interventions. Physical inte...
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Dear editor
In the last issue of the journal, a review of tennis elbow and its management in tennis players appears. It is disappointing to see that the journal publishes a review with misleading treatment recommendations. The review article suffers from the inherent weaknesses of the narrative review form with an unjustified favourisation of "promising" pharmacological and surgical interventions. Physical interventions are not even mentioned in the conclusion, and the authors state that there is “no scientific evidence regarding the efficacy in the long term of the currently used conservative treatment options”. In addition, they recommend that “a wait-and-see approach is initially advised, as long-term results do not differ significantly between groups, but if complaints persist, a surgical approach can be considered”. In the treatment section of the review, steroid injections are claimed to be beneficial in the short term and not significantly different from other treatments in the long and intermediate term. This statement does not reflect the available evidence. Physiotherapy is acting faster than wait-and-see with significantly better results at 6 weeks [1], while physiotherapy is significantly better than steroid injections at 12, 26 and 52 weeks [2]. Thus, from a safety perspective it can be concluded that steroid injections increase the risk for chronic disability and possible permanent tendon damage [3]. It remains unanswered whether this negative effect is reversible or not in a timeframe beyond one year. Consequently, steroid injections should be discouraged in the management of tennis elbow. Regarding surgery, there is a scarcity of randomized controlled trials, and we found only one randomized trial showing no difference over botox injections [4]. The self-limiting nature of tennis elbow with scientific evidence showing a 92% success rate at 1 year after physiotherapy [2], leaves no place for surgery with the inherent risks and lack of documented effects in tennis elbow management. The final word about the contents of an optimal physiotherapy package for tennis elbow has probably not been said. The review cites two references with low level laser therapy (LLLT) reviews, which have missed large parts of the LLLT literature, and fail to address the validity of doses and LLLT procedures. Three LLLT-trials with positive results which we included in our 2001 LLLT-review of tendinopathies[5] were omitted from these reviews. One of the omitted trials showed a significantly positive short-term effect for LLLT over placebo in recreational tennis players [6]. Another two LLLT trials with exercise therapy regimens in tennis elbow from 2007 show that the addition of 904 nm LLLT with valid doses provides significantly faster pain-relief than placebo LLLT and exercises [7, 8]. From the above, modification of sports activity and an active approach with a physiotherapy package containing exercises, stretching, mobilisation and possibly LLLT emerges as the new gold standard in tennis elbow management. There is certainly no need to consider steroid injections or surgery for the average patient with tennis elbow complaints, when effective risk-free alternatives exist.
References
1. Bisset, L., et al., Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ, 2006. 333(7575): 939.
2. Bisset, L., et al., Conservative treatments for tennis elbow do subgroups of patients respond differently? Rheumatology (Oxford), 2007. 46(10): 1601-5.
3. Smidt, N. and D.A. van der Windt, Tennis elbow in primary care. BMJ, 2006. 333(7575): 927-8.
4. Keizer, S.B., et al., Botulinum toxin injection versus surgical treatment for tennis elbow: a randomized pilot study. Clin Orthop Relat Res, 2002(401): 125-31.
5. Bjordal, J., C. Couppé, and A. Ljunggreen, Low level laser therapy for tendinopathy. Evidence of a dose-response pattern. Physical Therapy Reviews, 2001. 6(2): 91-99.
6. Palmieri, B., Stratified double blind crossover study on tennis elbow in young amateur athletes using infrared lasertherapy. Medical Laser Report, 1984. 1: 1.
7. Lam, L.K. and G.L. Cheing, Effects of 904-nm Low-Level Laser Therapy in the Management of Lateral Epicondylitis: A Randomized Controlled Trial. Photomed Laser Surg, 2007. 25(2): 65-71.
8. Stergioulas, A., Effects of low-level laser and plyometric exercises in the treatment of lateral epicondylitis. Photomed Laser Surg, 2007. 25(3): 205-13.
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Conflict of Interest:
None declared.
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