1. The management of tennis elbow BMJ Clinical Review John Orchard, Alex Kountouris

2. What and who? • Systematic review • 2 Australians – Professor in School of Public Health at University of Sydney and the Australian cricket team physio

3. Cause, presentation Tendinopathy - not thought to be an inflammatory condition now, so “lateral epicondylitis” no longer favoured. The clinical features are • tenderness at the lateral epicondyle, • normal elbow range of motion, and • pain on resisted movements (particularly resisted third finger extension). If the elbow’s range of motion is restricted, other diagnoses should be considered…

4. Treatment • Eccentric exercises • NSAID • Steroid/local anaesthetic • GTN patch • Other injections • Surgery • Extracorporeal shockwave therapy • Wait and see

5. Treatment - Eccentric exercises • Needs to be accompanied by easing off overload - well studied, works well • What the physio’s are likely to recommend if you refer patients there

6. More treatments NSAIDs – topical or oral • no clear evidence, but anecdotally useful Injections (steroid +/- LA) • fine in short term, but harmful in longer term (recurrence more likely), so should generally be avoided

7. Even more treatments GTN patch • applied over the painful area act as a local and systemic vasodilator and improved outcomes in the first six months compared with placebo. • Longer term results have not shown benefit over placebo, although unlike cortisone injections no long term harm was seen Other injections • Autologous platelet-rich plasma injections – uncertain results, expensive • Hyaluronan gel injections – promising results from one study vs placebo • Botulinum toxin A injections (into extensor digitorum longus muscles of 3rd/4th fingers) – paralyses finger extensors for months, so inconvenient

8. and more… Surgery • very little evidence to support its use Extracorporeal shockwave therapy • only potentially useful if there’s calcification in the common extensor tendon …and finally… Wait and see

9. Key messages • Tennis elbow is a tendinopathy of the common extensor origin of the lateral elbow • Cortisone injections are harmful in the longer term and are no longer recommended in most cases • Rehabilitation (exercise) based treatment is helpful, but to be effective patients must usually remove tendon overload • Further research is needed on newer (minimally invasive) treatments, such as platelet-rich plasma injections, hyaluronan gel injections, and nitrate patches • Reserve surgery and botulinum toxin injections for the worst cases because patients can take six months to return to full function • Many cases of tennis elbow cases will naturally resolve in 6-12 months