Clinical Evidence Concise

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Tennis Elbow



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Am Fam Physician. 2007 Mar 1;75(5):701-702.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See Clinical Quiz on page 619.

What are the effects of treatments for tennis elbow?

LIKELY TO BE BENEFICIAL

Corticosteroid Injections (for Short-term Pain Relief)

Randomized controlled trials (RCTs) found limited evidence of short-term improvement in symptoms with corticosteroid injections compared with placebo or no treatment, local anesthetic, orthoses (elbow strapping), physiotherapy, or oral nonsteroidal anti-inflammatory drugs (NSAIDs). Overall, we found no good evidence on long-term effects of corticosteroids compared with placebo or no treatment, local anesthetic, physiotherapy, or orthoses, although we did find limited evidence that corticosteroid injections were less effective than physiotherapy or oral NSAIDs at improving symptoms in the long term. One RCT found limited evidence that corticosteroid injections were more effective than extracorporeal shock wave therapy at reducing pain at three months. We found limited data comparing one type of corticosteroid injection with another, or single versus repeated injections.

UNKNOWN EFFECTIVENESS

Acupuncture (for Short-term Pain Relief)

Small, methodologically weak RCTs provided conflicting evidence about the effects of needle acupuncture, laser acupuncture, or electroacupuncture in persons with tennis elbow. Three out of five RCTs comparing acupuncture versus placebo or no treatment found a small short-term benefit from acupuncture compared with placebo or no treatment, whereas two RCTs found no significant difference among groups.

Exercise and Mobilization

One RCT found that exercise improved pain and function after treatment and at 11 months compared with placebo. One RCT found that exercise improved pain at six to eight weeks compared with ultrasonography plus friction massage. We found limited evidence that physiotherapy was less effective than corticosteroid injections at improving symptoms in the short term but more effective in the long term. One RCT found no significant difference between exercise and watchful waiting in the short or long term (six to 52 weeks).

Oral NSAIDs(for Longer-term Pain Relief)

One systematic review found limited evidence that oral NSAIDS improved symptoms in the short term compared with placebo, although we also found limited evidence that they were less effective than corticosteroid injections in the short term. We found insufficient evidence to assess the longer-term effects of NSAIDs compared with placebo. One RCT found that oral NSAIDs were more effective than corticosteroid injections in the long term. We found no RCTs comparing oral versus topical NSAIDs.

Orthoses (Bracing)

One systematic review found insufficient evidence about the effects of orthoses compared with placebo, no treatment, physiotherapy, or nonsteroidal anti-inflammatory cream. It found limited evidence that there was less short-term improvement in symptoms with orthoses compared with corticosteroid injections. One additional RCT found that at six weeks, orthoses were less effective than physical therapy at improving pain outcomes or subjective satisfaction but more effective at improving functional ability.

Surgery

One systematic review found no RCTs comparing surgery versus no treatment or other treatments. One small unblinded RCT in persons who had failed 12 months of conservative treatment found that percutaneous tenotomy of the common extensor origin led to quicker recovery and return to work than did open excision of the abnormal tissue.

Topical NSAIDs (for Longer-term Pain Relief)

One systematic review found that topical NSAIDs improved symptoms in the short term compared with placebo. Minor adverse effects were reported with NSAIDs. We found insufficient evidence to assess the longer-term effects of NSAIDs compared with placebo. We found no RCTs comparing topical versus oral NSAIDs.

UNLIKELY TO BE BENEFICIAL

Extracorporeal Shock Wave Therapy

One systematic review, which included a total of nine placebo-controlled RCTs involving 1,006 people and an additional RCT of 62 people, found conflicting evidence about the benefits of shock wave therapy versus placebo. However, pooled analyses found no significant difference in pain outcomes between shock wave therapy and placebo. Adverse effects were mostly transient and included nausea and local pain and reddening of the skin. One RCT found limited evidence that extracorporeal shock wave therapy was less effective than corticosteroid injection at reducing pain at three months. We found no RCTs comparing early versus delayed shock wave treatment or comparing different modes of delivery.

Definition

Tennis elbow has many analogous terms, including lateral elbow pain, lateral epicondylitis, rowing elbow, tendonitis of the common extensor origin, and peritendinitis of the elbow. Tennis elbow is characterized by pain and tenderness over the lateral epicondyle of the humerus and pain on resisted dorsiflexion of the wrist, middle finger, or both. For the purposes of this review, tennis elbow is restricted to lateral elbow pain or lateral epicondylitis.

Incidence and Prevalence

Lateral elbow pain is common (population prevalence of 1 to 3 percent),1 with peak incidence occurring at 40 to 50 years of age. In women 42 to 46 years of age, incidence increases to 10 percent.2,3 In the United Kingdom, the Netherlands, and Scandinavia, the incidence of lateral elbow pain in general practice is four to seven per 1,000 persons a year.35

Etiology

Tennis elbow is considered to be an overload injury, typically presenting after minor and often unrecognized trauma of the extensor muscles of the forearm. Despite the term tennis elbow, tennis is a direct cause in only 5 percent of those with lateral epicondylitis.6

Prognosis

Although lateral elbow pain is generally self-limiting, in a minority of persons, symptoms persist for 18 months to two years and, in some cases, for much longer.7 Therefore, the cost is high in terms of lost productivity and health care use. In a general practice trial of an expectant waiting policy, 80 percent of persons with elbow pain of longer than four weeks' duration had recovered after one year.8

search date: August 2006

Adapted with permission from Buchbinder R, Green S, Struijs P. Tennis elbow. Clin Evid 2007;16:508–10.

 

REFERENCES

1. Allander E. Prevalence, incidence and remission rates of some common rheumatic diseases and syndromes. Scand J Rheumatol. 1974;3:145–53.

2. Chard MD, Hazleman BL. Tennis elbow—a reappraisal. Br J Rheumatol. 1989;28:186–90.

3. Verhaar J. Tennis elbow: anatomical, epidemiological and therapeutic aspects. Int Orthop. 1994;18:263–7.

4. Hamilton P. The prevalence of humeral epicondylitis: a survey in general practice. J R Coll Gen Pract. 1986;36:464–5.

5. Kivi P. The etiology and conservative treatment of lateral epicondylitis. Scand J Rehabil Med. 1983;15:37–41.

6. Murtagh J. Tennis elbow. Aust Fam Physician. 1988;17:90–1,94–5.

7. Hudak P, Cole D, Haines T. Understanding prognosis to improve rehabilitation: the example of lateral elbow pain. Arch Phys Rehabil. 1996;77:568–93.

8. Smidt N, van der Windt DAWM, Assendelft WJJ, et al. Corticosteroid injections for lateral epicondylitis are superior to physiotherapy and a wait and see policy at short-term follow-up, but inferior at long-term follow-up: results from a randomised controlled trial. Lancet. 2002;359:657–62.

This is one in a series of chapters excerpted from Clinical Evidence, published by the BMJ Publishing Group, London, U.K. The medical information contained herein is the most accurate available at the date of publication. More updated and comprehensive information on this topic may be available in future print editions of Clinical Evidence, as well as online at http://www.clinicalevidence.com (subscription required). Those who receive a complimentary print copy of Clinical Evidence from United Health Foundation can gain complimentary online access by registering on the Web site using the ISBN number of their book.


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