Manage symptoms or let it ride? Rethinking tennis elbow treatment

With tennis, pickleball, golf and other summer activities in full swing, physicians may be seeing more patients with lateral elbow pain. While up to 50% of regular tennis players get tennis elbow, they make up a tiny fraction of total diagnoses. Despite its name, most people who get tennis elbow don't play the relevant sports, though “pickleball elbow” is reportedly a common upper body injury given the recent explosion in popularity of the sport. According to the Mayo Clinic, painters, plumbers, carpenters, cooks and mechanics also face higher risks due to repetitive wrist extension and gripping. Studies note a higher correlation in people with a history of tobacco use or heavy, repetitive daily lifting. Even repetitive use of a computer mouse is a risk factor.The condition impacts about 1%-to-3% of the total population each year, most often showing up in adults between 40 and 60 years old, and equally in men and women, according to the National Institute of Health.When it comes to treating lateral epicondylitis, the message from the most recent Canadian guidance is more conservative than in the past: reassure patients, help them manage aggravating activities and be cautious about interventions that promise a quick fix.Published in the Canadian Journal of Surgery in 2022, the Canadian Shoulder and Elbow Society’s “Position statement: nonoperative management of lateral epicondylitis in adults,” reviewed randomized controlled trials examining physiotherapy, corticosteroid injections, platelet-rich plasma (PRP) and autologous blood injections. Its recommendations were based on pain and functional outcomes and assessed using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation).“The single most important update is our finding that corticosteroids should not be the mainstay of treatment of lateral epicondylitis,” said Dr. Peter Lapner, an orthopedic surgeon at the Ottawa Hospital and lead author of the position statement, in an email.Start with prognosis and reassuranceFor most patients, the first treatment is education and counselling, rather than an injection, procedure or physiotherapy referral, says Dr. Lapner.“Most patients improve on their own,” Dr. Lapner said. “About 25% improve over each three-month interval and 89% improve over one year.”That timeframe is important to explain because lateral epicondylitis can linger, and patients may assume that persistent symptoms mean the tendon is continuing to deteriorate or that more aggressive treatment is needed. “The foundation of treating lateral epicondylitis is education first, and reassuring patients that most cases resolve naturally.”Perhaps the most significant change in practice concerns corticosteroid injections, once commonly offered to patients seeking rapid relief.Dr. Lapner and colleagues found that although corticosteroids can improve symptoms in the short term, the longer-term picture is considerably less favourable.“In a meta-analysis of randomized controlled trials, we found that the control group—a placebo—had statistically superior pain scores and functional scores compared with corticosteroid injection,” he said.The Canadian Shoulder and Elbow Society position statement consequently recommends against routinely using corticosteroid injections for lateral epicondylitis. Choosing Wisely Canada has similarly highlighted the society's review, noting that available evidence does not support corticosteroids as a routine nonoperative treatment.The challenge is that patients may hear of corticosteroids helping a friend find relief—and that may very well be the case. But patients wanting to quickly get back on the tennis or pickleball court need to understand it's usually not the best choice, says Dr. Lapner.“It is important for physicians to educate patients that corticosteroids should not be used routinely, as they are associated with a high recurrence and worse longer-term outcomes even though they offer short-term symptom control,” he said.PRP not supported over placeboAs an alternative to corticosteroids, platelet-rich plasma (PRP) has been promoted as a regenerative alternative, particularly for chronic tendon problems. But Dr. Lapner cautions that the placebo-controlled evidence does not support routinely recommending it for tennis elbow.“The other important finding was that platelet-rich plasma was no better than placebo,” he said, adding that a more recent randomized trial has further supported that conclusion.Although some studies have found better longer-term outcomes with PRP than with corticosteroid injections, Dr. Lapner notes that placebo-controlled evidence has not shown PRP to be superior to placebo. (If corticosteroids produce poorer long-term outcomes, outperforming corticosteroids is different from outperforming placebo.) The position statement also found no clinically important advantage for autologous blood injections, which aim to trigger a natural healing response, compared with placebo.Dr. Lapner is also cautious about newer interventions. “Bone marrow aspirate should be considered experimental treatment and not standard care—our study did not find this to be effective either against controls.” Symptom managementComplete rest is not generally necessary, and instead, physicians should tell patients to avoid carrying loads that clearly exacerbate their symptoms. But Dr. Lapner gives a green light to activities that can be performed without exacerbation.“It is important that patients understand the importance of avoiding load bearing that can exacerbate the symptoms; but that it is fine to maintain activities that they can carry out within tolerance,” he explained.For symptom management, Canadian guidance supports that conservative approach. A CMAJ clinical review (“Lateral epicondylosis,” written by Canadian orthopedic physicians) recommends modifying activities that aggravate the elbow, while allowing patients to continue activities they can tolerate. Ice and simple analgesics or NSAIDs can be used for short-term pain relief, and a counterforce brace or wrist splint may help some patients during activity. As symptoms improve, stretching and progressive strengthening of the wrist and forearm can be introduced.What about physiotherapy?Perhaps surprisingly, the Canadian Shoulder and Elbow Society position statement did not find that exercise-based physiotherapy produced superior pain or functional outcomes compared with no active treatment. That finding does not mean physicians need to discourage patients from remaining active or gradually rebuilding strength, notes Dr. Lapner. But, it reinforces the importance of setting realistic expectations: No exercise program has been convincingly shown to dramatically alter the natural course of the condition, which may take a long time to resolve.When to investigate furtherGenerally diagnosed clinically, lateral epicondylitis does not require routine imaging. “Additional imaging, including radiographs, ultrasound or MRI, are only usually considered when symptoms are atypical, severe, persistent or associated with weakness, or when surgery is being considered,” Dr. Lapner said.Persistent or unusual symptoms should also prompt physicians to reconsider whether lateral epicondylitis is the correct diagnosis, with other potential causes of elbow pain including nerve entrapment, referred cervical pain and intra-articular or other elbow pathology."Referral to a surgeon can be considered in refractory cases,” Lapner said, “as surgical releases are effective in carefully selected cases.”For most patients, however, the message is considerably simpler, though perhaps frustrating. Tennis elbow can be stubborn, but with patience, the odds of recovery are good. Physicians may help patients most not by escalating treatment quickly, but by explaining the prognosis, keeping them cautiously active and steering them away from interventions that might promise fast relief but show little longer-term evidence of success.

Manage symptoms or let it ride? Rethinking tennis elbow treatment

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