Tennis and Golfer’s Elbow

With tennis elbow the pain is over the lateral epicondyle (the bony prominence on the outside of the elbow). There is focal tenderness over the insertion site, and usually resisted wrist extension and resisted middle finger extension are provocative of symptoms.

With golfer’s elbow the pain is over the medial epicondyle (the bony prominence on the inside of the elbow). There is focal tenderness over the insertion site, and this time there can be symptoms with resisted wrist flexion or resisted elbow pronation.

In both conditions range of movement in the elbow is generally preserved, and there are no instability signs. Biceps and triceps strength is generally unaffected.

Patients present to the clinic with the typical symptoms and history as discussed above. Ultrasound is helpful in confirming the diagnosis, as the tendinopathic changes can be easily seen. This usually involves the extensor carpi radialis brevis tendon (ECRB) insertion onto the superior attachment of the lateral epicondyle.Source: Diagnostic Musculoskeletal Ultrasound for the Evaluation of the Lateral Elbow: Implications for Rehabilitation Providers – PMC (opens in a new tab)

Ultrasound will also help confirm the integrity of the extensor and flexor tendons as well as the deeper collateral ligament complex, as these conditions can mimic tendinopathy in certain patients. MRI can do the same.Source: Ultrasonographic Differentiation of Lateral Elbow Pain – PMC (opens in a new tab)

• Activity modification, ergonomic modifications, +/- analgesia/short course of NSAIDs. These simple interventions can be helpful initially, allowing things to calm down. For tradesmen, fitting their tools with a bigger grip can often reduce the symptoms enough to allow them to continue to work. There are also padded clasp orthotics which can offload the tendon during certain activities with good effect.
• For persistent symptoms, formal physiotherapy can be helpful and is usually first-line management. Treatment typically consists of a structured and progressive rehab programme to improve the capacity and tolerance of the tendon. Shockwave therapy is a possible adjunct which can also be helpful for patients.
• Steroid injections can sometimes be considered. Research is quite clear that they help in the short term, but there is a strong likelihood of recurrence, and with repeated steroid injections patients may actually do worse in the long term. They may sometimes be appropriate for patients that can’t work due to their symptoms, but this is under the clear understanding of the associated risks.Source: Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomised controlled trial – PubMed (opens in a new tab)
• Platelet-rich plasma (PRP) injections are a further treatment option. By having a PRP injection we are, in effect, concentrating a patient’s platelets from whole blood, rich in growth factors, then injecting this directly into the tendon to stimulate the body’s natural healing process. PRP releases bioactive factors that promote cell growth, collagen production and reduce inflammation. Evidence is controversial, but there is support for its benefits as a better longer-term treatment option in persistent lateral elbow pain without the associated risks of steroid. Unfortunately, its response rate is measured over months, meaning you may not notice a reduction in symptoms until later down the line.Source: Corticosteroid injections for the treatment of lateral epicondylitis are superior to platelet-rich plasma at 1 month but platelet-rich plasma is more effective at 6 months: an updated systematic review and meta-analysis of level 1 and 2 studies – PubMed (opens in a new tab)
• Surgery, both arthroscopic and open. Surgery is usually the last resort for these conditions once other treatment options have failed. Surgery typically involves the debridement of the unhealthy portion of the tendon +/- a repair of the healthy tendon to allow better healing. Despite this, even with surgery, persistence of symptoms is not uncommon.Source: Surgery for tennis elbow: a systematic review – PMC (opens in a new tab)