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What matters: what works for tennis elbow.

While typing this column, I could not recall the last time I saw a patient with "tennis elbow" (lateral epicondylitis) from actual tennis.

Lateral epicondylitis peaks between the ages of 30 and 65 years and affects about 1.3% of this group--the vast majority of whom, I am quite suddenly convinced, do not play tennis. Pain is worse with wrist extension and typically affects the dominant hand. The most likely etiology is repeated microtrauma.

The examination is straightforward and about 90% will recover by 1 year without a surgical procedure. The unhappy customers who darken our doorways with worsening or nonimproving symptoms are the ones who make us wonder if we gave them effective conservative measures to begin with.

So what conservative measures are effective?

Sims and colleagues published a meta-analysis evaluating nonsurgical treatments for lateral epicondylitis. The review involved 58 studies (Hand 2014.9:419-46).

The investigators concluded that steroid injections provide relief only for the short term. The authors suggest that this may related to lateral epicondylitis being caused by repeated microtrauma rather than inflammation (perhaps this is why NSAIDs are not always beneficial either).

Botulinum A, which works by paralyzing the extensor muscles, thereby allowing them to heal, is comparable to steroids. But patients may not love the experience of extensor muscle paralysis.

Prolotherapy, injection of osmotics or irritants to promote inflammation in the target tissue, is also comparable to steroids. Platelet-rich plasma or autologous blood injections have uncertain relative benefit compared to steroids. Bracing with a counterforce brace (i.e., "tennis elbow strap") or wrist extension splint, physical therapy, and shock wave therapy do not lessen pain or improve function in a dependable way.

This review leaves primary care clinicians who are uncomfortable injecting steroids into the arm with not much in the way of clearly effective evidence-based therapies. Personally, I ask my Ortho Hand colleagues to help me with the injection part. But only when patients fail to respond to what I give them.

So, if this is a self-limited disease that gets better in 12-18 months, should we just be offering nothing more than activity modification? Patients will not accept this. My read on the data Sims collected is that there weren't any quality studies comparing the elbow strap to offering nothing and patients tended to improve with it --although admittedly not clearly more than other therapies such as strengthening exercises. So for now, I will continue to recommend: 1) the elbow strap; 2) home exercises, and 3) lots and lots of reassurance. It's all I got to give.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Scan the QR code to read more What Matters online, or visit

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Title Annotation:OPINION
Author:Ebbert, Jon O.
Publication:Internal Medicine News
Date:Feb 1, 2015
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