Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Management of Tennis elbow (Lateral Epicondylitis)

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Management of Tennis elbow (Lateral Epicondylitis) · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

0:00
Did you know that lateral elbow tendinopathy,
0:02
well, the condition most of us call tennis elbow,
0:05
affects maybe as many as one in 30 people every
0:08
single year? That's right. It translates to roughly
0:11
four to seven cases for every thousand adults.
0:14
And it's not just a minor thing, is it? It's
0:17
actually the most common reason people have that
0:19
persistent pain on the outside of their elbow.
0:21
Makes up about two thirds of those cases, yes.
0:23
So if you've ever felt that frustrating ache
0:25
yourself, or maybe know someone who has, Definitely,
0:29
definitely not alone. Welcome back to The Deep
0:31
Dive. This is the show where we cut through the
0:34
noise, take your sources, articles, research,
0:36
maybe even your own notes, and really pull out
0:39
the key insights. Think of it as a shortcut to
0:42
getting properly informed, hopefully with a few
0:44
surprising bits along the way. Now, this specific
0:47
deep dive was actually requested by one of you,
0:49
looking for some clarity on the latest evidence
0:52
-based ways to manage this really common, but
0:54
often quite misunderstood, condition and helping
0:57
us navigate the recent guidelines and research
0:59
today is a leading figure in orthopedics, someone
1:02
deeply involved in the very literature we're
1:05
about to explore. He's been central in reviewing
1:07
the evidence and contributing to the BES guidelines
1:10
on this topic, which are key sources for our
1:13
chat. It's a real pleasure to have you here.
1:15
Thank you. Happy to be here and ready to jump
1:16
in. Excellent. OK, let's set the scene then with
1:19
a quick rapid fire round. First one, what exactly
1:22
is lateral elbow tendinopathy and why do we all
1:24
call it tennis elbow? Seems confusing. Well,
1:27
at its heart, it's about altered tissue homeostasis.
1:31
Basically, something's not quite right in the
1:34
tendons that attach to the bone on the outside
1:36
of your elbow, the lateral epicondyle. This causes
1:39
pain. which often radiates down the forearm,
1:42
and it frequently affects your grip or your hand
1:44
dexterity. And the tennis elbow name. Ah, yes.
1:47
It comes from the fact that, well, it can affect
1:49
tennis players, but honestly, overwhelmingly,
1:53
it's linked to repetitive tasks or loading in
1:55
daily life or work, much less often from sport.
1:58
And the diagnosis itself is clinical. It's based
2:01
on your history and a physical examination. OK,
2:03
second rapid fire. We often hear this condition
2:06
can... just get better on its own. Is there truth
2:08
in that? And if so, how often, how quickly? Yes,
2:10
that's a really crucial point from the evidence.
2:13
A major finding from meta -analyses is that lateral
2:16
elbow tendinopathy is largely self -limiting.
2:19
Studies tracking patients who had minimal or
2:21
no active treatment show really high rates of
2:24
spontaneous improvement. How high? One key analysis
2:26
found around 89 % global improvement within a
2:29
year. 89 %? That's significant. It is. And what's
2:33
perhaps more surprising is the speed of improvement.
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The half -life for significant global improvement
2:39
is estimated around 2 .5 to 3 months. And interestingly,
2:43
this doesn't seem to be related to how long you've
2:45
actually had the symptoms when you first seek
2:47
help. That's genuinely quite reassuring for people
2:49
going through it. Okay, last rapid fire. Given
2:53
how common it is and that it often gets better
2:55
anyway, why is there still so much kind of conflicting
2:59
advice and debate about the best way to treat
3:01
it? That's a great question and really sets up
3:04
our deep dive nicely. The debate mostly comes
3:06
from the varying quality and consistency of evidence
3:10
for different treatments over the years. Past
3:12
guidelines have sometimes offered different advice.
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The goal of recent efforts, like the BES guidelines
3:17
we're using, is to apply really rigorous methods,
3:20
things like the GRADE system, which systematically
3:23
rates the certainty of evidence to give clearer
3:26
evidence -based recommendations and, importantly,
3:28
to highlight where the science is strong and,
3:30
frankly, where it's still a bit uncertain. All
3:32
right, bringing some clarity. Okay, let's unpack
3:34
this then. Starting with the non -surgical options,
3:37
which is where most people begin, isn't it? What's
3:39
the recommended initial approach, say, in primary
3:42
care? Yes, absolutely. Initial management really
3:45
emphasizes shared decision -making. This echoes
3:48
guidance from bodies like the GMC. It means properly
3:52
listening to the patient, giving them clear,
3:54
understandable information about their condition,
3:56
what to expect, respecting their choices, and
3:59
supporting self -care. And the diagnosis part.
4:01
It's clinical, as I mentioned. Relying on the
4:04
patient's history key things like the gradual
4:06
onset of pain, exactly where it is if it radiates
4:10
down the forearm, and what makes it worse. Often
4:13
actions like grasping or twisting. Then the physical
4:15
exam looks for tenderness over that bony bit
4:17
on the outside, the lateral epicondyle, and pain
4:20
when they extend their wrist or fingers against
4:23
resistance. There are also specific tests we
4:25
use, like Cousins, Mills, or Modsley's tests,
4:28
which can help confirm things. So no need for
4:31
pricey scans straight off the bat? Exactly. Plain
4:34
x -rays aren't usually needed for diagnosis,
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and specialist imaging like MRI or CT scans are
4:40
generally not required in primary care, only
4:43
really if there's genuine diagnostic uncertainty
4:45
or maybe a suspicion of something else going
4:47
on. And the initial treatment advice? It focuses
4:50
on patient education, explaining the self -limiting
4:53
nature, advising on activity modification to
4:56
reduce the irritating lows. you know, giving
4:58
them a break, and providing exercises, often
5:01
focusing on stretching and progressive strengthening.
5:04
Eccentric loading, where the muscle lengthens
5:06
under tension, is commonly included. Plus, simple
5:09
analgesics or NSAIDs are part of that initial
5:12
plan too. Okay, and what about those NSAIDs,
5:14
the rubs and the pills? What's the evidence say?
5:16
Well, systematic reviews suggest NSAIDs, whether
5:19
topical creams or oral tablets, can offer short
5:22
-term pain relief, usually effective for up to
5:25
about four weeks. But, The evidence quality for
5:28
both is actually low to very low. Topical endocides
5:31
are generally preferred because they carry less
5:33
risk of systemic side effects, especially stomach
5:36
issues, compared to the oral ones. The key point
5:39
from the evidence, though, is that their benefit
5:41
seems limited in time and is based on less robust
5:44
studies. Right. What about things like orthotics?
5:47
Those forearm bands or wrist braces you see people
5:50
wearing, do they actually help? The BESCA guidelines
5:54
give what's called a conditional recommendation
5:56
here. They may be offered, but importantly, patients
5:59
need to be aware that the evidence suggests they
6:02
may not actually provide a benefit. While some
6:05
sort of low quality evidence hints at an immediate
6:08
effect on reducing pain during gripping, there's
6:10
really no reliable evidence showing sustained
6:13
benefit over time compared to a placebo or a
6:16
sham device. Okay, let's move to physiotherapy
6:19
then. It feels like a very common and sort of
6:21
natural intervention. What's the recommendation
6:23
and the evidence look like there? Physiotherapy
6:25
gets a strong recommendation. Patients should
6:27
be offered it. Evidence from systematic reviews
6:30
shows strong evidence of benefit, but mainly
6:33
in the short term. Short term meaning? Usually
6:35
the first few weeks, maybe up to three months.
6:38
However, when you look longer term, medium and
6:40
long term, there's generally no significant difference
6:43
in outcomes compared to just, well, waiting for
6:47
spontaneous recovery or receiving no specific
6:49
intervention. Now, there is some lower quality
6:51
evidence hinting at a possible long -term benefit
6:54
from specific types of physiotherapy, but the
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certainty around that is currently low. That's
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a really important nuance, isn't it? Helps early
7:01
on, but maybe less clear difference compared
7:04
to just getting better naturally in the longer
7:06
run. What about for really chronic symptoms?
7:08
Say someone's had pain for over a year or after
7:12
surgery. Yeah, for chronic symptoms beyond 12
7:14
months, dedicated high -quality studies are a
7:17
bit thin on the ground. However, based on that
7:19
short -term evidence at earlier stages, the consensus
7:22
is that physiotherapy may still be offered, especially
7:25
if it hasn't actually been tried properly before.
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And for postoperative physiotherapy, specific
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evidence is also lacking, but clinical consensus
7:34
supports that it may be offered to help guide
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rehabilitation and recovery. Okay, now here's
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where I think it gets really interesting and
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maybe quite counterintuitive for many people.
7:43
For ages, corticosteroid injections felt like
7:46
the standard go -to treatment. What does the
7:49
latest evidence actually tell us about using
7:51
them? This is probably one of the most critical
7:53
takeaways, and it's backed by multiple meta -analyses
7:56
and high -quality trials. The recommendation
7:58
now is that corticosteroid injections should
8:01
not be used for lateral elbow tendinopathy. Should
8:03
not be used. That's quite definitive. It is.
8:06
The evidence, which ranges from moderate to very
8:08
low quality, depending on the specific study,
8:11
consistently shows only a minor temporary improvement
8:14
in pain, usually just in the first month or so.
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But, and this is the striking part, by six months
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the outcomes are often worse than if the patient
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had received a placebo injection or even no treatment
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at all. Worse? How so? The evidence suggests
8:28
they might actually hinder the natural healing
8:30
process and potentially increase the risk of
8:33
the pain coming back recurrence. It's this long
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-term negative effect that underpins the strong
8:38
recommendation against using them. Wow, that
8:41
reversal effect is huge. Clinicians and patients
8:43
really need to know that. Okay, so if steroids
8:45
are out, what about the range of other injections
8:48
and therapies that seem quite popular now? Things
8:50
like PRP, dry needling, shockwave therapy. Yes,
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the evidence picture for many of these is, well,
8:56
less clear or often negative when compared properly
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to placebo or sham treatments. For platelet -rich
9:01
plasma, PRP, the BESS recommendation is conditional
9:05
neutral. which basically means patients should
9:08
understand there may be no benefit compared to
9:10
placebo. The current evidence shows no significant
9:12
effect on pain or function and the quality of
9:15
that evidence is rated as very low. Autologous
9:18
blood injection using the patient's own blood
9:21
gets a conditional recommendation that it should
9:23
not be used. Moderate to very low quality evidence
9:27
suggests no real benefit over simple saline injections.
9:30
What about dry needling? That seems quite common
9:33
too. Dry needling also has a conditional neutral
9:35
recommendation. Again, patients should know there
9:38
is no evidence of benefit compared to placebo.
9:41
A key issue here is the lack of well -designed
9:43
studies comparing it to a proper placebo or sham
9:46
treatment. While some studies compare it to other
9:48
things, steroids, ibuprofen, even surgery or
9:51
PRP, the results are very mixed, making it impossible
9:54
to draw firm conclusions about its effectiveness
9:56
on its own merit. And extracorporeal shockwave
9:59
therapy, ECSWT. That receives a strong recommendation.
10:03
It should not be used. Moderate to very low quality
10:06
evidence shows no clinically significant improvement
10:09
in patient reported outcomes, pain, or grip strength
10:11
when compared to placebo or sham treatment in
10:14
the medium term, say around three to six months.
10:16
OK, so not much support there. And what about
10:18
the really novel therapies, things like ultrasonic
10:20
procedures, dextrous injections, arterial embolization?
10:24
For many of those newer or more experimental
10:26
therapies, the recommendation is also conditional
10:29
neutral. Patients should be aware there's currently
10:32
no evidence of benefit compared to placebo. The
10:35
evidence base is typically very low quality,
10:38
often just case series or small comparison studies.
10:41
The consensus really is that these should only
10:43
be considered within the context of research
10:45
trials at this point. That's a really clear rundown
10:48
of the non -surgical side, thanks, really highlights
10:50
where the evidence stands or doesn't. Let's switch
10:53
gears now and talk about surgery. Given everything
10:55
we've just discussed, why is surgery even considered
10:58
and what does the evidence actually show about
11:00
its role? It feels a bit controversial now. It
11:03
is quite controversial in the evidence -based
11:05
world. Surgery is typically reserved for patients
11:07
whose symptoms just haven't resolved after a
11:10
decent trial of non -surgical treatment, usually
11:12
defined as maybe three to six months in the BSS
11:15
guidelines. The Muir Scoping Review which looks
11:18
specifically at the surgical literature, found
11:20
the median time people had tried non -surgical
11:23
options before having surgery in the studies
11:25
was about six months. But you're right, its role
11:27
is debated, as highlighted by both the BSS guidelines
11:31
and that mirror review. OK, so what is the specific
11:34
recommendation in the BSS guidelines about surgery?
11:37
This feels like a key point. It is perhaps the
11:39
most surprising and important point regarding
11:42
surgery. The recommendation states, Patients
11:46
being offered surgery should be made aware that
11:48
there is no evidence of benefit compared to a
11:50
placebo. Hold on. No evidence of benefit compared
11:53
to a placebo. That sounds... Well, how can that
11:55
be? If surgery is being offered, surely there
11:57
must be some evidence it helps. What did that
12:00
Muir review actually find when it looked at all
12:02
the surgical studies? It's fascinating when you
12:04
dig into why that recommendation exists. The
12:07
Muir review analyzed 35 studies on surgical management.
12:11
covering over 1 ,500 patients. What they found
12:14
was that the literature is dominated by single
12:16
-center studies, often with quite small numbers
12:18
of patients in each. And there's a real lack
12:21
of high -quality multi -center trials. OK, so
12:24
the quality is maybe not ideal. Precisely. And
12:26
there's huge heterogeneity, meaning studies use
12:29
different methods, different patient groups,
12:31
measured outcomes differently. This makes it
12:33
incredibly difficult to combine the data and
12:35
draw really strong, generalizable conclusions.
12:38
Now most individual studies did report improvements
12:40
in pain and function after surgery. That's true.
12:43
But the critical issue is that these studies
12:45
very rarely compared surgery directly to a proper
12:48
placebo or sham procedure. or even to a well
12:51
-structured conservative management program.
12:53
The one trial they identified that did compare
12:55
open surgery to sham surgery actually found no
12:58
improvement in function in the group that had
13:00
the real surgery. Right. So many individual reports
13:04
say patients got better after we operated, but
13:07
the gold standard comparison surgery versus fake
13:10
surgery didn't show a benefit for the real thing.
13:12
That's the crux of it. It really raises the question,
13:16
are the improvements seen in many studies due
13:18
to the surgery itself? Or is it the post -operative
13:21
rehab, the placebo effect of just having a procedure,
13:24
or simply the natural history of the condition
13:26
resolving over time, which we know happens often
13:29
anyway? Because of that lack of high -quality
13:31
comparative trials, especially against placebo,
13:33
the BSAS committee couldn't find strong evidence
13:35
to recommend surgery over doing nothing or having
13:38
a sham procedure. Does the evidence tell us anything
13:40
about different surgical techniques, like open
13:43
surgery versus keyhole arthroscopic surgery?
13:46
The MU Review didn't find consistent differences
13:48
between open and arthroscopic techniques when
13:51
looking across the literature narratively, although
13:53
individual studies reported improvements with
13:55
both methods. So the BSS guidelines basically
13:59
say that if a patient does choose surgery, they
14:01
may have either technique, but they note the
14:03
evidence comparing them is limited by small study
14:06
sizes and a lack of long -term follow -up measures.
14:09
Percutaneous techniques were also looked at,
14:11
but the data there is even more limited. Okay.
14:14
And finally on surgery, is recurrence a risk?
14:17
Can the pain come back and are there things that
14:19
might make that more likely? Yes, recurrence
14:21
is definitely possible. A study mentioned in
14:23
the BS's guidelines reported a two -year recurrence
14:25
rate of around 8 .5%. And risk factors. Several
14:29
potential risk factors have been identified.
14:31
Things like older age, perhaps inadequate or
14:34
short recovery periods after treatment or surgery,
14:37
being involved in manual labor, having had previous
14:39
surgery on the same elbow. Also, having symptoms
14:42
for a very long time, say over 12 months, experiencing
14:45
very acute pain right at the start, poor adherence
14:48
to the recommended management plan, and notably
14:51
having received corticosteroid injections. There
14:55
are those steroid injections, again, linked to
14:57
potentially worse outcomes or recurrence. That's
14:59
really striking. It reinforces the earlier point,
15:02
yes. OK, wow. We have covered a huge amount of
15:05
ground there looking at the evidence for both
15:07
nonsurgical and surgical approaches. Let's try
15:10
and crystallize some of this. Time for a quick
15:12
lightning round for some sharp, concise answers.
15:15
Ready? Ready. What's the single most reliable
15:18
way to diagnose tennis elbow? Clinical history
15:21
and a thorough physical examination. Imaging
15:23
is generally not needed up front. Based purely
15:26
on the evidence, if I start getting tennis elbow
15:28
pain, what's the very first thing I should probably
15:30
try myself? Activity modification try to redo
15:33
the offending loads. Then, exercises, including
15:36
stretching and progressive strengthening like
15:39
eccentric loading, and maybe topical NFIDs for
15:43
short -term pain relief. Okay. What treatment
15:46
may be commonly used in the past does the evidence
15:48
now strongly suggest people should avoid because
15:51
it doesn't help long -term and might actually
15:53
worsen things? or increase recurrence risk. Corticosteroid
15:57
injections, definitely. Got it. What's the biggest
16:00
remaining question mark or area of uncertainty
16:02
in managing tennis elbow, according to the recent
16:05
literature we've discussed? I'd say it's the
16:07
exact role and the true benefit of surgery. especially
16:11
when compared rigorously against non -surgical
16:13
management or simply allowing for that natural,
16:16
spontaneous recovery. We really need more high
16:18
-quality placebo -controlled trials. Right. That
16:21
comparison is key. And finally, if someone's
16:23
tracking their own progress or looking at research,
16:25
what's a key outcome measure that patients and
16:27
clinicians should probably be aware of? The PRTE.
16:30
That's the Patient -Reported Tennis Elbow Evaluation
16:33
Questionnaire. It's recommended as the core outcome
16:35
measure for assessing disability in this condition.
16:38
PRT. Good to know. Excellent. Okay, to wrap everything
16:41
up from this really insightful deep dive into
16:44
your sources, let's quickly summarize, say, five
16:47
key actionable takeaways for our listeners. Absolutely.
16:50
Let's do that. Okay, first takeaway. Remember,
16:52
diagnosis is primarily clinical. It's about the
16:55
conversation with your doctor and the examination.
16:57
Imaging usually isn't needed unless the diagnosis
17:00
is really unclear. Second, this condition very
17:03
often improves on its own over time. Physiotherapy
17:06
can be very helpful for short -term relief and
17:08
function, but the evidence for its long -term
17:11
benefit compared to just natural recovery is
17:14
less certain. Third, and this feels like a headline
17:18
finding, the evidence strongly advises against
17:20
using corticosteroid injections. Any short -term
17:23
relief might be outweighed by worse outcomes
17:25
later on and potentially a higher risk of the
17:27
pain coming back. Spot on. Fourth, from any other
17:30
treatments that you might hear about things like
17:32
PRP, dry needling, shockwave therapy, the current
17:34
evidence, when compared properly to placebo,
17:37
is either weak, of very low quality, or simply
17:39
shows no significant benefit. Be aware of that
17:41
limited evidence. And fifth, the role of surgery
17:44
for tennis elbow remains quite debated. High
17:48
-level evidence, especially from reviews including
17:51
sham surgery trials, doesn't clearly show a benefit
17:54
compared to placebo. So given this uncertainty,
17:57
really understanding the evidence and engaging
18:00
in shared decision -making with your clinician
18:02
is crucial if surgery is ever on the table. Agreed
18:05
entirely. Making informed choices based on the
18:08
best available evidence is absolutely key to
18:11
managing this condition effectively. So what's
18:13
the final thought for you, the listener, from
18:15
all this? I think it's that understanding the
18:17
natural history of tennis -elda, the fact it
18:19
often gets better by itself, alongside the Frankly,
18:23
surprisingly weak or even negative evidence for
18:25
many common interventions really empowers you.
18:28
It means you can have much more informed conversations
18:30
about your treatment options. Knowing what the
18:33
science actually says is the vital first step
18:35
to choosing the path that's truly right for you.
18:37
If you found this deep dive helpful, please do
18:39
take a moment to rate and share the show with
18:41
your network. Thank you so much for sharing your
18:43
expertise and guiding us so clearly through these
18:45
important sources today. It's been my pleasure.
18:47
Thank you for having me. And thank you, our listener,
18:50
for joining us on the deep dive. We hope this
18:52
has shed some useful light on what can be an
18:55
incredibly common and sometimes very frustrating
18:57
condition. Until next time.