Several names exist for this issue: Tennis elbow, lateral elbow pain / tendinopathy, epicondylalgia, epicondylitis … They all refer to the same diagnosis.
Is it frequent?
It is a frequent issue among 35-54 years old people. It affects 1-3% of general population with an increased risk among smokers, manual workers, or tennis players.
How long is it?
For many persons, symptoms are self-limiting. Studies show that 83 to 90% of people without any treatment improve significantly at one year, although sometimes incomplete recovery. However, 1/3 of people still experience discomfort after 1 year despite treatment. A large proportion of people experience recurrence of symptoms after initial episode. Estimates suggest that 5% of people do not respond to conservative interventions and undergo a surgery with variable outcomes.
What is it, what is happening?
Tennis elbow is multimodal, it is not only a mechanical or structural issue. Current models suggest changes in the tendon’s matrix and cells, in combination with changes of the pain system and modifications of sensory and motor system.
How is it diagnosed?
It is diagnosed through a clinical examination by reproducing symptoms loading affected tendons. Pain can be reproduced on the epicondyle with palpation, resisted contraction of extensors of wrist or middle or second finger, and gripping. An in-depth clinical examination may be required to exclude other possible causes.
Shall I undergo imaging?
MRI and Ultrasound imaging have a very good capacity to exclude this pathology but a poor capacity to identify it when signs on imaging are present. Indeed, the same changes on imagery can be found in asymptomatic people. Studies show that we find the same changes in MRI in 50% of cases and in 53% with US in asymptomatic persons! However, when symptoms are present changes can be found in 90% of cases. In addition, studies show that severity of changes on imaging are not related to severity of symptoms for this pathology and other chronic tendinopathies. Hence the fact that imagery can exclude this problem but not diagnose it.
Which factors can affect improvement?
Universal treatment efficient for every person with tennis elbow unfortunately does not exist. The fact that this issue varies greatly among individuals suggest that a tailored treatment may be more beneficial. 6 factors influencing outcomes have been identified:
- The stage of the problem: reactive / degenerative or in between. It may change the treatment suggested
- Severity of initial symptoms. When they are more intense and disabling, the long-term prognostic is not as good.
- When Central Sensitization (CS) is present, the prognosis worsens. CS is a complex modification of central nervous system making light stimuli very painful, with changes in temperature perception leading (among other) cold to become painful.
- When shoulder or neck pain is associated, it may affect outcomes too. Neck pain is frequently associated with altered long-term results, while shoulder pain is frequently associated with altered short-term outcomes.
- Associated neuromuscular impairments lower prognosis. Strength deficit of extensor of wrist, grip, or all affected limb and a speed deficit and muscular reaction time of both arms in patient with unilateral tennis elbow have been reported. If these are not assessed and treated when present, they may contribute to chronicity.
- Psychosocial factors and work-related factors have been linked with increased risk of developing tennis elbow and with a lower one-year prognosis. They include use of tools, heavy loads, repetitive movements, activities involving strength with wrist flexion and low control on work.
In addition, we know that tendons’ health is largely affected by lifestyle. The following elements are risk factors of developing tendon issues:
- Smoking
- Obesity
- High fatty food intake
- Hish processed food intake
- Physical inactivity
- High cholesterol levels
- Diabetes
- Sudden changes in activity levels
What are available treatment options?
Pharmacotherapy: Results of oral nonsteroidal anti- inflammatory medication in the treatment of tennis elbow are conflicting. They are speculated to be more efficient in reactive phase.
Corticosteroid medication: We have strong evidence that corticoid injection therapy allows a short-term pain relief but lead to poorer outcomes at 6 month and 1 year and an increase in recurrences when compared to no treatment or physiotherapy. In addition, adding a multi- modal physical therapy program do not ameliorate the late delay in recovery or recurrence observed after a single corticosteroid injection. Therefore, corticosteroid injections are not recommended as a first line treatment.
Antidepressant or antiepileptic drugs may be appropriate for patients with severe pain where central sensitization is suspected, although no studies have been conducted in this population to date but it has on other groups like people with fibromyalgia.
Prolotherapy PRP and nitric oxide patches have demonstrated long term effects on patients with persistent epicondylalgia (>3 months). However, their efficacy depends on the technique used in combination as when used with stretching only they have not demonstrated any effects.
Despite current interest there is growing evidence that injection of autologous blood or platelet- rich blood products is not effective in treating tennis elbow.
Manual therapy (MT): We have moderate evidence of immediate effects of MT on pain and pain-free grip and short term benefits when used in conjunction with gradual exercises. There is also evidence that MT of cervical and thoracic spine has additional benefits in addition to local treatment when these areas present limitations.
Therapeutic exercises: Exercises are paramount in the treatment of tennis elbow with evidence of exercises alone or as a component of a multimodal approach. For patients with persistent epicondylalgia, exercises have shown a quicker reduction in pain, less sick leave, less medical appointments, and an increased work capacity. Despite clear benefits, currently there is no recommendations on type, intensity, frequency, or optimal duration for exercises. Current guidelines recommend a gradual increase in resistance, with focus on wrist extensors. There are conflicting views on pain during exercise, some authors insist on avoiding pain while others think it should stay tolerable (5<10). Given the heterogeneity of the clinical presentation and pathology it is more likely that optimal dosage may differ for each person according to stage, severity, and functional demand before injury.
Education: Natural history is self-limiting. Delays may be long 12 weeks of rehabilitation, sometimes 1 year to obtain an improvement of symptoms that may be incomplete. Recurrences may happen. Some factors increase the risk to develop the condition or that delay recovery. Rehabilitation is multimodal and tailored to individuals. Initial rest (regarding provoking activities) is important then gradual loading is required to recover the function of the limb. It is crucial to gradually reintroduce more strenuous tasks and to reduce tendon load if recurrence is experienced.
Bibliographie / Sources :
(Coombes, Bisset, & Vicenzino, 2015; Hoogvliet, Randsdorp, Dingemanse, Koes, & Huisstede, 2013; Vuvan, Vicenzino, Mellor, Heales, & Coombes, 2019)
Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 938–949. https://doi.org/10.2519/jospt.2015.5841
Hoogvliet, P., Randsdorp, M. S., Dingemanse, R., Koes, B. W., & Huisstede, B. M. A. (2013). Does effectiveness of exercise therapy and mobilization techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. British Journal of Sports Medicine, 47(17), 1112–1119. https://doi.org/10.1136/bjsports-2012-091990
Vuvan, V., Vicenzino, B., Mellor, R., Heales, L. J., & Coombes, B. K. (2019). Unsupervised Isometric Exercise versus Wait-and-See for Lateral Elbow Tendinopathy. Medicine and Science in Sports and Exercise, 52(2), 287–295. https://doi.org/10.1249/MSS.0000000000002128