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Tennis elbow: A clinical review article

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DOI: 10.1016/j.jor.2019.08.005

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Contents lists available at ScienceDirect

Journal of Orthopaedics
journal homepage: www.elsevier.com/locate/jor

Tennis elbow: A clinical review article T

a,∗ a a b
S. Cutts , Shafat Gangoo , Nitin Modi , Chandra Pasapula
a
James Paget Hospital, United Kingdom
b
Queen Elizabeth Hospital Kings Lynn, United Kingdom

A R T I C LE I N FO A B S T R A C T

Keywords: Lateral epicondylitis, or tennis elbow is a common condition that presents with pain and tenderness around the
Lateral epicondylitis common extensor origin of the elbow.
Tennis elbow Tennis elbow is estimated to affect 1–3% of the adult population each year and is more common in the
Repetitive strain dominant arm. It is generally regarded as an overuse injury involving repeated wrist extension against resistance,
Treatment
although it can occur as an acute injury (trauma to the lateral elbow). Up to 50% of all tennis players develop
symptoms due to various factors including poor swing technique the use of heavy racquet. It's also seen in
labourers who utilise heavy tools or engage in repetitive gripping or lifting task.
In this article, we discuss the existing literature in the field and the current thinking on optimum treatment
modalities. We have reviewed the literature available on med line and have discussed the condition with our
specialist colleagues in the field.

1. Introduction regular tennis players.4 There was no correlation with gender in this
series although there was a clear cut association with those who's oc-
Tennis Elbow was first described by Runge1 in 1873 and eventually cupation involved repetitive forearm and hand movement. It should be
given the label ‘Lawn Tennis Arm’ by Henry Morris, writing in the remembered that the most “at risk group” for tennis elbow are also
Lancet in 1882.2 It has, however, acquired a number of other names likely to suffer from concomitant elbow pathology. There is, for ex-
including tendonosis, lateral epicondylitis and angiofibroblastic hy- ample an ill defined overlap with radial tunnel syndrome.
perplasia. As the most popular term suggests, it tends to occur in regular Amongst the extensor tendons taking origin in the region of the
tennis players where there is a clear association with the late back hand lateral epicondyle, the extensor carpi radialis brevis has often been
and forced wrist extension. implicated as the key structure in tennis elbow. Its unusual anatomy
Patients complain of an area of pain and tenderness over the bony exposes it to shearing forces in almost all movements of the arm.
prominence of the lateral epicondyle. This structure is also the common Biomechanical studies by Briggs5 support the view that tennis elbow is
origin of the long extensor tendons for the forearm and hand and the primarily a mechanically induced condition.
underlying pathology appears to be an area of degenerative change However, recent anecdotal reports suggest a possible association
within these tendons. There is a wide spectrum of severity ranging from with the use of fluoroquinolone antibiotics. This phenomenon has been
slight tenderness to severe, continuous pain. Pain is characteristically previously reported in the Achilles tendon although it should be re-
exacerbated by resisted extension of the middle finger and also by ex- membered that these are infrequently used drugs and the risk is quite
tension of the wrist. obviously very low.6
Lateral epicondylitis (tennis elbow) is 7 times more common than its
medial equivalent (golfers elbow). Like most musculoskeletal condi- 2. Histology
tions, it has a natural tendency to fade with time although, in a pro-
portion of patients, it will deteriorate. Terms such as tendonitis and epicondylitis suggest an inflammatory
In 1974, Alanger3 estimated the prevalence in Sweden to be be- process and in that sense, these are both misnomers. The histological
tween 1 and 3%. The peak age interval is 40–50 years and in this group, picture here is dominated by dense populations of fibroblasts, vascular
the prevalence rises to 19%. Later in the United States, Dimberg de- hyperplasia and disorganised collagen. This has been termed angiofi-
scribed the condition in 7.4% of industrial workers and 40–50% of broblastic hyperplasia and is believed to occur in tendon that has

∗
Corresponding author.
E-mail address: [email protected] (S. Cutts).

https://doi.org/10.1016/j.jor.2019.08.005
Received 10 May 2019; Accepted 9 August 2019
Available online 10 August 2019
0972-978X/ Crown Copyright © 2019 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation. All rights reserved.
S. Cutts, et al. Journal of Orthopaedics 17 (2020) 203–207

damaged by repetitive micro trauma. 6. Treatment

Given the absence of inflammatory changes in tennis elbow, it is not
entirely clear why the condition should be painful although for some Over 40 treatments have been described for tennis elbow and so
patients it is exquisitely painful. Tendons involved in locomotion and many of are used routinely that there is clearly no single optimum
ballistic performance which transmit loads under elastic and eccentric treatment. Well established treatments for tennis elbow are often jus-
conditions are regarded as being susceptible to injury of this kind. tified by level five evidence (i.e. expert opinion).
Those with poor blood supply and those that straddle two joints are also In 1993, Labelle et al. attempted to write a quantitative meta ana-
more sensitive to damage. Muscles within the forearm fit into this lysis paper of previous publications on tennis elbow but found them-
bracket. selves forced to publish a qualitative review instead.20 The authors
observed that only a minority (18) of the 185 papers reviewed satisfied
3. Investigations their inclusion criteria. The problems then, as now, are multiple. There
is no consensus on the definition of the disease with the distinction
The diagnosis of tennis elbow is usually made on physical signs. between acute and chronic epicondylitis being poorly defined. Simi-
About 2/3 of patients will demonstrate an altered signal around the larly, objective outcome variables are difficult to find. Some, but not all
lateral epicondyle on MRI scanning7 and this phenomenon may con- authors use Visual Analogue Scales to assess changes in pain. Grip
tinue long after the symptoms have resolved.8 strength is compromised in tennis elbow and this parameter is com-
Infra red thermography has been used to demonstrate a hot focus monly measured in the upper limb clinic as a matter of routine. Pain
around the lateral epicondyle in 94–100% of tennis elbow patients.9 inhibition characteristically reduces the power of middle finger exten-
Isotope bone scan is also positive in 71% of cases although in practise, sion in tennis elbow and measurements of this force are relatively easy
both of these would be considered exotic investigations. to make, with changes in middle finger extension power being a
Laser Doppler flowmetry has been used to investigate the blood common though far from universal outcome variable in this field. Since
supply in this region. There is some evidence that intramuscular blood there are no standard outcome variables, meta-analysis of existing pa-
flow is reduced around the origin of extensor carpi radialis brevis pers is almost impossible.
(ECRB) muscle.10 It has been suggested that reduced blood flow and To date, there are no universally accepted regime of treatment.
anaerobic metabolism within the ERCB muscle may have a causative However, some general principles of treatment should be taken into
role in the pain of lateral epicondylitis. consideration. Initially pain and inflammation need to be settled with
pharmacological (analgesics, NSAIDS) and physical modalities: ice,
4. Differentials for epicondylitis rest, electrotherapies such as ultrasound, laser and high frequency
galvanic stimulation, massage and trigger point injections.
These include radial tunnel syndrome, tenosynovitis or chronic
wrist pain. It can be difficult to differentiate between these conditions. 6.1. Local steroid injections
There is ambiguity in the literature as to where Posterior Interosseous
Nerve (PIN) compression begins and tennis elbow ends. The injection of corticosteroid preparation with local anaesthetic is
the main stay of treatment for this condition. The physician feels for the
5. Radial tunnel syndrome point of maximum tenderness and then injects the cocktail using aseptic
technique. Given the absence of inflammatory changes on microscopy,
Radial tunnel syndrome is the main differential for pain in the re- it is perhaps surprising how many patients respond to this type of
gion of the lateral epicondyle. Patients with repetitive manual tasks treatment.
seem to be at risk of both tennis elbow and radial tunnel compression Hay et al. et al. have looked at the use of local steroid injection and
with the junction between the two conditions being difficult to define. compared it to oral nonsteroidal in new patients in a primary care
The Posterior Interosseous Nerve (PIN) is believed to be crushed under setting.21 Hay's study is interesting in that as a group, primary care
the free edge of the supinator muscle. However, other adjacent struc- patients with tennis elbow may be very different from the cohort that is
tures (including ERCB) may play a role. eventually referred to the hospital specialist. In this study, local corti-
The condition is associated with pain on resisted supination and costeroid injection was found to be an effective safe treatment with
resisted extension of the middle finger. clear clinical advantage at four weeks when compared to naproxen.
PIN decompression has been shown to be effective in relieving pain However as with the treatment of many musculoskeletal complaints,
in this region.11 the correlation between initial response and longer term follow up was
Indeed, Jalovaara has suggested that around 30% of cases of tennis poor.
elbow are in fact suffering from PIN entrapment12 (i.e. radial tunnel
syndrome) although this figure is difficult to measure with any accu- 7. NSAIDS
racy. Some authors openly acknowledge that it is impossible to distin-
guish clinically between the two conditions. It is traditional to offer oral NSAIDS for tennis elbow.22
From an anatomical point of view, the inseparable origin of the In 2007 Green reviewed the use of NSAIDS in tennis elbow for the
radial wrist extensors and supinator muscle seems to link tennis elbow Cochrane review. He found some evidence that topical NSAIDS relieve
and radial tunnel syndrome.13 elbow pain at least in the short term. Evidence regarding oral NSAIDS is
The well known surgical technique of Wilhelm denervates and re- more ambiguous and may be less effective than a local steroid injection.
leases PIN at the same time.14 Similarly, most tennis elbow procedures In spite of this, it is common for patients in our own practise to claim
will relax the ECRB tendon and indirectly, decompress the radial nerve, that oral NSAIDS are of benefit.
raising the possibility that at least some patients who appear to respond
to surgery for tennis elbow are in fact recovering from radial tunnel 7.1. Exercise/physiotherapy
syndrome.15,16
Again, however, the evidence on this is mixed with De Smet casting Various exercise regimes have been proposed for the treatment for
doubt on the importance of PIN compression.17 tennis elbow. Martinez-Silvestini et al. were unable to differentiate
Pfandl et al. has suggested that PIN release should be performed in between the outcome of stretching exercises alone versus stretching and
those tennis elbow patients that have proved resistant to other thera- eccentric or concentric strengthening.23
pies.18,19 Croisier et al. has described the results of an iso-kinetic eccentric

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S. Cutts, et al. Journal of Orthopaedics 17 (2020) 203–207

programme of exercises in comparison to a non strengthening exercise 8.1. Extracorporeal Shock Wave Treatment (ECSWT)
programme and concluded that iso-kinetic exercises were more effec-
tive.24 In a prospective randomised, placebo controlled trial, Petrrone et al.
have shown that Extracorporeal Shock Wave Therapy is a safe and ef-
7.2. Autologous Blood Injection (ABI) fective treatment for lateral epicondylitis.33 Similarly, Radwan et al.
have shown that ECSWT is at least as effective as percutaneous te-
In 2011 Creaney, reported a prospective randomised trial on the use notomy.34 However, as with the other therapies for this condition, other
of growth factor to enhance healing in musculoskeletal injuries, parti- authors have struggled to reproduce these results. Haake et al. reported
cularly in sports medicine.25 Autologous blood injections are thought to that ECSWT was ineffective in tennis elbow, concluding that previous
work by stimulating an inflammatory response which will bring in the studies appeared to have detected a positive effect due to poor design.35
necessary nutrients to promote healing. However, no benefit in the
long-term follow-up has been found and its use is only recommended 8.2. Botox
for those recalcitrant cases, where other modalities of treatment have
failed. Botulinum toxin may induce a period of temporary paralysis that
gives time for the soft tissue pathology to recover. Patients treated with
botox appear to have some resolution of the reduced muscular blood
7.3. Orthotics
supply reported in epicondylitis.36
Again, there is no consensus in the literature as to whether this
The lateral epicondylar brace or elbow clamp is a popular treatment
technique gives any real benefit. Wong et al. concluded that there may
for tennis elbow. In 2004, a Dutch group compared the effectiveness of
be some improvement in elbow pain using botox but that many patients
such a brace to physiotherapy using a combination of the two in a third
experience a period of digital paralysis with weakness in extension.37
group.26 Their results were ambiguous. A brace alone may be useful as
Placzek et al. also described finger weakness following botox in-
an initial therapy. In this study, combination therapy was found to be
jections although his work did conclude that botox was an effective
more effective than bracing alone but only for a short time.
treatment for this condition.38
In contrast, Hayton et al. failed to find a significant difference be-
7.4. Platelet Rich Plasma injections (PRP)
tween treatment and control groups using botox although in this case,
the study size was limited.39
Platelet rich plasma (PRP) is blood plasma with concentrated pla-
telets. The concentrated platelets found in PRP contain growth factors
8.3. Lasers
that are vital to initiate and accelerate tissue repair and regeneration.
These bioactive proteins initiate connective tissue healing and repair,
Sterigioulas has reported good results using lasers as a treatment for
promote development of new blood vessels, and stimulate the healing
tennis elbow.40 Studies of this kind generally use a similar coloured
process.
light source as a sham treatment for the placebo group. In a compara-
The technique requires patient-blood extraction, centrifugation and
tive study in Turkey, Oken et al. found that laser therapy offered no
re-injection of the plasma into the lateral epicondyle. Good outcomes
long-term advantages over a brace or Ultrasound treatment for tennis
have been reported.27 However, studies by Thanasas in 2011 showed no
elbow.41
differences between PRP and whole blood injections.28 Moreover, sig-
nificant differences among available commercial systems and variations
8.4. Acupuncture
in the technique make it difficult to draw clear conclusions about the
use of PRP.
Acupuncture has been used in the treatment of many musculoske-
Current research on PRP and lateral epicondylitis is promising and
letal complaints and tennis elbow is no exception. Trinh et al. has re-
more research is necessary to fully prove PRP's effectiveness.
viewed the literature in this field and concluded that acupuncture is
effective in the short-term relief of the condition.42
7.5. Wrist extension splints
8.5. Surgery
The functional position of the hand is one of slight extension and
pronation, and since active muscle tone is required to achieve this, any Majority of patients with lateral epicondylitis (tennis elbow) re-
kind of activity using the hand may be painful in lateral epicondylitis. spond to conservative measures and do not require surgical interven-
For this reason, some workers have attempted to use wrist extension tion. However, if symptoms were unresponsive after a prolonged period
splints to hold the wrist in extension, thus obviating the need for any of conservative therapy. They should be reevaluated for surgical in-
sort of background muscle tone. Certainly, the use of extension braces terventions. Numerous surgical procedures have been described for the
has been shown to reduce muscle tone on EMG study.29 treatment of lateral epicondylitis. Most involve debridement of the
Altan et al. found marginally better relief of pain in the wrist ex- diseased tissue of the ECRB with decortication of the lateral epicondyle.
tensor in comparison to the use of an elbow brace but concluded that This procedure has can performed through open, percutaneous, and
for many people, wrist extensors are difficult to wear.30 arthroscopic approaches. In addition to debridement, rotation of the
Luginbuhl et al. working in Switzerland found no effect in patients anconeus muscle flap has been reported to improve outcomes.
treated with extensor strengthening exercises and forearm banding and
concluded that patients tend to improve with time irrespective of the 8.6. Open surgical technique
treatment used.31
In a seminal article published in 1979, Nirschl described a technique
8. Ice that included the excision of an identifiable lesion in the origin of ex-
tensor carpi radialis brevis.43 The authors reported a 97.7% improve-
The local application of ice has been a traditional household remedy ment in a series of 88 elbows.
for musculoskeletal aches and pains. The evidence on this is limited but In 2008, Dunn et al. reported 97% improved results from a series of
in a controlled clinical trial, Manias et al. was unable to demonstrate 139 elbows using the Nirschl technique.44
any advantage to the use of ice with exercises over exercise alone.32 Again, Verhaar et al. reported success with lateral extensor release

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S. Cutts, et al. Journal of Orthopaedics 17 (2020) 203–207

in 1993, suggesting that this was the procedure against which other epicondylitis) in a population of workers in an engineering industry. Ergonomics.
treatments should be compared.45 1987;30:537–539.
5. Briggs CA, Elliott BG. Lateral epicondylitis. A review of structures associated with
Wilhelm and other authors have suggested that denervation of the tennis elbow. Anat Clin. 1985;7(3):149–153.
tender area is effective in removing pain.46 It is not inconceivable that 6. Le Huec, Schaeverbeke T, Chauveaux D, Rivel J, Dehias J, Le Rebekker AL.
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8.7. Percutaneous release condylitis of the elbow. Eur Radiol. 2004 Jun;14(6):964–969.
9. Thomas D, Siahamis G, Marion M, Boyle C. Computerised infrared thermography and
The percutaneous release of the common extensor origin was first istopic bone scanning in tennis elbow. Ann rheum dis. 1992;52:103–107.
10. Oskarsson E, Gustafson BE, Pettersson K, Aulin KP. Decreased intramuscular blood
reported by Loose at a meeting in 1962. This procedure involves the
flow in patients with lateral epicondylitis. Scand J Med Sci Sport. 2007
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point of origin at the epicondyle. 11. Lawrence T, Mobbs P, Fortems Y, Stanley JK. Radial tunnel syndrome. A retro-
Nazar M et al. reported good results with this technique despite spective review of 30 decompressions of the radial nerve. J Hand Surg. 1995
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nique.48,49 Jerosch et al. reported good results for this technique in extensor carpi radialis brevis muscle. Arch Orthop Trauma Surg. 2001
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in 3 out of 16 elbows.51 The authors noted that arthroscopy provides 17. De Smet L, Raebroeckx T, Van Ransbeeck H. Radial tunnel release and tennis elbow:
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the option of addressing these other pathologies at the same time al-
18. Pfandl S, Wetzel R, Hackspacher J, Puhl W. Supinator tunnel syndrome – a differ-
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23. Martinez-Silversrini JA, Newcomer KL, Gay RE, Schaefer MP, Kortebein P, Arendt
When we try to interpret research papers on this condition, it is KW. Chronic lateral epicondylitis: comparative effectiveness of a home exercise
program including stretching alone versus stretching supplemented with eccentric or
important to remember just how different the various cohorts are. For
concentric strengthening. J Hand Ther. 2005 Oct-Dec;18(4):411–419 quiz 420.
example, few surgeons would choose surgery as their first line treat- 24. Croisier JL, Foidart-Dessalle M, Tinant F, Crielaard JM, Forthomme B. An isokinetic
ment and most patients entering a study using surgical treatment have eccentric programme for the management of chronic lateral epicondylar tendino-
pathy. Br J Sports Med. 2007 Apr;41(4):269–275 Epub 2007 Jan 15.
already failed to respond to more mundane treatments such as time,
25. Creaney L, Wallace A, Curtis M, Connell D. Growth factor-based therapies provide
steroid injection and physiotherapy. additional benefit beyond physical therapy in resistant elbow tendinopathy: a pro-
The partial relief of chronic mild to moderate pain is a notoriously spective, single-blind, randomised trial of autologous blood injections versus platelet-
difficult field to work in and the apparent confusion in the literature is rich plasma injections. Br J Sports Med. 2011 Sep:966–971.
26. Struijs PAA, Kerkhoffs GMMJ, Assendelft WJJ, Van Dijk C. N Brace versus physical
to be expected. Inconsistencies in study design make precise compar- therapy or a combination of both – a randomized clinical trial the. Am J Sports Med.
ison between different research papers almost impossible. It is clear that 2004;32:462–469.
neither botox nor ECSWT represent definitive cures for this condition. 27. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-
rich plasma. Am J Sports Med. 2006:1774–1778.
Where available, they may provide relief in a proportion of patients that 28. Thanasas C, Papadimitriou G, Charalambidis C, Paraskevopoulos I, Papanikolaou A.
have proven themselves to be resistant to other treatment modalities. Platelet-rich plasma versus autologous whole blood for the treatment of chronic
lateral elbow epicondylitis: a randomized controlled clinical trial. Am J Sports Med.
2011 Oct;39(10):2130–2134. https://doi.org/10.1177/0363546511417113 Epub
Conflicts of interest 2011 Aug 2.
29. Van Elk N, Faesm, Degens H, Koolos JG, De Lint JA. Hopman MT the application of
As a review article with no original data, the authors have no an external wrist extension force reduces electromyographic activity of wrist ex-
tensor muscles during gripping. J Orthop Sport Phys Ther. 2004 May;34(5):228–234.
conflict of interest in writing this article. No author has received fi-
30. Altan L, Kanat E. Conservative treatment of lateral epicondylitis: a comparison of two
nancial reward of any kind for this work. different orthotic devices. Clin Rheumatol. 2008 Aug;27(8):1015–1019 Epub 2008
Mar 26.
31. Luginbuhl R, Brunner F. Schneeberger AG No effect of forearm band and extensor
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