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Effective Treatment for Tennis Elbow: What's the Evidence?
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Posted on: 11/30/1999
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Believe it or not, a wait-and-see approach is still the best way to treat lateral epicondylitis, more commonly known as tennis elbow. What? You say you've had acupuncture and it worked fine? Or maybe you saw a physical therapist and recovered nicely. Some people swear by steroid injections. Others have tried laser therapy.
But what's the evidence that any of these outperform the others? Or that anything works better than letting nature take its course over time? Dr. R.M. Szabo, Professor of Orthopaedics and Plastic Surgery at the University of California, Davis, School of Medicine took the time to research various treatment approaches to lateral epicondylitis and present a summary in this review article.
After looking at all the evidence around each of these modalities, Dr. Szabo's found that the wait-and-see approach still has merit. Tennis elbow will go away on its own with time and activity modification. Most people get annoyed that this condition gets in the way of the things they want to do (golf, fish, play tennis). They would rather have a quick fix (e.g., steroid injection) than wait around.
But the evidence suggests that lateral epicondylitis is common in adults in their 40s and 50s. Steroid injections may actually delay tissue healing, thus prolonging the course of recovery. And until research can show one treatment works better than any others, the cost of intervention may not be justified.
You may ask: what about some of these newer treatments like laser, BOTOX, or shockwave therapy? Aren't they supposed to use today's technology to get the physiology back on track for healing? Yes, but -- results from high-quality studies has been inconsistent. When compared with placebo treatment, some patients get better, others don't.
Other studies have compared shockwave therapy to steroid injections. Shockwave therapy stimulates the release of growth factors to get a healing response at the local tendon. Steroid injections bathe the disrupted tissue with a numbing agent and an antiinflammatory. Steroid treatment is less expensive than shockwave therapy and more successful, but there is still the downside of steroids to consider. Besides the potential for delayed healing with steroids, post-injection pain is reported as worse than preinjection pain for half the patients studied.
Acupuncture for back pain has gotten a lot of press lately as being effective. How well does it work for tennis elbow? After analyzing all the data currently available, it looks like acupuncture provides short-term relief of pain. It certainly works better for pain control than doing nothing. But there isn't enough proof that the results last more than 24 hours. So making it a top choice for treatment isn't advised.
Similar results were found using botulinum toxin type A (BOTOX). This agent temporarily paralyzes the troublesome tendon (common extensor tendon). A single injection gives short-term pain relief but doesn't change the long-term outcomes. Pain, weakness, and reduced activity are still reported as equal in results when compared to other treatments such as steroid injections or surgery.
So, where does that leave us? Back where we started: letting the condition run its full course until the body heals itself. How long does that take? Well, scientists understanding that this is the situation is fairly new. Studies looking at the natural history of lateral epicondylitis suggest perhaps as much as a full year may be required for complete resolution of the problem.
Physician may be tempted to give in to their patients’ demands for injections, but the evidence just isn't there to support this idea. Patient education and support may not be a popular approach, but until clear or consistent evidence to suggest otherwise is available, that's the current guideline for best practice.
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References:
Robert M. Szabo, MD. Steroid Injection for Lateral Epicondylitis. In The Journal of Hand Surgery. February 2009. Vol. 34A. No. 2. Pp. 326-330.
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