Lateral Epicondylitis or 'Tennis Elbow'
In this eZine I am looking at some current issues relating to treatment options for lateral elbow pain. The first paper compares PRP, steroid and saline injections. Then I look at the more common options of steroid and or physiotherapy management and finally in the needling area a SR examining acupuncture solo for acute pain. Rounding out the discussion is a look at the evidence of a support, either brace or sleeve.
Treatment of Lateral Epicondylitis With Platelet-Rich Plasma, Glucocorticoid, or Saline: A Randomized, Double-Blind, Placebo-Controlled Trial. Reference Link
Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T.
BACKGROUND:Lateral epicondylitis (LE) is a common musculoskeletal disorder for which an effective treatment strategy remains unknown.
PURPOSE & DESIGN:To examine whether a single injection of platelet-rich plasma (PRP) is more effective than placebo (saline) or glucocorticoid in reducing pain in adults with LE after 3 months. Randomized controlled trial; Level of evidence, 1.
METHODS:A total of 60 patients with chronic LE were randomized (1:1:1) to receive either a blinded injection of PRP, saline, or glucocorticoid. The primary end point was a change in pain using the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire at 3 months. Secondary outcomes were ultrasonographic changes in tendon thickness and color Doppler activity.
RESULTS:Pain reduction at 3 months (primary end point) was observed in all 3 groups, with no statistically significant difference between the groups; mean differences were the following: glucocorticoid versus saline: -3.8 (95% CI, -9.9 to 2.4); PRP versus saline: -2.7 (95% CI, -8.8 to 3.5); and glucocorticoid versus PRP: -1.1 (95% CI, -7.2 to 5.0). At 1 month, however, glucocorticoid reduced pain more effectively than did both saline and PRP; mean differences were the following: glucocorticoid versus saline: -8.1 (95% CI, -14.3 to -1.9); and glucocorticoid versus PRP: -9.3 (95% CI, -15.4 to -3.2). Among the secondary outcomes, at 3 months, glucocorticoid was more effective than PRP and saline in reducing color Doppler activity and tendon thickness. For color Doppler activity, mean differences were the following: glucocorticoid versus PRP: -2.6 (95% CI, -3.1 to -2.2); and glucocorticoid versus saline: -2.0 (95% CI, -2.5 to -1.6). For tendon thickness, mean differences were the following: glucocorticoid versus PRP: -0.5 (95% CI, -0.8 to -0.2); and glucocorticoid versus saline: -0.8 (95% CI, -1.2 to -0.5).
CONCLUSION: Neither injection of PRP nor glucocorticoid was superior to saline with regard to pain reduction in LE at the primary end point at 3 months. However, injection of glucocorticoid had a short-term pain-reducing effect at 1 month in contrast to the other therapies. Injection of glucocorticoid in LE reduces both color Doppler activity and tendon thickness compared with PRP and saline.
Steroid & Physiotherapy
As a common finding with other papers, the pain and functional benefit of steroid is greatest in the short term (1-3 months), however as this paper points out there were no differences in pain reduction and outcome regardless of what substance was injected. Shame they didn't have a real control, like No injected material. However, other papers have indicated that the result would have been similar; it seems it is not the substance injected, rather the tissue trauma provoking a healing response that is important. In this regard I will needle all muscle trigger points in local and distal related muscles (e.g. supraspinatus and infraspinatus) to increase blood flow and remove any possible local nociceptive sources.
Another recent reference paper looking at a 12 month followup of steroid +/- physio and placebo injection +/- physio, showed that the steroid group was worse off at 12 months and the best group was the placebo injection plus physio at 12 months. (The placebo was saline).
A systematic review of acupuncture and lateral elbow pain was conducted by Trinh KV, Phillips SD, Ho E, Damsma K. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology 2004;43:1085-90. They found strong evidence (even though a degree heterogenicity in papers) for acute pain relief using both classical and anatomical acupuncture.
I generally recommend to my clients, that if they need to gain sufficient pain relief quickly for work, then to seek advice and consider an injection from their GP. However, this is only a short term at best solution and long term will set them back (as per research findings). They then need to start a 3-4 months progressive strength and flexibility program targeting their assessed limitations. If they prefer to go 'natural' then I provide acupuncture/dry needling for pain relief. There are some practitioners that also periosteal peek. Personally I am not a fan of this, as it is so painful for the client, but the aim is to provoke a new inflammatory cycle and restart the cellular healing. Again for a long term solution, the new collagen needs to be serially loaded over several months.
Support and Bracing
There is also good evidence, that for mild to moderate loads an elbow brace or sleeve is effective. For this reason we always recommend in the short term a form of support. The latest research indicates either a sleeve or elbow brace are equally effective. Some references to delve into are;
- Orchard J, Kountouris A. The management of tennis elbow. BMJ 2011;342:d2687
- Garg R, Adamson GJ, Dawson PA, Shankwiler JA, Pink MM. A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis. J Shoulder Elbow Surg 2010;19:508-12
- Altan L, Kanat E. Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices. Clin Rheumatol 2008;27:1015-9
- Jafarian FS, Demneh ES, Tyson SF. The immediate effect of orthotic management on grip strength of patients with lateral epicondylosis. J Orthop Sports Phys Ther 2009;39:484-9
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All the best,
Doug Cary FACP
Specialist Musculoskeletal Physiotherapist
email doug@aapeducation.com.au
ph/fx 08 90715055
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