It’s often referred to as tennis elbow but despite its name, the most common chronic musculoskeletal condition to impact the elbow mainly affects people working in manual jobs who perform repetitive hand tasks, such as meat processing and factory workers.
Tennis elbow, also known as lateral epicondylalgia, is not only a prevalent condition, it can also be an incredibly painful, debilitating and complex injury to treat.
Dr Leanne Bisset (PhD), a musculoskeletal physiotherapist and senior lecturer at Griffith University’s Menzies Health Institute Queensland, says tennis elbow has also been the focus of hundreds of research trials and published papers, making it difficult for time-poor practitioners to keep up to date with the latest and best evidence-based practice.
Dr Bisset, a clinician and researcher in chronic upper limb musculoskeletal conditions, recently joined Physiotherapy Professor Bill Vicenzino, of the University of Queensland and the NHMRC Centre for Research Excellence in Translation of Research into Improved Outcomes in Musculoskeletal Pain and Health, to review the research and provide a summary for physiotherapists on tennis elbow.
Their paper, titled ‘Physiotherapy management of lateral epicondylalgia’, published in the Journal of Physiotherapy last year, has become a much-read snapshot examining not only the burden of tennis elbow but also its diagnosis, assessment and treatment.
Most importantly, it covers the management of tennis elbow through a range of physiotherapy interventions, such as exercise, manual therapy and manipulation, orthotics and taping, acupuncture and dry needling, laser, ultrasound and phonophoresis, shock wave therapy and multimodal programs.
“What’s unique about this paper is that it brings together the whole picture of this condition and it also gives clinicians an evidence-informed clinical reasoning process or guide. We discuss the clinical reasoning behind the evidence, to try and help clinicians interpret and apply the evidence to the individual patient in their clinical practice,” Dr Bisset says.
The review shows about 40 per cent of people will experience tennis elbow at some stage in their life, with it mostly affecting men and women aged between 35 and 54.
The condition can also have a devastating impact on people’s ability to maintain their work, home and social life, Dr Bisset says.
“A lot of the time my patients will report that they can’t even pick up a cup of coffee because their elbow pain is so severe – it can have a significant negative impact, especially when it’s really severe.”
Tennis elbow is relatively easy to diagnose using clinical assessment, with the condition typically presenting as pain on the outside (lateral humeral epicondyle) of the elbow. Patients often report that it hurts to grip or contract those muscles attached to the outside elbow area.
Dr Bisset says there is a broad spectrum of severity with tennis elbow, with some patients presenting with mild, localised symptoms while others experience more widespread or severe pain.
“Because of the differences in the way that patients present with tennis elbow, we can’t approach all those patients using the same treatment,” she says.
“There is also a group of about 20 per cent of people with tennis elbow who don’t seem to recover, regardless of the treatment they receive. They seem to be a more severe group who are at risk of more long-term pain and disability.”
Research suggests that the persistent pain may be the result of changes to the central nervous system.
“Involvement of the central nervous system is often associated with more widespread and severe symptoms, and the standard treatments that we use may not be as effective in those patients,” Dr Bisset says.
“So the challenge clinicians face is being able to not just diagnose the condition but also be able to understand where they fit into this spectrum - from mild to severe, and then be able to target the treatments that are going to be most appropriate and most effective to that individual patient.”
In evaluating the management of tennis elbow, Dr Bisset and Professor Vicenzino found exercise may be more effective at reducing pain and improving function than other interventions.
They found some evidence to support other modalities, such as acupuncture and laser therapy, for relieving pain in the short-term, and while braces may help reduce the patient’s pain, there’s no evidence that their use results in improved function.
“Overall, yes a patient might use a brace and it’s okay for patients to trial them,” Dr Bisset says.
“If they work - great. If they don’t get pain relief while they’re wearing the brace, then there is probably no need to persist with it.”
Dr Bisset says the best evidence lies in physiotherapists using a multimodal program of mobilisation-with-movement manual therapy coupled with exercise.
“That combination seems to work very well, it’s better than doing nothing in the short-term and it’s superior to corticosteroid injections in the long-term.
“Certainly work conducted with Dr Brooke Coombes (Research Fellow at UQ) has shown that corticosteroid injections should not be used for this condition because it seems to have negative long-term consequences that far outweigh any short-term transient improvements, even if combined with the efficacious physiotherapy program.”
The best place for physiotherapists to start is by utilising the Patient Rated Tennis Elbow Evaluation questionnaire to help identify patients with severe pain and disability.
“If the patient presents with high levels of pain and disability, if they’re manual workers and if they’ve already had their pain for a longer period of time, for example greater than three months, then the physiotherapist should counsel those patients in terms of modifying their workload and minimising aggravating activities,” she says.
“The multimodal program with the manual therapy and exercise combination is probably the best treatment choice to be used in the first instance.”
Dr Bisset advises physiotherapists who have patients with pain spreading down their forearm, into their wrist or up their arm and into their shoulder or neck, to consider using diagnostic imaging (such as musculoskeletal ultrasound at the lateral elbow tendons) to ensure a correct diagnosis of tennis elbow while considering further pain management strategies.
For patients with mild pain, experienced for less than three months, she suggests educating the patient on managing their load while avoiding aggravating activities, perhaps while also introducing an exercise program.
“They should still be monitored so that if their pain is not improving over the next eight to 12 weeks then they need to start thinking about more treatment and particularly this multimodal physiotherapy program.”
Despite the large body of research, the authors concede a gap exists in the evidence and more research is needed to determine which exercise, and what dose, is best for treating patients with tennis elbow.
A multidisciplinary approach is the best way to manage patients with severe tennis elbow, Dr Bisset says.
“I think we need to be able to identify patients with more severe symptoms early and try and manage them more effectively.
""Otherwise they end up with pain for 18 months or longer and, in some cases, four to five years down the track they are still suffering pain. I think we can do better.”