Performed by – Ankit Desai, Gareth Hill, Philip Rosell

This is a painful inflammatory condition which is noted for pain and loss of power at the elbow. The pain is felt over the origin of the muscles which extend the wrist and forearm. Usually it is not associated with any alteration in sensation but has pain which gets worse with resistance when bending the wrist back against pressure or resistance. Despite its name it is not directly associated with tennis players but can occur after an injury or a change in activity.

The condition is usually associated with inflammation or damage and partial tearing in the tendons of the forearm muscles where they attach to the bone at the elbow.

Treatment
The initial treatment should be the cessation of the painful activity if possible and rest for up to 6 weeks. This should be supplemented with a structured exercises programme to help with your initial symptoms but also help decrease the risk of re-occurrence.

Splintage
There are a number of different patterns of splints available on the market which have a varied effectiveness. In general, the clamp type of splint can be more effective as it offloads the injured tendons to allow them to recover. The splint will however need regular adjustment during the day to maintain effectiveness and may not be suitable in manual workers due to constant movement of the arm. The splint should be worn to prevent pain and therefore should be worn at all times when performing activities that are known to worsen pain e.g. racquet sports, repetitive movements, heaving lifting.

Biological stimulation of healing
The natural healing processes can be stimulated using some simple techniques. These are needle barbotage (also called dry needling), shockwave treatment or injections of platelet rich plasma (PRP).

Needle barbotage is usually carried out under ultrasound guidance and is where the tendon origin is perforated multiple times with a needle to encourage bleeding. This in turn will bring the healing compounds and growth factors from your blood supply. It can be uncomfortable, and you will need to avoid anti-inflammatory drugs and ice treatment for 6 weeks. It has good effects in about 50% of patients and is simple to perform with a low risk profile.

Shockwave treatment is a physical treatment where the tender/damaged area of the tendon is treated using a small pneumatic shock wave probe which generates a shock wave causing a local reaction. Treatment typically involves 2500 impulses over 10-15 minutes 3 times with a week between treatments. It stimulates your natural inflammatory response and increases local blood flow assisting healing. Shockwave therapy is uncomfortable and is not always tolerated but is non-invasive with few side effects and is successful 80% of the time according to the published evidence.

Platelet rich plasma is a treatment where the patient’s own blood is taken and concentrated in a centrifuge which can increase the concentration of growth and healing promoting compounds by 10 or more times. This is then injected into the area of damaged tendon to directly stimulate the healing response. It is a successful treatment with healing rates of over 90% published depending on the type of preparation used. After this treatment it can sometimes be quite painful, but it is important not to use anti-inflammatory drugs for 6 weeks (but paracetamol and codeine can be used).

Steroid Injection
An injection of steroids (e.g. Cortisone) into the affected area can reduce symptoms or even eliminate them altogether. However often the pain returns after a few months if activity modification and structured exercise programme has not taken place. Current evidence would favour avoidance of steroid injections however, in certain scenarios it may be utilised as a one off once the benefits and risks are discussed.

Surgery
In those conditions which do not settle with all other treatments we would consider surgery. The operation can be done under a general or local anaesthetic (depending on suitability) and is a day case procedure. It involves identifying the damaged portion of the tendon and excising it along with a release of the tendon around the damage to reduce the tension on the remaining tendon structure.

Results of treatment
Tennis elbow can be a difficult condition to treat with some cases being resistant to most forms of treatment. In these cases not even surgery has a guarantee of success. In general terms about 80% of people will get a good outcome from surgery for tennis elbow with half of the remainder getting some improvement but not a complete resolution of their symptoms.