Did you know that lateral elbow tendinopathy,
well, the condition most of us call tennis elbow,
affects maybe as many as one in 30 people every
single year? That's right. It translates to roughly
four to seven cases for every thousand adults.
And it's not just a minor thing, is it? It's
actually the most common reason people have that
persistent pain on the outside of their elbow.
Makes up about two thirds of those cases, yes.
So if you've ever felt that frustrating ache
yourself, or maybe know someone who has, Definitely,
definitely not alone. Welcome back to The Deep
Dive. This is the show where we cut through the
noise, take your sources, articles, research,
maybe even your own notes, and really pull out
the key insights. Think of it as a shortcut to
getting properly informed, hopefully with a few
surprising bits along the way. Now, this specific
deep dive was actually requested by one of you,
looking for some clarity on the latest evidence
-based ways to manage this really common, but
often quite misunderstood, condition and helping
us navigate the recent guidelines and research
today is a leading figure in orthopedics, someone
deeply involved in the very literature we're
about to explore. He's been central in reviewing
the evidence and contributing to the BES guidelines
on this topic, which are key sources for our
chat. It's a real pleasure to have you here.
Thank you. Happy to be here and ready to jump
in. Excellent. OK, let's set the scene then with
a quick rapid fire round. First one, what exactly
is lateral elbow tendinopathy and why do we all
call it tennis elbow? Seems confusing. Well,
at its heart, it's about altered tissue homeostasis.
Basically, something's not quite right in the
tendons that attach to the bone on the outside
of your elbow, the lateral epicondyle. This causes
pain. which often radiates down the forearm,
and it frequently affects your grip or your hand
dexterity. And the tennis elbow name. Ah, yes.
It comes from the fact that, well, it can affect
tennis players, but honestly, overwhelmingly,
it's linked to repetitive tasks or loading in
daily life or work, much less often from sport.
And the diagnosis itself is clinical. It's based
on your history and a physical examination. OK,
second rapid fire. We often hear this condition
can... just get better on its own. Is there truth
in that? And if so, how often, how quickly? Yes,
that's a really crucial point from the evidence.
A major finding from meta -analyses is that lateral
elbow tendinopathy is largely self -limiting.
Studies tracking patients who had minimal or
no active treatment show really high rates of
spontaneous improvement. How high? One key analysis
found around 89 % global improvement within a
year. 89 %? That's significant. It is. And what's
perhaps more surprising is the speed of improvement.
The half -life for significant global improvement
is estimated around 2 .5 to 3 months. And interestingly,
this doesn't seem to be related to how long you've
actually had the symptoms when you first seek
help. That's genuinely quite reassuring for people
going through it. Okay, last rapid fire. Given
how common it is and that it often gets better
anyway, why is there still so much kind of conflicting
advice and debate about the best way to treat
it? That's a great question and really sets up
our deep dive nicely. The debate mostly comes
from the varying quality and consistency of evidence
for different treatments over the years. Past
guidelines have sometimes offered different advice.
The goal of recent efforts, like the BES guidelines
we're using, is to apply really rigorous methods,
things like the GRADE system, which systematically
rates the certainty of evidence to give clearer
evidence -based recommendations and, importantly,
to highlight where the science is strong and,
frankly, where it's still a bit uncertain. All
right, bringing some clarity. Okay, let's unpack
this then. Starting with the non -surgical options,
which is where most people begin, isn't it? What's
the recommended initial approach, say, in primary
care? Yes, absolutely. Initial management really
emphasizes shared decision -making. This echoes
guidance from bodies like the GMC. It means properly
listening to the patient, giving them clear,
understandable information about their condition,
what to expect, respecting their choices, and
supporting self -care. And the diagnosis part.
It's clinical, as I mentioned. Relying on the
patient's history key things like the gradual
onset of pain, exactly where it is if it radiates
down the forearm, and what makes it worse. Often
actions like grasping or twisting. Then the physical
exam looks for tenderness over that bony bit
on the outside, the lateral epicondyle, and pain
when they extend their wrist or fingers against
resistance. There are also specific tests we
use, like Cousins, Mills, or Modsley's tests,
which can help confirm things. So no need for
pricey scans straight off the bat? Exactly. Plain
x -rays aren't usually needed for diagnosis,
and specialist imaging like MRI or CT scans are
generally not required in primary care, only
really if there's genuine diagnostic uncertainty
or maybe a suspicion of something else going
on. And the initial treatment advice? It focuses
on patient education, explaining the self -limiting
nature, advising on activity modification to
reduce the irritating lows. you know, giving
them a break, and providing exercises, often
focusing on stretching and progressive strengthening.
Eccentric loading, where the muscle lengthens
under tension, is commonly included. Plus, simple
analgesics or NSAIDs are part of that initial
plan too. Okay, and what about those NSAIDs,
the rubs and the pills? What's the evidence say?
Well, systematic reviews suggest NSAIDs, whether
topical creams or oral tablets, can offer short
-term pain relief, usually effective for up to
about four weeks. But, The evidence quality for
both is actually low to very low. Topical endocides
are generally preferred because they carry less
risk of systemic side effects, especially stomach
issues, compared to the oral ones. The key point
from the evidence, though, is that their benefit
seems limited in time and is based on less robust
studies. Right. What about things like orthotics?
Those forearm bands or wrist braces you see people
wearing, do they actually help? The BESCA guidelines
give what's called a conditional recommendation
here. They may be offered, but importantly, patients
need to be aware that the evidence suggests they
may not actually provide a benefit. While some
sort of low quality evidence hints at an immediate
effect on reducing pain during gripping, there's
really no reliable evidence showing sustained
benefit over time compared to a placebo or a
sham device. Okay, let's move to physiotherapy
then. It feels like a very common and sort of
natural intervention. What's the recommendation
and the evidence look like there? Physiotherapy
gets a strong recommendation. Patients should
be offered it. Evidence from systematic reviews
shows strong evidence of benefit, but mainly
in the short term. Short term meaning? Usually
the first few weeks, maybe up to three months.
However, when you look longer term, medium and
long term, there's generally no significant difference
in outcomes compared to just, well, waiting for
spontaneous recovery or receiving no specific
intervention. Now, there is some lower quality
evidence hinting at a possible long -term benefit
from specific types of physiotherapy, but the
certainty around that is currently low. That's
a really important nuance, isn't it? Helps early
on, but maybe less clear difference compared
to just getting better naturally in the longer
run. What about for really chronic symptoms?
Say someone's had pain for over a year or after
surgery. Yeah, for chronic symptoms beyond 12
months, dedicated high -quality studies are a
bit thin on the ground. However, based on that
short -term evidence at earlier stages, the consensus
is that physiotherapy may still be offered, especially
if it hasn't actually been tried properly before.
And for postoperative physiotherapy, specific
evidence is also lacking, but clinical consensus
supports that it may be offered to help guide
rehabilitation and recovery. Okay, now here's
where I think it gets really interesting and
maybe quite counterintuitive for many people.
For ages, corticosteroid injections felt like
the standard go -to treatment. What does the
latest evidence actually tell us about using
them? This is probably one of the most critical
takeaways, and it's backed by multiple meta -analyses
and high -quality trials. The recommendation
now is that corticosteroid injections should
not be used for lateral elbow tendinopathy. Should
not be used. That's quite definitive. It is.
The evidence, which ranges from moderate to very
low quality, depending on the specific study,
consistently shows only a minor temporary improvement
in pain, usually just in the first month or so.
But, and this is the striking part, by six months
the outcomes are often worse than if the patient
had received a placebo injection or even no treatment
at all. Worse? How so? The evidence suggests
they might actually hinder the natural healing
process and potentially increase the risk of
the pain coming back recurrence. It's this long
-term negative effect that underpins the strong
recommendation against using them. Wow, that
reversal effect is huge. Clinicians and patients
really need to know that. Okay, so if steroids
are out, what about the range of other injections
and therapies that seem quite popular now? Things
like PRP, dry needling, shockwave therapy. Yes,
the evidence picture for many of these is, well,
less clear or often negative when compared properly
to placebo or sham treatments. For platelet -rich
plasma, PRP, the BESS recommendation is conditional
neutral. which basically means patients should
understand there may be no benefit compared to
placebo. The current evidence shows no significant
effect on pain or function and the quality of
that evidence is rated as very low. Autologous
blood injection using the patient's own blood
gets a conditional recommendation that it should
not be used. Moderate to very low quality evidence
suggests no real benefit over simple saline injections.
What about dry needling? That seems quite common
too. Dry needling also has a conditional neutral
recommendation. Again, patients should know there
is no evidence of benefit compared to placebo.
A key issue here is the lack of well -designed
studies comparing it to a proper placebo or sham
treatment. While some studies compare it to other
things, steroids, ibuprofen, even surgery or
PRP, the results are very mixed, making it impossible
to draw firm conclusions about its effectiveness
on its own merit. And extracorporeal shockwave
therapy, ECSWT. That receives a strong recommendation.
It should not be used. Moderate to very low quality
evidence shows no clinically significant improvement
in patient reported outcomes, pain, or grip strength
when compared to placebo or sham treatment in
the medium term, say around three to six months.
OK, so not much support there. And what about
the really novel therapies, things like ultrasonic
procedures, dextrous injections, arterial embolization?
For many of those newer or more experimental
therapies, the recommendation is also conditional
neutral. Patients should be aware there's currently
no evidence of benefit compared to placebo. The
evidence base is typically very low quality,
often just case series or small comparison studies.
The consensus really is that these should only
be considered within the context of research
trials at this point. That's a really clear rundown
of the non -surgical side, thanks, really highlights
where the evidence stands or doesn't. Let's switch
gears now and talk about surgery. Given everything
we've just discussed, why is surgery even considered
and what does the evidence actually show about
its role? It feels a bit controversial now. It
is quite controversial in the evidence -based
world. Surgery is typically reserved for patients
whose symptoms just haven't resolved after a
decent trial of non -surgical treatment, usually
defined as maybe three to six months in the BSS
guidelines. The Muir Scoping Review which looks
specifically at the surgical literature, found
the median time people had tried non -surgical
options before having surgery in the studies
was about six months. But you're right, its role
is debated, as highlighted by both the BSS guidelines
and that mirror review. OK, so what is the specific
recommendation in the BSS guidelines about surgery?
This feels like a key point. It is perhaps the
most surprising and important point regarding
surgery. The recommendation states, Patients
being offered surgery should be made aware that
there is no evidence of benefit compared to a
placebo. Hold on. No evidence of benefit compared
to a placebo. That sounds... Well, how can that
be? If surgery is being offered, surely there
must be some evidence it helps. What did that
Muir review actually find when it looked at all
the surgical studies? It's fascinating when you
dig into why that recommendation exists. The
Muir review analyzed 35 studies on surgical management.
covering over 1 ,500 patients. What they found
was that the literature is dominated by single
-center studies, often with quite small numbers
of patients in each. And there's a real lack
of high -quality multi -center trials. OK, so
the quality is maybe not ideal. Precisely. And
there's huge heterogeneity, meaning studies use
different methods, different patient groups,
measured outcomes differently. This makes it
incredibly difficult to combine the data and
draw really strong, generalizable conclusions.
Now most individual studies did report improvements
in pain and function after surgery. That's true.
But the critical issue is that these studies
very rarely compared surgery directly to a proper
placebo or sham procedure. or even to a well
-structured conservative management program.
The one trial they identified that did compare
open surgery to sham surgery actually found no
improvement in function in the group that had
the real surgery. Right. So many individual reports
say patients got better after we operated, but
the gold standard comparison surgery versus fake
surgery didn't show a benefit for the real thing.
That's the crux of it. It really raises the question,
are the improvements seen in many studies due
to the surgery itself? Or is it the post -operative
rehab, the placebo effect of just having a procedure,
or simply the natural history of the condition
resolving over time, which we know happens often
anyway? Because of that lack of high -quality
comparative trials, especially against placebo,
the BSAS committee couldn't find strong evidence
to recommend surgery over doing nothing or having
a sham procedure. Does the evidence tell us anything
about different surgical techniques, like open
surgery versus keyhole arthroscopic surgery?
The MU Review didn't find consistent differences
between open and arthroscopic techniques when
looking across the literature narratively, although
individual studies reported improvements with
both methods. So the BSS guidelines basically
say that if a patient does choose surgery, they
may have either technique, but they note the
evidence comparing them is limited by small study
sizes and a lack of long -term follow -up measures.
Percutaneous techniques were also looked at,
but the data there is even more limited. Okay.
And finally on surgery, is recurrence a risk?
Can the pain come back and are there things that
might make that more likely? Yes, recurrence
is definitely possible. A study mentioned in
the BS's guidelines reported a two -year recurrence
rate of around 8 .5%. And risk factors. Several
potential risk factors have been identified.
Things like older age, perhaps inadequate or
short recovery periods after treatment or surgery,
being involved in manual labor, having had previous
surgery on the same elbow. Also, having symptoms
for a very long time, say over 12 months, experiencing
very acute pain right at the start, poor adherence
to the recommended management plan, and notably
having received corticosteroid injections. There
are those steroid injections, again, linked to
potentially worse outcomes or recurrence. That's
really striking. It reinforces the earlier point,
yes. OK, wow. We have covered a huge amount of
ground there looking at the evidence for both
nonsurgical and surgical approaches. Let's try
and crystallize some of this. Time for a quick
lightning round for some sharp, concise answers.
Ready? Ready. What's the single most reliable
way to diagnose tennis elbow? Clinical history
and a thorough physical examination. Imaging
is generally not needed up front. Based purely
on the evidence, if I start getting tennis elbow
pain, what's the very first thing I should probably
try myself? Activity modification try to redo
the offending loads. Then, exercises, including
stretching and progressive strengthening like
eccentric loading, and maybe topical NFIDs for
short -term pain relief. Okay. What treatment
may be commonly used in the past does the evidence
now strongly suggest people should avoid because
it doesn't help long -term and might actually
worsen things? or increase recurrence risk. Corticosteroid
injections, definitely. Got it. What's the biggest
remaining question mark or area of uncertainty
in managing tennis elbow, according to the recent
literature we've discussed? I'd say it's the
exact role and the true benefit of surgery. especially
when compared rigorously against non -surgical
management or simply allowing for that natural,
spontaneous recovery. We really need more high
-quality placebo -controlled trials. Right. That
comparison is key. And finally, if someone's
tracking their own progress or looking at research,
what's a key outcome measure that patients and
clinicians should probably be aware of? The PRTE.
That's the Patient -Reported Tennis Elbow Evaluation
Questionnaire. It's recommended as the core outcome
measure for assessing disability in this condition.
PRT. Good to know. Excellent. Okay, to wrap everything
up from this really insightful deep dive into
your sources, let's quickly summarize, say, five
key actionable takeaways for our listeners. Absolutely.
Let's do that. Okay, first takeaway. Remember,
diagnosis is primarily clinical. It's about the
conversation with your doctor and the examination.
Imaging usually isn't needed unless the diagnosis
is really unclear. Second, this condition very
often improves on its own over time. Physiotherapy
can be very helpful for short -term relief and
function, but the evidence for its long -term
benefit compared to just natural recovery is
less certain. Third, and this feels like a headline
finding, the evidence strongly advises against
using corticosteroid injections. Any short -term
relief might be outweighed by worse outcomes
later on and potentially a higher risk of the
pain coming back. Spot on. Fourth, from any other
treatments that you might hear about things like
PRP, dry needling, shockwave therapy, the current
evidence, when compared properly to placebo,
is either weak, of very low quality, or simply
shows no significant benefit. Be aware of that
limited evidence. And fifth, the role of surgery
for tennis elbow remains quite debated. High
-level evidence, especially from reviews including
sham surgery trials, doesn't clearly show a benefit
compared to placebo. So given this uncertainty,
really understanding the evidence and engaging
in shared decision -making with your clinician
is crucial if surgery is ever on the table. Agreed
entirely. Making informed choices based on the
best available evidence is absolutely key to
managing this condition effectively. So what's
the final thought for you, the listener, from
all this? I think it's that understanding the
natural history of tennis -elda, the fact it
often gets better by itself, alongside the Frankly,
surprisingly weak or even negative evidence for
many common interventions really empowers you.
It means you can have much more informed conversations
about your treatment options. Knowing what the
science actually says is the vital first step
to choosing the path that's truly right for you.
If you found this deep dive helpful, please do
take a moment to rate and share the show with
your network. Thank you so much for sharing your
expertise and guiding us so clearly through these
important sources today. It's been my pleasure.
Thank you for having me. And thank you, our listener,
for joining us on the deep dive. We hope this
has shed some useful light on what can be an
incredibly common and sometimes very frustrating
condition. Until next time.