WEBVTT 00:00:00.000 --> 00:00:02.720 Did you know that lateral elbow tendinopathy, 00:00:02.919 --> 00:00:05.259 well, the condition most of us call tennis elbow, 00:00:05.940 --> 00:00:08.900 affects maybe as many as one in 30 people every 00:00:08.900 --> 00:00:11.699 single year? That's right. It translates to roughly 00:00:11.699 --> 00:00:14.720 four to seven cases for every thousand adults. 00:00:14.980 --> 00:00:17.120 And it's not just a minor thing, is it? It's 00:00:17.120 --> 00:00:19.420 actually the most common reason people have that 00:00:19.420 --> 00:00:21.199 persistent pain on the outside of their elbow. 00:00:21.399 --> 00:00:23.160 Makes up about two thirds of those cases, yes. 00:00:23.379 --> 00:00:25.320 So if you've ever felt that frustrating ache 00:00:25.320 --> 00:00:28.839 yourself, or maybe know someone who has, Definitely, 00:00:29.039 --> 00:00:31.960 definitely not alone. Welcome back to The Deep 00:00:31.960 --> 00:00:34.039 Dive. This is the show where we cut through the 00:00:34.039 --> 00:00:36.579 noise, take your sources, articles, research, 00:00:36.880 --> 00:00:39.420 maybe even your own notes, and really pull out 00:00:39.420 --> 00:00:42.200 the key insights. Think of it as a shortcut to 00:00:42.200 --> 00:00:44.159 getting properly informed, hopefully with a few 00:00:44.159 --> 00:00:47.159 surprising bits along the way. Now, this specific 00:00:47.159 --> 00:00:49.539 deep dive was actually requested by one of you, 00:00:49.780 --> 00:00:52.520 looking for some clarity on the latest evidence 00:00:52.520 --> 00:00:54.880 -based ways to manage this really common, but 00:00:54.880 --> 00:00:57.880 often quite misunderstood, condition and helping 00:00:57.880 --> 00:00:59.979 us navigate the recent guidelines and research 00:00:59.979 --> 00:01:02.979 today is a leading figure in orthopedics, someone 00:01:02.979 --> 00:01:05.040 deeply involved in the very literature we're 00:01:05.040 --> 00:01:07.540 about to explore. He's been central in reviewing 00:01:07.540 --> 00:01:10.359 the evidence and contributing to the BES guidelines 00:01:10.359 --> 00:01:13.239 on this topic, which are key sources for our 00:01:13.239 --> 00:01:15.079 chat. It's a real pleasure to have you here. 00:01:15.299 --> 00:01:16.920 Thank you. Happy to be here and ready to jump 00:01:16.920 --> 00:01:19.459 in. Excellent. OK, let's set the scene then with 00:01:19.459 --> 00:01:22.120 a quick rapid fire round. First one, what exactly 00:01:22.120 --> 00:01:24.620 is lateral elbow tendinopathy and why do we all 00:01:24.620 --> 00:01:27.340 call it tennis elbow? Seems confusing. Well, 00:01:27.439 --> 00:01:30.920 at its heart, it's about altered tissue homeostasis. 00:01:31.400 --> 00:01:34.079 Basically, something's not quite right in the 00:01:34.079 --> 00:01:36.019 tendons that attach to the bone on the outside 00:01:36.019 --> 00:01:39.459 of your elbow, the lateral epicondyle. This causes 00:01:39.459 --> 00:01:42.040 pain. which often radiates down the forearm, 00:01:42.420 --> 00:01:44.900 and it frequently affects your grip or your hand 00:01:44.900 --> 00:01:47.579 dexterity. And the tennis elbow name. Ah, yes. 00:01:47.760 --> 00:01:49.640 It comes from the fact that, well, it can affect 00:01:49.640 --> 00:01:52.519 tennis players, but honestly, overwhelmingly, 00:01:53.079 --> 00:01:55.379 it's linked to repetitive tasks or loading in 00:01:55.379 --> 00:01:58.299 daily life or work, much less often from sport. 00:01:58.400 --> 00:02:01.060 And the diagnosis itself is clinical. It's based 00:02:01.060 --> 00:02:03.560 on your history and a physical examination. OK, 00:02:03.760 --> 00:02:06.299 second rapid fire. We often hear this condition 00:02:06.299 --> 00:02:08.659 can... just get better on its own. Is there truth 00:02:08.659 --> 00:02:10.900 in that? And if so, how often, how quickly? Yes, 00:02:10.900 --> 00:02:12.860 that's a really crucial point from the evidence. 00:02:13.240 --> 00:02:16.099 A major finding from meta -analyses is that lateral 00:02:16.099 --> 00:02:18.719 elbow tendinopathy is largely self -limiting. 00:02:19.259 --> 00:02:21.439 Studies tracking patients who had minimal or 00:02:21.439 --> 00:02:24.219 no active treatment show really high rates of 00:02:24.219 --> 00:02:26.879 spontaneous improvement. How high? One key analysis 00:02:26.879 --> 00:02:29.699 found around 89 % global improvement within a 00:02:29.699 --> 00:02:33.479 year. 89 %? That's significant. It is. And what's 00:02:33.479 --> 00:02:36.020 perhaps more surprising is the speed of improvement. 00:02:36.300 --> 00:02:39.819 The half -life for significant global improvement 00:02:39.819 --> 00:02:43.879 is estimated around 2 .5 to 3 months. And interestingly, 00:02:43.960 --> 00:02:45.780 this doesn't seem to be related to how long you've 00:02:45.780 --> 00:02:47.520 actually had the symptoms when you first seek 00:02:47.520 --> 00:02:49.719 help. That's genuinely quite reassuring for people 00:02:49.719 --> 00:02:53.060 going through it. Okay, last rapid fire. Given 00:02:53.060 --> 00:02:55.460 how common it is and that it often gets better 00:02:55.460 --> 00:02:59.039 anyway, why is there still so much kind of conflicting 00:02:59.039 --> 00:03:01.479 advice and debate about the best way to treat 00:03:01.479 --> 00:03:04.400 it? That's a great question and really sets up 00:03:04.400 --> 00:03:06.710 our deep dive nicely. The debate mostly comes 00:03:06.710 --> 00:03:10.129 from the varying quality and consistency of evidence 00:03:10.129 --> 00:03:12.449 for different treatments over the years. Past 00:03:12.449 --> 00:03:14.490 guidelines have sometimes offered different advice. 00:03:14.789 --> 00:03:17.509 The goal of recent efforts, like the BES guidelines 00:03:17.509 --> 00:03:20.469 we're using, is to apply really rigorous methods, 00:03:20.949 --> 00:03:23.189 things like the GRADE system, which systematically 00:03:23.189 --> 00:03:26.030 rates the certainty of evidence to give clearer 00:03:26.030 --> 00:03:28.349 evidence -based recommendations and, importantly, 00:03:28.490 --> 00:03:30.550 to highlight where the science is strong and, 00:03:30.550 --> 00:03:32.400 frankly, where it's still a bit uncertain. All 00:03:32.400 --> 00:03:34.280 right, bringing some clarity. Okay, let's unpack 00:03:34.280 --> 00:03:37.360 this then. Starting with the non -surgical options, 00:03:37.439 --> 00:03:39.900 which is where most people begin, isn't it? What's 00:03:39.900 --> 00:03:42.500 the recommended initial approach, say, in primary 00:03:42.500 --> 00:03:45.400 care? Yes, absolutely. Initial management really 00:03:45.400 --> 00:03:48.560 emphasizes shared decision -making. This echoes 00:03:48.560 --> 00:03:52.199 guidance from bodies like the GMC. It means properly 00:03:52.199 --> 00:03:54.520 listening to the patient, giving them clear, 00:03:54.860 --> 00:03:56.460 understandable information about their condition, 00:03:56.840 --> 00:03:59.659 what to expect, respecting their choices, and 00:03:59.659 --> 00:04:01.620 supporting self -care. And the diagnosis part. 00:04:01.879 --> 00:04:04.719 It's clinical, as I mentioned. Relying on the 00:04:04.719 --> 00:04:06.900 patient's history key things like the gradual 00:04:06.900 --> 00:04:10.159 onset of pain, exactly where it is if it radiates 00:04:10.159 --> 00:04:13.259 down the forearm, and what makes it worse. Often 00:04:13.259 --> 00:04:15.879 actions like grasping or twisting. Then the physical 00:04:15.879 --> 00:04:17.819 exam looks for tenderness over that bony bit 00:04:17.819 --> 00:04:20.959 on the outside, the lateral epicondyle, and pain 00:04:20.959 --> 00:04:23.079 when they extend their wrist or fingers against 00:04:23.079 --> 00:04:25.879 resistance. There are also specific tests we 00:04:25.879 --> 00:04:28.459 use, like Cousins, Mills, or Modsley's tests, 00:04:28.740 --> 00:04:31.500 which can help confirm things. So no need for 00:04:31.500 --> 00:04:34.319 pricey scans straight off the bat? Exactly. Plain 00:04:34.319 --> 00:04:36.240 x -rays aren't usually needed for diagnosis, 00:04:37.019 --> 00:04:40.560 and specialist imaging like MRI or CT scans are 00:04:40.560 --> 00:04:43.120 generally not required in primary care, only 00:04:43.120 --> 00:04:45.420 really if there's genuine diagnostic uncertainty 00:04:45.420 --> 00:04:47.620 or maybe a suspicion of something else going 00:04:47.620 --> 00:04:50.220 on. And the initial treatment advice? It focuses 00:04:50.220 --> 00:04:53.060 on patient education, explaining the self -limiting 00:04:53.060 --> 00:04:56.000 nature, advising on activity modification to 00:04:56.000 --> 00:04:58.339 reduce the irritating lows. you know, giving 00:04:58.339 --> 00:05:01.560 them a break, and providing exercises, often 00:05:01.560 --> 00:05:03.759 focusing on stretching and progressive strengthening. 00:05:04.639 --> 00:05:06.620 Eccentric loading, where the muscle lengthens 00:05:06.620 --> 00:05:09.959 under tension, is commonly included. Plus, simple 00:05:09.959 --> 00:05:12.180 analgesics or NSAIDs are part of that initial 00:05:12.180 --> 00:05:14.779 plan too. Okay, and what about those NSAIDs, 00:05:14.819 --> 00:05:16.579 the rubs and the pills? What's the evidence say? 00:05:16.720 --> 00:05:19.920 Well, systematic reviews suggest NSAIDs, whether 00:05:19.920 --> 00:05:22.600 topical creams or oral tablets, can offer short 00:05:22.600 --> 00:05:25.060 -term pain relief, usually effective for up to 00:05:25.060 --> 00:05:28.079 about four weeks. But, The evidence quality for 00:05:28.079 --> 00:05:31.319 both is actually low to very low. Topical endocides 00:05:31.319 --> 00:05:33.579 are generally preferred because they carry less 00:05:33.579 --> 00:05:36.240 risk of systemic side effects, especially stomach 00:05:36.240 --> 00:05:39.079 issues, compared to the oral ones. The key point 00:05:39.079 --> 00:05:41.100 from the evidence, though, is that their benefit 00:05:41.100 --> 00:05:44.040 seems limited in time and is based on less robust 00:05:44.040 --> 00:05:46.899 studies. Right. What about things like orthotics? 00:05:47.060 --> 00:05:50.199 Those forearm bands or wrist braces you see people 00:05:50.199 --> 00:05:54.279 wearing, do they actually help? The BESCA guidelines 00:05:54.279 --> 00:05:56.399 give what's called a conditional recommendation 00:05:56.399 --> 00:05:59.819 here. They may be offered, but importantly, patients 00:05:59.819 --> 00:06:02.120 need to be aware that the evidence suggests they 00:06:02.120 --> 00:06:05.819 may not actually provide a benefit. While some 00:06:05.819 --> 00:06:08.379 sort of low quality evidence hints at an immediate 00:06:08.379 --> 00:06:10.939 effect on reducing pain during gripping, there's 00:06:10.939 --> 00:06:13.240 really no reliable evidence showing sustained 00:06:13.240 --> 00:06:16.360 benefit over time compared to a placebo or a 00:06:16.360 --> 00:06:19.350 sham device. Okay, let's move to physiotherapy 00:06:19.350 --> 00:06:21.470 then. It feels like a very common and sort of 00:06:21.470 --> 00:06:23.629 natural intervention. What's the recommendation 00:06:23.629 --> 00:06:25.769 and the evidence look like there? Physiotherapy 00:06:25.769 --> 00:06:27.850 gets a strong recommendation. Patients should 00:06:27.850 --> 00:06:30.709 be offered it. Evidence from systematic reviews 00:06:30.709 --> 00:06:33.410 shows strong evidence of benefit, but mainly 00:06:33.410 --> 00:06:35.350 in the short term. Short term meaning? Usually 00:06:35.350 --> 00:06:37.290 the first few weeks, maybe up to three months. 00:06:38.089 --> 00:06:40.370 However, when you look longer term, medium and 00:06:40.370 --> 00:06:43.930 long term, there's generally no significant difference 00:06:43.930 --> 00:06:47.069 in outcomes compared to just, well, waiting for 00:06:47.069 --> 00:06:49.430 spontaneous recovery or receiving no specific 00:06:49.430 --> 00:06:51.870 intervention. Now, there is some lower quality 00:06:51.870 --> 00:06:54.269 evidence hinting at a possible long -term benefit 00:06:54.269 --> 00:06:56.910 from specific types of physiotherapy, but the 00:06:56.910 --> 00:06:59.029 certainty around that is currently low. That's 00:06:59.029 --> 00:07:01.790 a really important nuance, isn't it? Helps early 00:07:01.790 --> 00:07:04.170 on, but maybe less clear difference compared 00:07:04.170 --> 00:07:06.029 to just getting better naturally in the longer 00:07:06.029 --> 00:07:08.610 run. What about for really chronic symptoms? 00:07:08.769 --> 00:07:12.089 Say someone's had pain for over a year or after 00:07:12.089 --> 00:07:14.759 surgery. Yeah, for chronic symptoms beyond 12 00:07:14.759 --> 00:07:17.319 months, dedicated high -quality studies are a 00:07:17.319 --> 00:07:19.980 bit thin on the ground. However, based on that 00:07:19.980 --> 00:07:22.740 short -term evidence at earlier stages, the consensus 00:07:22.740 --> 00:07:25.519 is that physiotherapy may still be offered, especially 00:07:25.519 --> 00:07:27.620 if it hasn't actually been tried properly before. 00:07:27.899 --> 00:07:31.240 And for postoperative physiotherapy, specific 00:07:31.240 --> 00:07:34.160 evidence is also lacking, but clinical consensus 00:07:34.160 --> 00:07:36.899 supports that it may be offered to help guide 00:07:36.899 --> 00:07:38.860 rehabilitation and recovery. Okay, now here's 00:07:38.860 --> 00:07:40.860 where I think it gets really interesting and 00:07:40.860 --> 00:07:43.000 maybe quite counterintuitive for many people. 00:07:43.420 --> 00:07:46.360 For ages, corticosteroid injections felt like 00:07:46.360 --> 00:07:49.180 the standard go -to treatment. What does the 00:07:49.180 --> 00:07:51.560 latest evidence actually tell us about using 00:07:51.560 --> 00:07:53.720 them? This is probably one of the most critical 00:07:53.720 --> 00:07:56.339 takeaways, and it's backed by multiple meta -analyses 00:07:56.339 --> 00:07:58.759 and high -quality trials. The recommendation 00:07:58.759 --> 00:08:01.019 now is that corticosteroid injections should 00:08:01.019 --> 00:08:03.519 not be used for lateral elbow tendinopathy. Should 00:08:03.519 --> 00:08:05.819 not be used. That's quite definitive. It is. 00:08:06.180 --> 00:08:08.860 The evidence, which ranges from moderate to very 00:08:08.860 --> 00:08:10.899 low quality, depending on the specific study, 00:08:11.500 --> 00:08:14.329 consistently shows only a minor temporary improvement 00:08:14.329 --> 00:08:17.509 in pain, usually just in the first month or so. 00:08:17.930 --> 00:08:20.689 But, and this is the striking part, by six months 00:08:20.689 --> 00:08:23.029 the outcomes are often worse than if the patient 00:08:23.029 --> 00:08:25.709 had received a placebo injection or even no treatment 00:08:25.709 --> 00:08:28.709 at all. Worse? How so? The evidence suggests 00:08:28.709 --> 00:08:30.949 they might actually hinder the natural healing 00:08:30.949 --> 00:08:33.590 process and potentially increase the risk of 00:08:33.590 --> 00:08:36.490 the pain coming back recurrence. It's this long 00:08:36.490 --> 00:08:38.549 -term negative effect that underpins the strong 00:08:38.549 --> 00:08:41.179 recommendation against using them. Wow, that 00:08:41.179 --> 00:08:43.360 reversal effect is huge. Clinicians and patients 00:08:43.360 --> 00:08:45.899 really need to know that. Okay, so if steroids 00:08:45.899 --> 00:08:48.159 are out, what about the range of other injections 00:08:48.159 --> 00:08:50.600 and therapies that seem quite popular now? Things 00:08:50.600 --> 00:08:53.679 like PRP, dry needling, shockwave therapy. Yes, 00:08:53.919 --> 00:08:56.159 the evidence picture for many of these is, well, 00:08:56.360 --> 00:08:58.539 less clear or often negative when compared properly 00:08:58.539 --> 00:09:01.600 to placebo or sham treatments. For platelet -rich 00:09:01.600 --> 00:09:05.320 plasma, PRP, the BESS recommendation is conditional 00:09:05.320 --> 00:09:08.019 neutral. which basically means patients should 00:09:08.019 --> 00:09:10.320 understand there may be no benefit compared to 00:09:10.320 --> 00:09:12.700 placebo. The current evidence shows no significant 00:09:12.700 --> 00:09:15.659 effect on pain or function and the quality of 00:09:15.659 --> 00:09:18.840 that evidence is rated as very low. Autologous 00:09:18.840 --> 00:09:21.600 blood injection using the patient's own blood 00:09:21.600 --> 00:09:23.799 gets a conditional recommendation that it should 00:09:23.799 --> 00:09:27.379 not be used. Moderate to very low quality evidence 00:09:27.379 --> 00:09:30.399 suggests no real benefit over simple saline injections. 00:09:30.860 --> 00:09:33.320 What about dry needling? That seems quite common 00:09:33.320 --> 00:09:35.940 too. Dry needling also has a conditional neutral 00:09:35.940 --> 00:09:38.779 recommendation. Again, patients should know there 00:09:38.779 --> 00:09:40.899 is no evidence of benefit compared to placebo. 00:09:41.080 --> 00:09:43.320 A key issue here is the lack of well -designed 00:09:43.320 --> 00:09:46.220 studies comparing it to a proper placebo or sham 00:09:46.220 --> 00:09:48.519 treatment. While some studies compare it to other 00:09:48.519 --> 00:09:51.179 things, steroids, ibuprofen, even surgery or 00:09:51.179 --> 00:09:54.580 PRP, the results are very mixed, making it impossible 00:09:54.580 --> 00:09:56.720 to draw firm conclusions about its effectiveness 00:09:56.720 --> 00:09:59.559 on its own merit. And extracorporeal shockwave 00:09:59.559 --> 00:10:03.179 therapy, ECSWT. That receives a strong recommendation. 00:10:03.450 --> 00:10:06.730 It should not be used. Moderate to very low quality 00:10:06.730 --> 00:10:09.009 evidence shows no clinically significant improvement 00:10:09.009 --> 00:10:11.830 in patient reported outcomes, pain, or grip strength 00:10:11.830 --> 00:10:14.070 when compared to placebo or sham treatment in 00:10:14.070 --> 00:10:15.889 the medium term, say around three to six months. 00:10:16.129 --> 00:10:18.350 OK, so not much support there. And what about 00:10:18.350 --> 00:10:20.929 the really novel therapies, things like ultrasonic 00:10:20.929 --> 00:10:24.370 procedures, dextrous injections, arterial embolization? 00:10:24.629 --> 00:10:26.730 For many of those newer or more experimental 00:10:26.730 --> 00:10:29.570 therapies, the recommendation is also conditional 00:10:29.570 --> 00:10:32.470 neutral. Patients should be aware there's currently 00:10:32.470 --> 00:10:35.789 no evidence of benefit compared to placebo. The 00:10:35.789 --> 00:10:38.029 evidence base is typically very low quality, 00:10:38.210 --> 00:10:40.809 often just case series or small comparison studies. 00:10:41.429 --> 00:10:43.149 The consensus really is that these should only 00:10:43.149 --> 00:10:45.029 be considered within the context of research 00:10:45.029 --> 00:10:48.009 trials at this point. That's a really clear rundown 00:10:48.009 --> 00:10:50.750 of the non -surgical side, thanks, really highlights 00:10:50.750 --> 00:10:53.049 where the evidence stands or doesn't. Let's switch 00:10:53.049 --> 00:10:55.679 gears now and talk about surgery. Given everything 00:10:55.679 --> 00:10:58.360 we've just discussed, why is surgery even considered 00:10:58.360 --> 00:11:00.440 and what does the evidence actually show about 00:11:00.440 --> 00:11:03.139 its role? It feels a bit controversial now. It 00:11:03.139 --> 00:11:05.240 is quite controversial in the evidence -based 00:11:05.240 --> 00:11:07.840 world. Surgery is typically reserved for patients 00:11:07.840 --> 00:11:10.019 whose symptoms just haven't resolved after a 00:11:10.019 --> 00:11:12.799 decent trial of non -surgical treatment, usually 00:11:12.799 --> 00:11:15.159 defined as maybe three to six months in the BSS 00:11:15.159 --> 00:11:18.519 guidelines. The Muir Scoping Review which looks 00:11:18.519 --> 00:11:20.919 specifically at the surgical literature, found 00:11:20.919 --> 00:11:23.000 the median time people had tried non -surgical 00:11:23.000 --> 00:11:25.000 options before having surgery in the studies 00:11:25.000 --> 00:11:27.899 was about six months. But you're right, its role 00:11:27.899 --> 00:11:31.019 is debated, as highlighted by both the BSS guidelines 00:11:31.019 --> 00:11:34.279 and that mirror review. OK, so what is the specific 00:11:34.279 --> 00:11:37.320 recommendation in the BSS guidelines about surgery? 00:11:37.419 --> 00:11:39.679 This feels like a key point. It is perhaps the 00:11:39.679 --> 00:11:42.580 most surprising and important point regarding 00:11:42.580 --> 00:11:46.100 surgery. The recommendation states, Patients 00:11:46.100 --> 00:11:48.279 being offered surgery should be made aware that 00:11:48.279 --> 00:11:50.519 there is no evidence of benefit compared to a 00:11:50.519 --> 00:11:53.519 placebo. Hold on. No evidence of benefit compared 00:11:53.519 --> 00:11:55.639 to a placebo. That sounds... Well, how can that 00:11:55.639 --> 00:11:57.799 be? If surgery is being offered, surely there 00:11:57.799 --> 00:12:00.240 must be some evidence it helps. What did that 00:12:00.240 --> 00:12:02.220 Muir review actually find when it looked at all 00:12:02.220 --> 00:12:04.820 the surgical studies? It's fascinating when you 00:12:04.820 --> 00:12:07.960 dig into why that recommendation exists. The 00:12:07.960 --> 00:12:11.080 Muir review analyzed 35 studies on surgical management. 00:12:11.179 --> 00:12:14.179 covering over 1 ,500 patients. What they found 00:12:14.179 --> 00:12:16.720 was that the literature is dominated by single 00:12:16.720 --> 00:12:18.919 -center studies, often with quite small numbers 00:12:18.919 --> 00:12:21.320 of patients in each. And there's a real lack 00:12:21.320 --> 00:12:24.080 of high -quality multi -center trials. OK, so 00:12:24.080 --> 00:12:26.679 the quality is maybe not ideal. Precisely. And 00:12:26.679 --> 00:12:29.059 there's huge heterogeneity, meaning studies use 00:12:29.059 --> 00:12:30.740 different methods, different patient groups, 00:12:31.179 --> 00:12:33.299 measured outcomes differently. This makes it 00:12:33.299 --> 00:12:35.559 incredibly difficult to combine the data and 00:12:35.559 --> 00:12:37.960 draw really strong, generalizable conclusions. 00:12:38.519 --> 00:12:40.799 Now most individual studies did report improvements 00:12:40.799 --> 00:12:42.940 in pain and function after surgery. That's true. 00:12:43.340 --> 00:12:45.580 But the critical issue is that these studies 00:12:45.580 --> 00:12:48.399 very rarely compared surgery directly to a proper 00:12:48.399 --> 00:12:51.340 placebo or sham procedure. or even to a well 00:12:51.340 --> 00:12:53.279 -structured conservative management program. 00:12:53.679 --> 00:12:55.820 The one trial they identified that did compare 00:12:55.820 --> 00:12:58.639 open surgery to sham surgery actually found no 00:12:58.639 --> 00:13:00.700 improvement in function in the group that had 00:13:00.700 --> 00:13:04.259 the real surgery. Right. So many individual reports 00:13:04.259 --> 00:13:07.559 say patients got better after we operated, but 00:13:07.559 --> 00:13:10.480 the gold standard comparison surgery versus fake 00:13:10.480 --> 00:13:12.720 surgery didn't show a benefit for the real thing. 00:13:12.940 --> 00:13:15.399 That's the crux of it. It really raises the question, 00:13:16.059 --> 00:13:18.500 are the improvements seen in many studies due 00:13:18.500 --> 00:13:21.600 to the surgery itself? Or is it the post -operative 00:13:21.600 --> 00:13:24.440 rehab, the placebo effect of just having a procedure, 00:13:24.899 --> 00:13:26.840 or simply the natural history of the condition 00:13:26.840 --> 00:13:29.019 resolving over time, which we know happens often 00:13:29.019 --> 00:13:31.220 anyway? Because of that lack of high -quality 00:13:31.220 --> 00:13:33.139 comparative trials, especially against placebo, 00:13:33.740 --> 00:13:35.840 the BSAS committee couldn't find strong evidence 00:13:35.840 --> 00:13:38.379 to recommend surgery over doing nothing or having 00:13:38.379 --> 00:13:40.539 a sham procedure. Does the evidence tell us anything 00:13:40.539 --> 00:13:43.259 about different surgical techniques, like open 00:13:43.259 --> 00:13:45.960 surgery versus keyhole arthroscopic surgery? 00:13:46.090 --> 00:13:48.330 The MU Review didn't find consistent differences 00:13:48.330 --> 00:13:51.049 between open and arthroscopic techniques when 00:13:51.049 --> 00:13:53.570 looking across the literature narratively, although 00:13:53.570 --> 00:13:55.610 individual studies reported improvements with 00:13:55.610 --> 00:13:59.129 both methods. So the BSS guidelines basically 00:13:59.129 --> 00:14:01.470 say that if a patient does choose surgery, they 00:14:01.470 --> 00:14:03.909 may have either technique, but they note the 00:14:03.909 --> 00:14:06.250 evidence comparing them is limited by small study 00:14:06.250 --> 00:14:09.049 sizes and a lack of long -term follow -up measures. 00:14:09.610 --> 00:14:11.450 Percutaneous techniques were also looked at, 00:14:11.629 --> 00:14:14.070 but the data there is even more limited. Okay. 00:14:14.240 --> 00:14:17.080 And finally on surgery, is recurrence a risk? 00:14:17.200 --> 00:14:19.320 Can the pain come back and are there things that 00:14:19.320 --> 00:14:21.600 might make that more likely? Yes, recurrence 00:14:21.600 --> 00:14:23.580 is definitely possible. A study mentioned in 00:14:23.580 --> 00:14:25.879 the BS's guidelines reported a two -year recurrence 00:14:25.879 --> 00:14:29.279 rate of around 8 .5%. And risk factors. Several 00:14:29.279 --> 00:14:31.179 potential risk factors have been identified. 00:14:31.779 --> 00:14:34.120 Things like older age, perhaps inadequate or 00:14:34.120 --> 00:14:36.539 short recovery periods after treatment or surgery, 00:14:37.059 --> 00:14:39.620 being involved in manual labor, having had previous 00:14:39.620 --> 00:14:42.759 surgery on the same elbow. Also, having symptoms 00:14:42.759 --> 00:14:45.919 for a very long time, say over 12 months, experiencing 00:14:45.919 --> 00:14:48.879 very acute pain right at the start, poor adherence 00:14:48.879 --> 00:14:51.600 to the recommended management plan, and notably 00:14:51.600 --> 00:14:55.519 having received corticosteroid injections. There 00:14:55.519 --> 00:14:57.779 are those steroid injections, again, linked to 00:14:57.779 --> 00:14:59.980 potentially worse outcomes or recurrence. That's 00:14:59.980 --> 00:15:02.340 really striking. It reinforces the earlier point, 00:15:02.500 --> 00:15:05.779 yes. OK, wow. We have covered a huge amount of 00:15:05.779 --> 00:15:07.639 ground there looking at the evidence for both 00:15:07.639 --> 00:15:10.299 nonsurgical and surgical approaches. Let's try 00:15:10.299 --> 00:15:12.440 and crystallize some of this. Time for a quick 00:15:12.440 --> 00:15:14.740 lightning round for some sharp, concise answers. 00:15:15.399 --> 00:15:18.179 Ready? Ready. What's the single most reliable 00:15:18.179 --> 00:15:21.000 way to diagnose tennis elbow? Clinical history 00:15:21.000 --> 00:15:23.460 and a thorough physical examination. Imaging 00:15:23.460 --> 00:15:26.029 is generally not needed up front. Based purely 00:15:26.029 --> 00:15:28.629 on the evidence, if I start getting tennis elbow 00:15:28.629 --> 00:15:30.370 pain, what's the very first thing I should probably 00:15:30.370 --> 00:15:33.009 try myself? Activity modification try to redo 00:15:33.009 --> 00:15:36.909 the offending loads. Then, exercises, including 00:15:36.909 --> 00:15:39.149 stretching and progressive strengthening like 00:15:39.149 --> 00:15:43.070 eccentric loading, and maybe topical NFIDs for 00:15:43.070 --> 00:15:46.269 short -term pain relief. Okay. What treatment 00:15:46.269 --> 00:15:48.730 may be commonly used in the past does the evidence 00:15:48.730 --> 00:15:51.370 now strongly suggest people should avoid because 00:15:51.370 --> 00:15:53.789 it doesn't help long -term and might actually 00:15:53.789 --> 00:15:57.250 worsen things? or increase recurrence risk. Corticosteroid 00:15:57.250 --> 00:16:00.409 injections, definitely. Got it. What's the biggest 00:16:00.409 --> 00:16:02.970 remaining question mark or area of uncertainty 00:16:02.970 --> 00:16:05.570 in managing tennis elbow, according to the recent 00:16:05.570 --> 00:16:07.549 literature we've discussed? I'd say it's the 00:16:07.549 --> 00:16:11.009 exact role and the true benefit of surgery. especially 00:16:11.009 --> 00:16:13.190 when compared rigorously against non -surgical 00:16:13.190 --> 00:16:16.049 management or simply allowing for that natural, 00:16:16.169 --> 00:16:18.990 spontaneous recovery. We really need more high 00:16:18.990 --> 00:16:21.470 -quality placebo -controlled trials. Right. That 00:16:21.470 --> 00:16:23.710 comparison is key. And finally, if someone's 00:16:23.710 --> 00:16:25.590 tracking their own progress or looking at research, 00:16:25.669 --> 00:16:27.950 what's a key outcome measure that patients and 00:16:27.950 --> 00:16:30.610 clinicians should probably be aware of? The PRTE. 00:16:30.750 --> 00:16:33.169 That's the Patient -Reported Tennis Elbow Evaluation 00:16:33.169 --> 00:16:35.970 Questionnaire. It's recommended as the core outcome 00:16:35.970 --> 00:16:38.110 measure for assessing disability in this condition. 00:16:38.509 --> 00:16:41.980 PRT. Good to know. Excellent. Okay, to wrap everything 00:16:41.980 --> 00:16:44.080 up from this really insightful deep dive into 00:16:44.080 --> 00:16:47.139 your sources, let's quickly summarize, say, five 00:16:47.139 --> 00:16:50.299 key actionable takeaways for our listeners. Absolutely. 00:16:50.419 --> 00:16:52.659 Let's do that. Okay, first takeaway. Remember, 00:16:52.879 --> 00:16:55.179 diagnosis is primarily clinical. It's about the 00:16:55.179 --> 00:16:57.059 conversation with your doctor and the examination. 00:16:57.580 --> 00:17:00.240 Imaging usually isn't needed unless the diagnosis 00:17:00.240 --> 00:17:03.620 is really unclear. Second, this condition very 00:17:03.620 --> 00:17:06.750 often improves on its own over time. Physiotherapy 00:17:06.750 --> 00:17:08.990 can be very helpful for short -term relief and 00:17:08.990 --> 00:17:11.589 function, but the evidence for its long -term 00:17:11.589 --> 00:17:14.589 benefit compared to just natural recovery is 00:17:14.589 --> 00:17:18.009 less certain. Third, and this feels like a headline 00:17:18.009 --> 00:17:20.470 finding, the evidence strongly advises against 00:17:20.470 --> 00:17:23.309 using corticosteroid injections. Any short -term 00:17:23.309 --> 00:17:25.029 relief might be outweighed by worse outcomes 00:17:25.029 --> 00:17:27.190 later on and potentially a higher risk of the 00:17:27.190 --> 00:17:30.599 pain coming back. Spot on. Fourth, from any other 00:17:30.599 --> 00:17:32.359 treatments that you might hear about things like 00:17:32.359 --> 00:17:34.960 PRP, dry needling, shockwave therapy, the current 00:17:34.960 --> 00:17:36.920 evidence, when compared properly to placebo, 00:17:37.039 --> 00:17:39.440 is either weak, of very low quality, or simply 00:17:39.440 --> 00:17:41.799 shows no significant benefit. Be aware of that 00:17:41.799 --> 00:17:44.839 limited evidence. And fifth, the role of surgery 00:17:44.839 --> 00:17:48.140 for tennis elbow remains quite debated. High 00:17:48.140 --> 00:17:51.079 -level evidence, especially from reviews including 00:17:51.079 --> 00:17:54.200 sham surgery trials, doesn't clearly show a benefit 00:17:54.200 --> 00:17:57.099 compared to placebo. So given this uncertainty, 00:17:57.559 --> 00:18:00.000 really understanding the evidence and engaging 00:18:00.000 --> 00:18:02.160 in shared decision -making with your clinician 00:18:02.160 --> 00:18:05.079 is crucial if surgery is ever on the table. Agreed 00:18:05.079 --> 00:18:08.420 entirely. Making informed choices based on the 00:18:08.420 --> 00:18:11.200 best available evidence is absolutely key to 00:18:11.200 --> 00:18:13.900 managing this condition effectively. So what's 00:18:13.900 --> 00:18:15.700 the final thought for you, the listener, from 00:18:15.700 --> 00:18:17.579 all this? I think it's that understanding the 00:18:17.579 --> 00:18:19.859 natural history of tennis -elda, the fact it 00:18:19.859 --> 00:18:23.420 often gets better by itself, alongside the Frankly, 00:18:23.839 --> 00:18:25.940 surprisingly weak or even negative evidence for 00:18:25.940 --> 00:18:28.660 many common interventions really empowers you. 00:18:28.839 --> 00:18:30.880 It means you can have much more informed conversations 00:18:30.880 --> 00:18:33.299 about your treatment options. Knowing what the 00:18:33.299 --> 00:18:35.700 science actually says is the vital first step 00:18:35.700 --> 00:18:37.539 to choosing the path that's truly right for you. 00:18:37.700 --> 00:18:39.539 If you found this deep dive helpful, please do 00:18:39.539 --> 00:18:41.259 take a moment to rate and share the show with 00:18:41.259 --> 00:18:43.519 your network. Thank you so much for sharing your 00:18:43.519 --> 00:18:45.680 expertise and guiding us so clearly through these 00:18:45.680 --> 00:18:47.720 important sources today. It's been my pleasure. 00:18:47.819 --> 00:18:50.380 Thank you for having me. And thank you, our listener, 00:18:50.539 --> 00:18:52.839 for joining us on the deep dive. We hope this 00:18:52.839 --> 00:18:55.500 has shed some useful light on what can be an 00:18:55.500 --> 00:18:57.700 incredibly common and sometimes very frustrating 00:18:57.700 --> 00:18:59.720 condition. Until next time.