Tennis elbow occurs when the extensor tendons of the forearm become inflamed due to overuse. It is a surprisingly prevalent condition, affecting approximately 1% to 3% of the general population at any time. But which treatments are available to aid the recovery from tennis elbow and what are the advantages and disadvantages of each treatment?
The good news is that the majority of individuals with tennis elbow (recent figures suggest that this is up to 90% of people) will make a full recovery within twelve months. It is most common for tennis elbow to last for a period between six months and two years in duration, as tendons tend to recover and heal fairly slowly. Whilst there are a number of treatments which can aid recovery from tennis elbow, the particular approach typically depends upon the severity of the injury. Simple treatment methods, including rest, exercise and over-the-counter medication, are typically sufficient to aid the recovery. In more severe cases, which can be diagnosed by a physiotherapist or general practitioner (GP), more specialist treatment may be required.
Rest, modification of activities and cold compresses
Tennis elbow is what is known as a ‘self-limiting’ injury; this means that the injury typically tends to heal on its own without any intervention being necessary. For this reason, simply resting the affected limb can, in most cases, alleviate the symptoms and hasten the recovery process. Additionally, it is important that the activity which caused the injury is avoided until the forearm has fully recovered. It is also important to reduce, or completely avoid any other form of activity which is likely to further exacerbate the injury: these will include activities which strain affected muscles and tendons. Furthermore, activities should be modified so that they are performed in a manner which reduces the strain upon affected areas. For example, methods which can help with this include ensuring that the palm is facing up, rather than down, when lifting objects, as this will reduce the level of strain upon the muscles and tendons; secondly, it is important to take regular breaks when performing activities which are likely to prolong the injury.
In some cases of tennis elbow, an individual may need to adjust their usual activities at work to reduce the likelihood of exacerbating the injury: this might include avoiding manual lifting, or avoiding performing repetitive actions. This will generally require talking to an employer, or an employer’s occupational health department, to change the nature of routine work duties to avoid further strain and provide time for the injury to fully heal and recover. One major positive of this treatment approach is that it is extremely simple and inexpensive. Similarly, the application of a cold compress, which is pressed against the affected area several times each day, can be effective and even using a frozen bag of peas can be used in this manner.
One treatment approach, besides rest and the avoidance of certain activities, is in the use of over-the-counter painkiller medication, which includes paracetamol and aspirin. One major benefit of this approach is that these medications are very easy to take and have excellent availability; however, these medications do not tend to be suitable for long-term use and it is not recommended that children under the age of 16 years take aspirin. If over-the-counter painkillers are being used, it is always recommended that people take the time to read the patient information leaflet or ask their pharmacist for advice.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Tennis elbow can also be treated using a type of medication which is known as a non-steroidal anti-inflammatory drug (known as an ‘NSAID’ for short). NSAIDs are available in different forms and can be of benefit in helping the mild pain and inflammation associated with the injury. NSAIDs are available in tablet form (as ibuprofen, which is readily available and very inexpensive) and in topical form, where they are applied as either a cream or a gel. Topical NSAIDs are applied directly to a specific area of the elbow or forearm to alleviate the pain and inflammation. Of the two types of NSAIDs, topical NSAIDs are typically recommended over the tablet form, since these treatments have a tendency to reduce the inflammation and pain whilst minimising the side effects. Depending on the type of NSAID which is used for treatment, these can either be obtained over the counter without requiring a prescription, or will require a prescription.
Whilst NSAIDs are easy to apply and can be easily available, some of the potential limitations can include side effects such as nausea, or diarrhoea, or unpredictable interactions with other medications. In some cases, the use of NSAIDs can cause hypersensitivity to light (which is known as photophobia), which tends to occur when ketoprofen is being used. Additionally, as is the case with over-the-counter painkillers, there is little evidence to support the long-term use of NSAIDs. A GP or pharmacist can discuss and recommend a particular NSAID.
In more severe cases of tennis elbow, where the pain is extreme or particularly persistent, GPs can arrange a referral to a physiotherapist. A physiotherapist may decide to trial a range of methods to treat the injury, which might include massage, stretching and special forearm exercises. Physiotherapists may also use orthoses (such as a brace, strapping or splint) to aid the recovery and may also demonstrate exercises which can be performed at home. A positive of physiotherapy is that it can provide long-term effective pain relief, but the main drawback of this approach is that individuals can sometimes be placed on a lengthy waiting list before they see a physiotherapist for treatment.
Corticosteroid injections, which contain synthetic cortisol (a special steroid hormone) can also be used as a treatment method when they are injected into the elbow area, with the intention of reducing both the pain and the associated swelling. Whilst these do tend to provide rapid short-term pain and symptom relief, the injection can be painful and there are a host of side effects associated with the treatment. These can include tissue atrophy and skin lightening. However, research suggests that corticosteroid injections are typically ineffective in the long-term and do not work after a period of six weeks. Additionally, the symptoms may relapse in the future.
Shock wave therapy
A further non-invasive treatment which can be adopted is shock wave therapy, which is when localised high-energy sound waves are targeted over the painful area. Whilst this can be of some use, there is currently a lack of clear evidence to demonstrate effectiveness, side effects can include skin damage and potential extensor tendon rupture. Additionally, the availability of this treatment is very limited at present.
Surgery is typically considered to be an extreme last resort for the treatment of tennis elbow, due to its invasive nature, when all other treatments have failed to alleviate the symptoms. Surgical treatments typically involve removing damaged parts of the tendon with the aim of reducing the pain. However, there is a lack of available evidence demonstrating the effectiveness of surgery and there is a long associated recovery period.