Treatments « Tennis Elbow: A Resource of Medical Evidence & Research

Tennis Elbow: A Resource of Medical Evidence & Research

Treatments

Astym treatment:

Qualified, specially trained physical and occupational therapists provide Astym treatment. Astym treatment is highly effective and was scientifically developed to stimulate regeneration of tendons and other soft tissues. Astym has its foundation in basic science research and is supported by clinical trials, case studies and extensive outcomes collected from multiple treatment sites3-18. A large, randomized clinical trial confirming Astym’s effectiveness on tennis elbow was awarded a platform presentation at the American Society for Surgery of the Hand’s national meeting11. This is a non-invasive treatment (no needles, no surgery). Instruments are applied on top of the skin to put light to moderate pressure on the underlying tissue and stimulate a healing/regenerative response. Most conditions resolve within 6 weeks and Astym is usually covered by insurance. A directory of therapists who are qualified to provide Astym treatment can be found at www.astym.com. Be sure check that directory to confirm your therapist is certified in the Astym rehabilitation process. Certification is extremely important, otherwise you will not receive proper treatment.

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Autologous Blood Injections:

Medical doctors (MDs) provide these injections. There is no certification or special training required, however, there is some instruction available to doctors. Be sure to inquire into your doctor’s training and experience. For this treatment, a physician draws your own blood and then injects it back into you at the site of pain, hoping to cause a physiological response that will ease pain and increase function. No controlled studies have been published on this treatment, and further study is needed to determine whether this approach will be useful in the treatment of tennis elbow. Health insurance companies generally consider this investigational and do not pay for this treatment.

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Corticosteroid Injections:

Medical doctors (MDs) provide these injections. Corticosteroid medication is injected around a tendon to reduce inflammation and ease pain. The use of corticosteroid injections ("CSI") for the treatment of tennis elbow is controversial. There can be side effects. Repeated injections may weaken a tendon, increasing the chance of a rupture or tear. There have been a number of case reports of tendon rupture after CSI19,20. Corticosteroid medications should not be injected directly into the tendon because that could contribute to a tendon rupture. In order to reduce this risk, the injection may be done with the assistance of image guidance (such as ultrasound or fluoroscopy) to make sure that the injection is being done around the tendon rather than into the tendon. CSI is often successful in reducing pain, however, since its goal is to reduce inflammation, it is questionable whether there is any long-term healing benefit to the tendon, and positive results are often short-lived.

Corticosteroid injection in tennis elbow has been studied, and although it was somewhat effective in the short term (2-6 weeks), patients received no long term benefit21,22. Long term effectiveness for this approach has not been demonstrated23. In fact, poor long term results have consistently been reported for the CSI approach in tennis elbow24,25,26. The true cause underlying most chronic tennis elbow is degeneration, so addressing this problem with a treatment aimed at stimulating regeneration would be more productive.

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Eccentric Exercise:

This kind of exercise program is supervised by physical therapists, occupational therapists, trainers and/or exercise instructors, and it focuses on the "return" or "lowering" portion of exercise. Eccentric exercise can be tedious, requiring dedication and time to allow for multiple repetitions of the exercise in the range of 100-150 times per day (7 days a week) for a period of at least 12 weeks. The exercises can be uncomfortable, but they have been shown to be effective in certain cases. These exercises are generally not suitable for more frail patients. There is some limited support for this approach in the medical literature, particularly for chronic, mid-portion tendinopathy of the Achilles tendon27, however, a recent study showed that the success of this approach was markedly lower than previously thought.28

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Electrical Stimulation and Iontophoresis:

Physical and occupational therapists provide these treatments. Equipment is used to deliver electrical current into the painful area over multiple sessions. Often a corticosteroid cream or patch or other medication is added and it is then pushed through the tissue with the electricity (this combination is known as Iontophoresis). There is little to no medical evidence that this approach works for chronic tennis elbow. Further investigation and study is needed. Health insurance companies are now becoming hesitant to pay for this, so check with your health insurance carrier if you plan on getting this treatment.

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Extracorporeal Shockwave Therapy (ESWT):

Medical doctors (MDs) provide this treatment. A physician (for high-energy application) or a physician’s office assistant (for low-energy application) uses equipment to deliver a series of high or low-energy shock waves directly over the affected area. Even though this has been studied for over ten years, how ESWT may work is unclear. More importantly, whether it works is unclear. Some studies have shown that the shock waves result in the degeneration of animal epidermal sensory nerve fibers (which would reduce the sensation of pain, but not fix the underlying problem), while other studies also show evidence of tenocytes releasing growth factors in response to ESWT, which would aid healing29. Published research studies offer conflicting results as to whether ESWT is effective in treating tendinopathies. Two systematic reviews conclude that ESWT provides little or no benefit in the treatment of tennis elbow (lateral epicondylitis)30,31.

The application of ESWT can vary widely in how long the treatment lasts, the intensity and frequency of shock waves, and the timing and number of treatments. This makes it hard to measure its overall effectiveness. ESWT can be very painful, and the high energy waves are only delivered under anesthesia or sedation in an operating room setting with assistance of imaging to ensure the shock waves are being delivered to the right area. The low energy waves can be delivered in an office, but be aware that even low energy ESWT is usually quite uncomfortable and each session will last approximately 15 minutes (multiple sessions are usually required). ESWT remains a controversial treatment for tennis elbow and is rarely covered by health insurance.

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Fenestration (percutaneous tenotomy):

Medical doctors (MDs) perform this procedure; it involves puncturing the affected area multiple times (50-100 punctures usually) per session with a needle. Local anesthesia helps the patient tolerate the procedure and it is often done under the guidance of ultrasound imaging. Most often, patients receive only one session. If the condition recurs or persists, and positive results were seen after the first procedure, then the patient may receive more sessions.

The local trauma and bleeding that is produced by the multiple punctures may cause a similar physiological response to actually injecting your own blood around the affected area (autologous blood injections). This may be how fenestration might help tendons to heal. In addition to multiple punctures to the tendon, the procedure can include mechanically breaking up calcifications and abrading the adjacent bone. Preliminary research indicates that this procedure improves tendinopathy in a notable number of patients 32, 33 . If you elect to have this procedure done, it is important to select an experienced physician. It is questionable whether health insurance will pay for this procedure.

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Friction Massage – both tooled and traditional:

Almost anyone can do this type of treatment. Many people do this on themselves. It is a deep massage that moves across muscles and tendons, and it’s purpose is to mechanically break down tissue. There is little to no medical evidence showing that this approach consistently works, however, there have been reports from individuals who have had some positive benefit. The Cochrane Review, an official medical review analyzing medical literature, concluded there was no benefit to this approach over controls34.

There are a number of different tools that are used to do this type of massage. Some of the tools are: Intracell, Acuforce, GSO, Graston, Fuzion, Jacknobber, Sastm, T-Bars, handles of reflex hammers and various kitchen utensils. Some tools promote a friction massage approach called Instrument Assisted Cross-Fiber Massage or Instrument Assisted Soft Tissue Mobilization, such as Graston and Sastm. The only published article on Instrumented Cross-Friction Mobilization shows that it has minimal to no long-term (12 weeks or more) benefit on healing35.

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Glyceryl Trinitrate (Nitroglycerin) Patches:

These patches are prescribed by medical doctors (MDs); they are meant to be used to treat cardiovascular disease. Their use in the treatment of tennis elbow is an "off-label" use. In other words, the FDA has not approved this drug’s use for the treatment of tennis elbow. There is no standard dosing for this drug in the treatment of tennis elbow, so the effectiveness and side effects from these patches can vary depending on how much you are given. Usually patients have to cut up these patches on their own and then apply the smaller pieces over the affected area daily for at least 12 weeks to experience any noticeable change in symptoms.

On the whole, studies performed on this treatment show that there can be benefit with pain relief and healing, although there is a question as to whether this simply has a short-term analgesic (pain-relief) effect rather than an actual healing benefit in the treatment of tendinopathy36. A recent study revealed that there are no significant, comparative long term clinical benefits from this treatment for chronic tennis elbow37. There can be side effects; the most common of which are headaches and a drop in blood pressure that can result in fainting. If these side effects become severe enough, treatment should be stopped.

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Laser/Light Therapy:

This type of treatment is usually delivered by chiropractors, physical therapists, and occupational therapists. Laser or light energy is aimed over the affected area, either through "cold" low level laser therapy (LLLT) or through light emitting diodes (LED) or super luminous diodes (SLD). The effectiveness of this type of therapy for tennis elbow is not supported by the medical literature, however, there is some evidence that it may have a positive effect on the healing of skin ulcers/wounds. Low-level laser treatment (LLLT) has been studied with inconsistent results. Four systematic reviews in the medical literature have evaluated LLLT, and all agreed the evidence does not support the use of LLLT in the treatment of tendinopathy38,39,40,41. This therapy is generally not covered by health insurance for the treatment of tennis elbow.

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NSAIDs/Anti-inflammatory Drugs:

There are both prescription strength and over-the-counter versions of these drugs. Oral NSAIDs (non-steroidal anti-inflammatory drugs), have been used to treat tennis elbow for decades. Recently, gels or patches with these drugs have also been used. The medical literature contains frequent references to the use of NSAIDs in the treatment of tennis elbow and other tendinopathies, however, there is "surprisingly little quality evidence supporting this …option"1.

The research shows that although these drugs may provide short-term pain relief, there is little to no evidence of a positive effect on long-term healing36. As a matter of fact, there is conflicting evidence in animal models regarding the effect of NSAIDs, with a suggestion that NSAIDs may actually inhibit healing42,43,44. The medical literature now consistently refers to tennis elbow and other tendinopathies as primarily degenerative in nature, rather than inflammatory, so it is easy to understand why a drug designed to reduce inflammation has little effect on the underlying degenerative problem of tennis elbow. Instead of trying to reduce inflammation, the better goal would be to try and stimulate regeneration (and reverse the degeneration, which is the real cause of most chronic tennis elbow).

It is important to be aware that long-term use of NSAIDs carries the risk of significant side-effects, such as increased risk of gastrointestinal bleeding, renal failure, liver damage, and cardiovascular complications associated with this type of medicine36. Common names of some NSAIDs include generic Ibuprofen (and brands such as Advil® and Motrin®) and generic Naproxen Sodium (brand name Aleve®) and prescription strength brand Celebrex®.

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Platelet Rich Plasma (PRP) Injections:

These injections are provided by medical doctors (MDs). The physician draws blood from the patient and puts it into a machine that spins the blood out and leaves a layer of platelet rich plasma (PRP). The physician then injects the patient with this derivative of their own blood, in an attempt to cause a physiological response that will ease pain and increase function.

There are several different brands of machines which produce different platelet layer concentrations. This method of treatment is similar to Autologous Blood Injections, however, the platelet rich portion of the blood is separated and only the platelet rich plasma is injected, which may cause less local inflammation but will require more blood to initially be drawn out of the patient.

If good PRP injection is guided by imaging (ultrasound), it may be effective on a small area of tendinopathy (about ½ inch square) if it is followed by appropriate rehabilitation. The growth factors from a PRP injection only spread out so far and once in the tissue the growth factors degrade rapidly – that is why its potential effectiveness, like most injection techniques, is limited to a small area. If PRP is not guided by imaging (ultrasound) to target the area of degeneration in the tendon, it can easily miss the optimal injection site and therefore not have the potential to be effective. PRP can require multiple injections (if a patient doesn’t respond immediately) and most of the time the patient must limit their activity and training for a period of time (2-4 weeks) after each injection. The treatment course may easily take up to 6 months. Most of the time, PRP procedures will use a large needle (>22).

Previously, very limited research had been done on this approach for tennis elbow and other tendinopathy45. There was hope that this method would be proved effective through research, however, a well-designed study was just published in the Journal of the American Medical Association (JAMA) and it clearly shows that PRP is no more effective than placebo (ineffective or sham treatment) in the treatment of tendinopathy46. Some former proponents of this method are now questioning its application in tennis elbow and other tendinopathies. It is generally considered experimental or investigational by health insurance companies and is not covered under health insurance. It is likely you would have to pay cash for this service.

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Prolotherapy (Sclerotherapy):

Medical doctors (MDs) provide these injections. The doctor injects an irritating substance into the problem area, and it is believed that the area then scars down as a result of this injection, and further, the injection may destroy the nerve fibers that are transmitting pain. Originally, prolotherapy was used to scar down an area of instability in a joint. If a joint was loose, the creation of scar tissue could help "tighten up" the area by adding dense scar tissue to the joint capsule. Some more adventurous doctors have now applied this to the treatment of tennis elbow and other tendinopathies.

How prolotherapy would work (the "mechanism of action") in the treatment of tennis elbow and other tendinopathies is unclear47. Initial study has been done on this technique, but so far the research has mostly been underpowered and not well designed/controlled1, so there is no solid support in the medical literature for this procedure in the treatment of tennis elbow and other tendinopathies. However, there are some individual stories with perceived positive results that have been published in the popular media. Proper, well-designed research would have to include patients consistently being injected with the same substance.

In current practice, different doctors often inject very different substances for this procedure. Another concern with this procedure is that scarring down one area may lead to increased stress on structures in other areas of the body with the potential for injuries or pain in other areas of the body. Prolotherapy is generally considered investigational or experimental by health insurance carriers, and not covered under their policies. You will probably have to pay cash for this service.

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Relative Rest/Splinting/Immobilization:

Medical doctors (MDs), and physical and occupational therapists often recommend these courses of treatment. This is a common recommendation for patients with tennis elbow and other tendinopathies. However, once resting is over, splints are removed and immobilization (not moving) is stopped, tennis elbow often returns. Resting the area rarely leads to healing or resolution of the underlying problem of chronic tennis elbow (the degeneration of the tendon). However, it may help where tennis elbow is acute (sudden, short-term) and the underlying problem is only inflammation.

When patients wear splints, they will often complain of tightness or weakness as a result of wearing the splint and can become dependant upon their splints, and want to keep wearing them even after the recommended course of treatment is over. As a whole, the medical literature does not show strong support for the use of orthotics (splints) in tennis elbow, and effectiveness of this approach is uncertain48. One review of medical literature concluded that: "current prescriptions of elbow orthoses [splints] cannot be evidence based, because no scientific evidence on elbow orthoses is available."49 In addition, a study has shown that wearing a splint can cause increased stress on other structures in the body50. This has the potential to cause additional injury or pain in other areas of the body.

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Stretching/Ice:

Stretching may help guide the healing of the body, and also may help align tissue properly. Stretching alone rarely provides enough stimulation to cause significant healing of tennis elbow or other tendinopathies. It is often recommended as part of pain management and rehabilitation, yet relatively little is known about its effectiveness; recent research indicates that although stretching can increase tolerance to the discomfort associated with the stretch, it did not change muscle extensibility in patients with chronic musculoskeletal pain51. Ice has been traditionally used for its analgesic effect and inflammation reduction, but most times inflammation is not present in tennis elbow where symptoms are of longer duration (greater than 4-6 weeks).

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Surgery:

These procedures are performed by medical doctors (MDs). Surgery is usually only recommended as a last resort. The outcome can be unpredictable1. The surgery for tennis elbow is most commonly "open surgery" and done on an outpatient basis. Also, arthroscopic (tiny instruments/small incision) surgery may be an option, and it also is usually done as an outpatient surgery. Most surgical procedures for tennis elbow involve removing diseased tissue. All surgery has risks. Those associated with the surgery for tennis elbow include: infection, nerve and blood vessel damage, possible prolonged rehabilitation, loss of strength, loss of flexibility, and the need for further surgery.

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Ultrasound and Phonophoresis:

These procedures are done by physical and occupational therapists. They use ultrasound equipment to deliver high frequency sound waves into the affected area and multiple sessions are usually done. The sound wave energy results in local heating/warming of the targeted tissues.

Often a corticosteroid cream or other medication is applied to the skin over the affected area and this medication is pushed through the tissue using the ultrasound waves (this combination is known as phonophoresis) There is little to no medical evidence that ultrasound is effective in the treatment of chronic tennis elbow or other tendinopathies52. Sometimes this is covered by insurance, but now certain health insurance companies are beginning to deny payment for this form of treatment.

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