Practical changes • Identify and eliminate the cause of the problem. If this is due to sport, the grip size of the racket, stick or club may need to be adjusted or faulty actions or training regimes reassessed
• Give the patient a full explanation of the injury – this has been found to be beneficial in teaching them how to modify aggravating activities and achieve recovery as quickly as possible
• Encourage patients to lift or grip using supination rather than pronation
• Elbow or forearm supports which are designed to alter stress to the common extensor origin may also be useful
Corticosteroid injection
This is the most common and effective treatment particularly in the early stages of management where inflammation is a key factor. Once the degenerative process becomes predominant corticosteroid injection may not be as effective.
Rest from the aggravating factors is necessary after the injection which will reduce the pain and inflammation. Normal pain free movement will then encourage alignment of collagen fibres and mobility of the scar tissue.
Injection techniques • Sterilise the injection area and vial cap using surgical spirit
• Use a single dose vial to avoid the possibility of contaminants in the injection solution
• With the patient’s forearm resting in 90 degrees flexion and fully supinated, the facet of tendon attachment to the humerus faces forwards and is about the size of the patient’s little finger nail
• Palpate to find the area of greatest tenderness
• This area can also be identified by asking the patient to extend their hand against your resistance
• Mark this point with a pen or thumb pressure and insert the needle from an anterior direction, perpendicular to the facet (Figs.2&3)
• A guidance dosage is 10mg of corticosteroid such as Kenalog, made up to a total volume of 1ml with a 1% solution of lidocaine
• The injection should be delivered by a ‘peppering’ technique – injecting several small droplets of the solution into the tender areas via one skin puncture
Other treatment options
• Mill’s manipulation – can only be used at the teno-osseous site and aims to elongate the scar tissue by rupturing adhesions at the teno-osseous junction
• Transverse friction massage – best used before Mill’s manipulation to soften the scar tissue and numb the area
• Central mobilisation of the cervical spine – cervical lesions can refer pain into the forearm and mimic tennis elbow
• Neural mobilisation of the radial nerve – the posterior interosseous nerve passes through the two heads of the supinator muscle at the elbow and may be a site of possible nerve entrapment
• Acupuncture – traditional acupuncture points along the appropriate meridians may be chosen or acupuncture can be applied on a trigger point basis
• Electrotherapy – ultrasound is a commonly used modality for tennis elbow. It improves extensibility of mature collagen by promoting reorganisation of collegen fibres
KEY POINTS • There is no definitive cure for tennis elbow
• Several treatment options exist and selection of these must be based on the individual
• Early management is key to the treatment being successful
• Chronic tennis elbow results in degenerative changes which significantly reduce the success rate of treatment
FACTS Of the total diagnosed:
• 34-64% are associated with overuse in work related activities
• 8% are associated with tennis players (although 50% of professional tennis players will suffer at least one episode of the condition)
• Incidence peaks between the ages of 35-54
• Average episode lasts between six months and two years
Figures 3 and 4: Point and direction of injection
Monica Kesson MCSP, Dr Ian Davies RCGP and Elaine Atkins MCSP are course principals for the Society of Orthopaedic Medicine, which runs courses on the diagnosis and treatment of non- surgical musculoskeletal lesions. For more information about these courses telephone (01795) 535168.