Tennis elbow (lateral epicondylitis or lateral elbow tendinopathy) is a self-limiting condition in most patients. Surgery is often offered to patients who fail to improve with conservative treatment. However, there is no evidence to support the superiority of surgery over continued nonoperative care or no treatment. New evidence also suggests that the prognosis of tennis elbow is not influenced by the duration of symptoms, and that there is a 50% probability of recovery every three to four months. This finding challenges the belief that failed nonoperative care is an indication for surgery. In this annotation, we discuss the clinical and research implications of the benign clinical course of tennis elbow.

Cite this article: Bone Joint J 2023;105-B(2):109–111.

Autologous injection of platelet rich plasma (PRP) stimulates healing process in degenerated tendons. The purpose of this study is to compare the functional outcome of lateral epicondylitis treated with PRP and steroid injection. Tennis elbow patients who failed conservative medical therapy were included and were allocated randomly steroid group (n=70) and PRP group (n=63). Data were collected before procedure, at 4, 8, 12 weeks, 1 year and 2 years after procedure. The main outcome measures were visual analogue score, Mayo elbow performance score, DASH score and hand grip strength. Successful treatment was defined as more than a 25% reduction in visual analogue score or DASH score and more than 75 score in Mayo elbow performance score. We observed that 35 of the 70 patients (50%) in corticosteroid group and 47 of the 63 patients (75%) in PRP group were successful, which was significantly different (p<.001), according to DASH score 37 of the 70 patients (53%) and 47 of the 63 patients (75%) in the PRP group were successful which was also significantly different (P = .005), Mayo elbow performance score was successful in 36 of the 70 patients (51%) in corticosteroid group and 49 of the 63 patients (78%) in PRP group. The improvement in hand grip strength of hand from 24.7kg (mean) 26kg in corticosteroid group and 23.5kg (mean) to 32.9kg (mean) in PRP group. PRP injection for chronic lateral epicondylitis reduces pain, improve functionality and hand grip strength when compared to steroid injection

Platelet Rich Plasma (PRP) has shown to be a general stimulation for repair and 1 year results showed promising success percentages. To determine the effectiveness of PRP compared with corticosteroid injections in patients with chronic lateral epicondylitis with a two-year follow-up. A double-blind randomized controlled trial was conducted between May 2006 and January 2008. The trial was conducted in two Dutch teaching hospitals. 100 patients with chronic lateral epicondylitis were randomly assigned to a leucocyte-enriched PRP group (n=51) or in the corticosteroid group (n=49). Randomization and allocation to the trial group were carried out by a central computer system. Patients received either a corticosteroid injection or an autologous platelet concentrate injection through a peppering needling technique. The primary analysis included Visual Analogue Scale (VAS) pain scores and Disabilities of the Arm, Shoulder, and Hand Outcome (DASH) scores. The PRP group was more often successfully treated than the corticosteroid group (p<.0001). Success was defined as a reduction of 25% on VAS or DASH scores without a re-intervention after 2 years. When baseline VAS and DASH scores were compared with the scores at 2 years follow-up, both groups significantly improved across time (intention-to-treat principle). However, the DASH scores of the corticosteroid group returned back to baseline levels, while the PRP significantly improved (as-treated principle). There were no complications related to the use of PRP. Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and increases function significantly, exceeding the effect of corticosteroid injection even after a follow-up of two years. Future decisions for application of PRP for lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible costs and harms as well as benefits

Goodfellow & Bullough (1968) first described the pattern of articular cartilage wear in the elbow. More recent post mortem studies have shown that advanced degenerative changes can develop in the radio-capitellar (lateral) compartment of elbow joints of elderly subjects in which the humero-ulnar (medial) compartment remains remarkably well preserved. The significance of this post-mortem findings,in an elderly population, with unknown elbow symptom logy, who died from diverse causes, is unknown. There has been no clinically based,in vivo,study of this subject. Our study would support these observations, but indicates that symptomatic degenerative change occurs at a much earlier age than had previously been thought. We have reviewed the findings in a consecutive series of 117 elbow arthroscopies performed on patients with elbow pain resistant to conservative treatments (age range 21–80 years: mean age 51 years). We documented established degenerative changes involving articular cartilage in 68 patients (59%). In this group we found that in 60 patients (88%) the degenerative changes were confined to the lateral compartment and contrasted with normal appearances of the articular cartilage of the medial compartment. The findings presented in this work are in full agreement with previous work on the articular wear and biomechanics of the elbow joint. Previous studies which have been on cadaveric specimens, with findings of uncertain symptomatic relevance. To our knowledge, this finding has not previously been demonstrated in a symptomatic, young population. Unicompartmental lateral degeneration of the elbow is therefore a real clinical entity rather than a interesting post mortem finding. As such, it demands consideration in terms of investigation, diagnosis and treatment. It is likely that in the past, many patients have been misdiagnosed as having chronic lateral epicondylitis. We consider that lateral compartment degenerative change is a distinct clinical entity. It begins in relatively young patients in whom the x ray appearance may be normal or near normal and is often diagnosed as lateral epicondylitis. Our observations taken together with the reported post mortem studies indicate that primary osteoarthritis of the elbow begins in the lateral compartment of the joint and may remain confined to the lateral compartment throughout life. We believe that new treatment strategies need to be developed specifically for patients with primary osteoarthritis as opposed to degenerative joint disease due to other causes

OBJECTIVE: The purpose of this study is to examine the effect of a single percutaneous injection of platelet-rich-plasma compared to an injection of corticosteroids in patients with chronic lateral epicondylitis. BACKGROUND: Lateral epicondylitis is a common problem that usually resolves with nonoperative treatments. Platelet Rich Plasma (PRP) is a component of whole blood that contains concentrated amounts of powerful growth factors. PRP has been used for a variety of orthopedic applications including tendinopathy, wound healing and spinal fusion with varying degrees of success. Buffered PRP has also been used to enhance cell proliferation in-vitro. HYPOTHESIS: Treatment of chronic severe lateral epicondylitis with buffered platelet-rich plasma will reduce pain and increase function in patients considering surgery for their problem. METHODS: One hundred patients with persistent lateral epicondylar pain were evaluated in this study. All these patients were initially given a variety of nonoperative treatments. These patients had significant persistent pain for at least 3 months despite these interventions. All patients were considering surgery. This cohort of patients who had failed nonoperative treatment was then given either a single percutaneous injection of platelet-rich plasma (experimental group, n = 50) or corticosteroids (control group, n = 50). RESULTS: PRP has a significant better effect on lateral epicondylitis than corticosteroid injections. CONCLUSION: This in-vivo data suggest that tendon healing is occurring in lateral epicondylitis using PRP

Aims. Lateral epicondylitis is a frequent pathology usually resolved with conservative methods but ocasionally evolve to chronic unresolved tendinosis. Bipolar Radiofrequency has potentially the effect to stimulate a healing response on chronic tendinosis. We present the results of 15 cases with chronic epicondylitis treated with Bipolar Radiofrequency. Methods. Fifteen patients with chronically lateral epicondylitis and previously failed conservative treatment during 6 months with antiinflamatory drugs, phisiotherapy and at least 3 corticosteroid injections were treated with open Bipolar Radiofrequency. Using local anesthesia, and through a 2 cm incision the tendon was stimulated using the TOPAZ ward (Arthrocare,CA). It was done at 5 mm. distance intervals in a clock-wise fashion in the symptomatic area. The incision was closed with 2 sutures and a compressive bandage was applied. No movement was restricted and rehabilitation began immediately. Results. After an average follow-up of 18 months (6–24), results were excellent in 14 cases and good in one case. The postoperative VAS scores were decreased by 60% at 7 days postoperative, 80% at three weeks and 95% at 6 months. Return to job was at an average of 3 weeks (15 days–4 weeks). All patients were satisfied with the result. Conclusions. Bipolar Radiofrequency is an alternative, effective and safe method for treatment of chronic lateral epicondylitis when conservative treatments are not effective

Aims: Primary aim of this study was to evaluate the inßuence of simultaneous local anesthesia on the clinical outcome after repetitive low-energy extracorpreal shock wave therapy (ESWT) for chronic tennis elbow. Methods: 51 patients were treated in a randomized single-blind international multicenter trial with a parallel-group design and blinded independent observer to evaluate low-energy ESWT with local anesthesia versus placebo ESWT with local anesthesia for patients with a chronic tennis elbow at three-month follow-up. 85% of patients of the verum group did not achieve good/ excellent results in the Roles & Maudsley score, they were offered once again application of the identical active treatment concept, this time without local anesthesia. 80% of the patients of the placebo group did not achieve good/excellent results, they were offered crossover therapy, i.e. identical active treatment with local anesthesia. Results: Reception of active therapy without local anesthesia resulted in excellent or good outcomes in 80% of patients of the original verum group at three-month follow-up, while application of active therapy with local anesthesia lead to good outcomes in 27% of the original placebo group (p= 0.0092, power= 0.8). Conclusions: Local anesthesia has a negative inßuence on the clinical outcome after repetitive low-energy ESWT for chronic tennis elbow

Tennis elbow (lateral epicondylitis) is a common upper limb condition, possibly resulting from angiofibroblastic degeneration. Conservative treatment comprises corticosteroid injections, rest and splints, however, occasionally surgery is necessary. Recent data comparing Botulinum Toxin Type A (BTX-A) (Botox®, Allergan Inc, Irvine, CA) with surgery suggested BTX-A is effective in treating resistant tennis elbow by providing temporary, reversible paralysis of affected muscle, thereby alleviating tensile forces and allowing tissue healing. This double-blind, randomised, controlled trial compared BTX-A with placebo in 40 patients with chronic tennis elbow (> 6 months). Recruited patients were randomised to 50U BTX-A+2mL normal saline or 2mL normal saline (placebo). Injections were administered 5cm distal to the maximal area of lateral epicondyle tenderness. Quality of life (SF-12), pain (visual analogue scale) and grip strength (Jamar dynamometer) were assessed pre- and 3 months post-injection in both affected and non-affected arms. Following BTX-A treatment patients had average 19% improvement in grip strength in the affected arm compared to average 2% for placebo, however, this difference did not reach statistical significance (p=0.08, 95% CI −2.31, 35.64). No difference between the groups was seen for the unaffected arm (BTX-A 4% improvement, placebo 1% improvement). Both groups showed similar improvements in pain assessment and also in quality of life. BTX-A treated-patients demonstrated improved grip strength in the affected arm compared to placebo, however this difference was not statistically significant

We report a controlled, prospective study to investigate the effect of treatment by low-energy extracorporeal shock waves on pain in tennis elbow. We assigned at random 100 patients who had had symptoms for more than 12 months to two groups to receive low-energy shock-wave therapy. Group I received a total of 3000 impulses of 0.08 mJ/mm² and group II, the control group, 30 impulses.

The patients were reviewed after 3, 6 and 24 weeks. There was significant alleviation of pain and improvement of function after treatment in group I in which there was a good or excellent outcome in 48% and an acceptable result in 42% at the final review, compared with 6% and 24%, respectively, in group II.