The treatment options for tennis elbow

Doctors sometimes recommend very different treatments for both tennis elbow and golfer's elbow. According to the studies done so far, the following treatments can help:

• Stretching and strengthening exercises: Special exercises that stretch and strengthen the muscles of the arm and wrist.
• Manual therapy: This includes active and passive exercises.
• Painkillers: especially non-steroidal anti-inflammatory drugs (NSAIDs).
• Injections: steroid injections.
• Ultrasound therapy: The arm is exposed to high-frequency sound waves. This warms the tissue, which improves the circulation of blood.

The main treatment for symptom relief is usually a combination of stretching and strengthening exercises. NSAIDs are an option for short-term treatment. Steroid injections can also relieve the pain, but they may disrupt the healing process.

Most of the following treatment options for tennis elbow and golfer’s elbow have not been scientifically proven to work.

• Braces / bandages: These are worn around the elbow or on the forearm to take strain off the muscles.
• Injections: Injections into the elbow with various substances, such as Botox, hyaluronic acid or autologous blood (the body’s own blood).
• Extracorporeal shockwave therapy (ESWT): A device generates shock or pressure waves that are transferred to the tissue through the skin. This is supposed to improve the circulation of blood in the tissue and speed up the healing process.
• Laser therapy: The tissue is treated with concentrated beams of light. This is supposed to stimulate the circulation of blood and the body’s cell metabolism.
• Transcutaneous electrical nerve stimulation (TENS): TENS devices transfer electrical impulses to the nervous system through the skin. These are supposed to keep the pain signals from reaching the brain.
• Acupuncture: The acupuncture needles are inserted into certain points on the surface of the arm. Here, too, the aim is to minimize the perception of pain.
• Cold: The elbow is regularly cooled with ice packs.
• Massages: A massage technique called “transverse friction massage” is often used to treat tennis elbow and golfer's elbow. It is applied to the tendons and the muscles, using the tips of one or two fingers.
• Surgery: Different surgical approaches are used. Most of them involve detaching parts of the forearm muscles or separating and destroying the nerves that carry the pain signals.

In the first few days or weeks after the symptoms appear, it makes sense to put as little strain as possible on the arm, and especially to avoid any activities that trigger the pain. If the pain arises when you do specific exercises, for example, then you should stop doing them for a few weeks. If some activities are impossible to avoid completely – like working on the computer, lifting or writing – the strain should at least be reduced enough so that the pain improves.

Some people wear a brace or a bandage to reduce the strain put on the muscles, but it isn’t clear whether this helps.

You can only start to gradually put more strain on the arm and do daily strengthening exercises once the pain has improved a lot.

Special stretching and strengthening exercises can speed up the healing process. Studies have shown that the pain goes away faster in people who regularly do these kinds of exercises. The exercises improve flexibility, too. Manual therapy can also help.

The best studied type of exercises for tennis elbow are known as “eccentric” exercises. This type of treatment involves simultaneously stretching and strengthening the extensor muscles of the forearm. There has not yet been enough research on which eccentric exercises are most effective. It’s also not clear how effective simple stretching exercises are.

According to the studies done so far, it’s most effective to do the exercises about three times a day for about 1 to 3 months. You can start doing them as soon as the pain allows it. It’s important to start carefully and not to put too much strain on your arm. These exercises can make the symptoms of tennis elbow even worse if you overdo it.

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and diclofenac can probably relieve the pain somewhat. They are most useful at the start, when the pain is the most severe. These medicines can either be applied to the elbow in the form of a gel or taken in the form of a tablet. NSAIDs are not suitable for long-term use because they can lead to stomach problems, among other things. There is no evidence to suggest that they speed up the healing process.

Different types of injection-based treatments are often suggested for tennis elbow or golfer's elbow. According to the research on tennis elbow so far, most of them don't live up to their promises. They can also have side effects. These are usually temporary, like pain at the injection site. Each injection is also associated with a low risk of inflammation or injury to the elbow. Most of these injections contain one of the following active ingredients:

• Steroids: reduce the inflammation. Studies show that steroid injections can temporarily relieve the pain. But there is also evidence that they can disrupt the healing process: People who were first given several steroid injections had more pain after a few months than people who didn’t receive any steroid injections. Frequent steroid injections carry the risk of tissue dying (atrophy), for instance, leaving a visible mark on the elbow.
• Hyaluronic acid: A substance made by the body, found in tissue and joints. It is typically used to treat osteoarthritis. One study suggests that hyaluronic acid might be effective in the treatment of tennis elbow. But further research is needed to assess its pros and cons.
• Botox: inhibits the sending of signals between the nerve cells. This has a paralyzing effect on the muscles. According to studies done on this so far, Botox can relieve the pain just a little at most. Also, Botox injections can have side effects like partial paralysis in the fingers that can last several weeks.
• Autologous blood injections: Blood is taken from a vein in the arm and then injected into the elbow. This blood may be treated in different ways before it is injected. One common form of treatment with autologous blood is called platelet-rich plasma (PRP) therapy. It involves separating the blood into its various elements in a centrifuge. Then a concentrated solution of blood platelets is injected into the elbow. Studies show that it's not very effective, though.

So previous research suggests that it's a good idea to be very cautious when injection treatments are offered.

A few studies suggest that ultrasound therapy may have a slight pain-relieving effect. It probably takes about 5 to 10 weeks for treatment using ultrasound waves to have a noticeable effect. This treatment hardly has any side effects.

There is currently no evidence that the following treatments are effective: extracorporeal shockwave treatment, transcutaneous electrical nerve stimulation (TENS) and laser therapy. Some good-quality studies looked into these treatments, but they didn’t find any pain-relieving effect. The extracorporeal shockwave treatment in particular can have side effects, though. People in the studies experienced skin redness, pain, bruising and nausea, for example.

It’s not clear whether massages or acupuncture help. There is not enough good data to assess how helpful cold pack treatments are.

Surgery usually isn't offered unless the symptoms have lasted for many months or years and other treatments haven’t helped. Based on the few studies that have been done in this area, it's not possible to draw any conclusions about how effective surgery then is.