Upon diagnosing elbow tendinopathy, the initial management plan usually includes activity modification, counterforce bracing, physiotherapy, and oral analgesics. Icing, NSAIDs, and glucocorticoids have limited evidence supporting their efficacy, and these therapies may cause more harm than good. Alternative modalities such as extracorporeal shockwave therapy, neuromuscular electrical stimulation, and acupuncture have also varying evidence.(1) In my experience, many patients continue to have persistent pain for many months despite the above conventional therapies. Others have some relief with rest only to have a recurrance of symptoms as soon as they try to return to their usual level of sports.
Topical Nitroglycerin: Nitric oxide may stimulate collagen synthesis and improve tendon healing. One controlled trial demonstrated improvements in symptoms and function of using a transdermal nitroglycerin patch compared to a placebo over six months. (1)
Prolotherapy: A recent systematic review found Hypertonic Dextrose Prolotherapy to be superior to corticosteroid for lateral epicondylitis for pain and a function score. However, the studies were generally small and larger studies are need to ensure reproducibility.(2)
Platelet-rich plasma: Compared to corticosteroid controls, PRP was superior to corticosteroids for pain and function scores in a systematic review of 26 RCTs with follow-up to 104 weeks.(4) The main disadvantage with PRP is the requirement of multiple costly treatments, and it is not usually insurance covered.
Hyaluronic Acid: Health Canada recently approved a soft tissue-adapted biocompatible Hyaluronic Acid product for lateral epicondylitis. A large study (n=331) done at Fowler Kennedy in London, Ontario, in patients with chronic (> three months) lateral epiepicondylitis, found that the injection allowed patients to return to pain-free and disability-free sport in 18 days. In contrast, no patients in the control group achieved this outcome after 365 days of follow-up.(5) A systematic review of this type of product for tendinopathies found no serious adverse events in 19 clinical trials.(6) This product is approximately ten times the cost of corticosteroids, yet it is not associated with the harm to soft tissue that is typically associated with corticosteroids. Fortunately, this option is covered by most third-party insurance.
Ultrasound-guidance: Due to the unique anatomy considerations in this location, the use of ultrasound guidance provides the best and safest outcome for patients. For the hyaluronic acid product in particular, the target is the peritendon which requires much precision.(7)
Conclusion: In my clinic, I use a comprehensive approach to lateral elbow tendinopathy, combining evidence-based strategies with image-guidance to optimize patient outcomes and facilitate long-term recovery. Please contact me if you would like to discuss a case with me, or send me a referral for consultation, so I may assist your practice.
References: 1. Uptodate.com “Elbow tendinopathy (tennis and golf elbow)” 2. Cureus. 2022 Dec; 14(12): e32560. 3. Archives of Physical Medicine and Rehabilitation. 2022; 103(11): 2209-2218. 4. Orthop J Sports Med. 2022 Apr; 10(4): 23259671221086920. 5. BMC Sports Sci Med Rehabil 2010; 2(4). 6. Journal of Back and Musculoskeletal Rehabilitation, vol. 35, no. 5, pp. 949-961, 2022 7. Diagnostics (Basel). 2023 Feb; 13(4): 717.
This blog from Arthur Musculoskeletal Health is a series of free online medical education posts dedicated to providing online primary care education for physicians, nurse practitioners, physician assistants, residents, and medical students. This blog is not intended to be medical advice for patients; please see your legally qualified medical practioner for your medical condition(s). The information provided is for general and informational purposes only and is not meant to diagnose, treat, or prevent any medical condition. The post information is stated in an individual capacity, and not as a part of my duties at my hospital or academic institutions.