Aoife’s experience of tennis elbow

Aoife is a 35 year old mother of three young children who started getting pain in her right elbow about five months previously. She could not recall any specific injury or event which triggered the problem although she did remember that the pain was initially a mild aching in her elbow for a couple of months but then got suddenly much worse after painting a bedroom at home. Since then the pain has been severe when doing even everyday tasks such as brushing her hair, turning the key in the lock and picking up even light objects or pouring the kettle. In fact she decided to go to the doctor when she found that she almost dropped a saucepan of boiling water because of the sudden pain in her elbow.

Her GP told her that it was probably tennis elbow and recommended physiotherapy. He explained to her that physiotherapy for tennis elbow was usually very effective. The GP also suggested an steroid injection to help with the pain. Aoife declined the steroid injection and instead sought physiotherapy. The GP also advised her to take anti-inflammatory medication.

When I first assessed Aoife, she told me that she was sceptical that the problem really was tennis elbow – particularly as she hadn’t played tennis since she was a child. In fact she reported doing no regular sport or exercise for the past 10 years. I explained that in fact most cases of tennis elbow have nothing to do with playing tennis and that it is simply the common name for a problem with the common extensor tendon at the elbow. However during the assessment it is very important to rule out other causes of elbow pain such as referred pain from the neck or shoulder, compression of one of the nerves that run down the arm, problems with the joints in the elbow or other tendon problems.

In this case, the GP was absolutely correct in the diagnosis and the problem was indeed related to pain from the main tendon at the elbow. This tendon is vulnerable because all of the muscles on the back of the forearm that extend (lift up) the wrist and fingers narrow to this one single tendon. It can easily develop changes in the tendon (called tendinosis) that make the tendon painful and weaker. The problem is usually triggered by a sudden change in the activity levels of the tendon. It used to be assumed that the pain was due to inflammation. However now we know from research studies that there are usually no inflammatory cells in this condition (an indeed in many tendon disorders). This probably explains why Aoife was not finding any real improvement from taking the anti-inflammatory medications.

I outlined the nature of tennis elbow to Aoife and we talked through the treatment options. I summarised the research evidence for the condition. Aoife was particularly interested in knowing whether she should have a steroid injection. The research evidence on steroid injections for tennis elbow is quite clear. A review of 13 studies published in the journal Pain in 2002 has shown that injections show significant benefit at six weeks but after this point show no benefit. When compared with physiotherapy people who had a steroid injection were worse after 6 months. Therefore the best type of treatment for this condition with the least risk is to have physiotherapy. However if the pain so severe that the patient cannot carry out physiotherapy then there is a case for having a steroid injection first.

In Aoife’s case, she was able to participate in physiotherapy, therefore a steroid injection was not indicated. However she was in significant amounts of pain and wondered if there were any other options to reduce it. We therefore discussed the evidence for acupuncture. I explained that a review of 6 research studies published in the journal Rheumatology in 2004 has shown that acupuncture has strong evidence for the short term relief of pain. The risks and side effects of having acupuncture (compared to a steroid injection) are minimal. My clinical experience has shown that often a short course of acupuncture can help to compliment physiotherapy exercises and settle the pain down whilst waiting for the physiotherapy exercises to have their effect.

We therefore agreed a treatment plan. I would teach Aoife her physiotherapy exercise programme and then she would undergo 4-6 sessions of acupuncture and carry out the exercises at home. Acupuncture has been shown to be most effective when carried out regularly so the sessions were scheduled for twice weekly.

After 5 sessions of acupuncture, Aoife reported that her pain was 60% better and this allowed her to increase the intensity of her exercises. The physiotherapy exercises that I prescribed are a very specific kind of exercise that focus on strengthening the problematic tendon. The most important element of the exercise however is to build up gradually. Tendons do not respond well to sudden changes in the intensity of exercise. I always say to patients that tendons don’t like change and we almost have to trick them into thinking that the exercises are not increasing in intensity. Typically it takes 6 weeks before there is a significant difference and 12 weeks before there is full resolution.

Aoife carried out her exercises diligently every day and was able to progress the intensity gradually without any major flare-ups. At one stage the elbow got a little worse again for a few days after over-doing it but this quickly settled down by taking the exercises back a stage for a few days and building up again.

Eventually by week 10, the elbow was 90% better and we spent some time making sure that the shoulder girdle posture was correct when carrying out lifting activities. Over the subsequent 2-3 weeks the pain completely resolved and Aoife has not had a recurrence since.