Corticosteroid injections for tennis elbow could do more harm than good, reports the BBC News summarising a study in The Lancet published October 2010.

The BBC story continued “It found that injections reduced pain for the first few weeks, but made the condition worse in the long term.”
Brooke K. Coombes of the University of Queensland and his researchers analysed the treatment of tendinopathy in more than 2,600 patients from 41 previous studies.
Writing in The Lancet, the authors concluded: “Our systematic review challenges continued use of corticosteroid injections by providing strong evidence that they are worse in the long term than are most conservative interventions for tendinopathy.”

This was particularly true for the treatment of lateral epicondylitis, known as tennis elbow.

The research found that in treating tennis elbow, corticosteroid injection had a large effect on reduction of pain compared with placebo in the short term, from three to six weeks.
But treatment with injections over a longer period, from four to six months up to 12 months, was not found to be beneficial.
In fact, researchers found that it made the pain from tennis elbow worse.
See Tennis Elbow Lateral Epicondylitis Therapy – Injection for Tennis Elbow? for other types of injections.

Tennis Elbow Injections do No Harm

These conclusions are disputed on NHS Website
The research demonstrates a short-term benefit of corticosteroids compared with doing nothing for pain related to tennis elbow, but that this particular treatment has no effect in the longer term. There is no conclusive evidence that the steroid injections ‘do more harm than good’ as suggested by the BBC News headline. Some of the studies favoured the treatments that the corticosteroids were being compared against. However, this was often in single-study results (not pooled results) and was not the case for all comparators.
An editorial that accompanies this article suggests, “today’s review might discourage clinicians from using corticosteroids in patients who are seeking medium-term and long-term cures”. It says the clinical implication here is that one corticosteroid injection is not helpful for elbow pain at 6 to 12 months, and that multiple injections do not improve outcomes. However, given the shortage of studies for some of these analyses, especially of alternatives to corticosteroid injections for tennis elbow, the short-term benefits may still be better than nothing for many patients. The editorial says that “there is no compelling evidence that any injection for tendinopathy is a magic bullet”.

Tennis Elbow / Lateral Epicondylitis Exercises are Best

Experts say exercising the affected area is preferable.

Writing about the findings in The Lancet, Dr Alexander Scott and Dr Karim Khan from the University of British Columbia in Canada, recommend exercise as the best way to cure tendinopathies.

“Specific exercise therapy might produce more cures at six and 12 months than one or more corticosteroid injections.”
Dr Khan said: “It sounds old-fashioned but specific exercise programmes are better than rest.”
“Exercise stimulates the tendon to repair by stimulating the tendon cells to make new proteins.”
“Tennis elbow and other tendinopathies have been shown to be a failure of tissue, not a result of inflammation, so exercise is the right thing to do.”

Conclusions

Draw your own conclusions if you will.

If you want mine :
I think that the injections are useful for a few months
BUT they have to be given to patients who are going to work at their stretching and strengthening programmes.

I think this is the best approach.
I would go as far as to say that the patient should demonstrate that they are doing stretching etc before they are given the injection!
I believe this would greatly improve the results….

Please Share your Comments Below

This video show some basic exercises to get you started. Take my Tennis Elbow Video Assessment for a full assessment of your problem for FREE

Take Our Medial and Lateral Epicondylitis Elbow Injuries Video Assessment Tool

The video playing on the left is a snapshot of many tests that you will interact with.
Depending on your answer you are then taken to the next video -
until you reach the point where I tell you what type of problem you have.


I will get you to check whether your neck is responsible for some or all of your pain.
Does your elbow joint work perfectly? – if not it is a major factor in your problem.
Is the pain coming from other muscle groups in your arm? – I will find out for you.
Do you have problems with your Radial Nerve? – I’ll help you decide.

So You Have Tennis Elbow Lateral Epicondylitis? Or Do You?

Are you sure it’s Tennis Elbow Lateral Epicondylitis?

Is it coming from Your Neck?

Do you have a Radial Nerve problem?

Have the soft tissues shortened?

Will exercise aggravate your Elbow?

Are you doing the right kind of exercises for your type of Tennis Elbow Lateral Epicondylitis?

Find Out for FREE!!

Self-Assess your elbow injury

We are different from other Tennis Elbow Lateral Epicondylitis sites

We deliver tailored exercise programs to your inbox

Generic “one size fits all” regimes currently flood the rehabilitation market.

Instead of building the website and then seeking feedback, we are doing things a little differently.

Our customers have an input into our site and shape content there.

Come to a site that delivers what you are looking for!

Take Our Medial and Lateral Epicondylitis Elbow Injuries Video Assessment Tool

Are you sure you have Epicondylitis?

Find out here!

Posterior view of left Humerus

EPICONDYLITIS EPICONDYLOSIS

Epicondylitis – means inflammation of the epicondyle or the structures attached to it. Epicondylosis is probably the more correct term to use as the condition is more often longstanding and this involves degenerative changes in the structures involved.

At the elbow you have two epicondyles one on the inner aspect of the lower humerus – the medial epicondyle (A in fig 1) and one on the outer aspect of the lower humerus the lateral epicondyle (B)

An epicondyle is an bony prominence near the “knuckle end” or rounded surface of the bone that forms the joint. It is there simply to make it easier for muscles or ligaments to attach close to the joint. An epicondyle is a raised bump of bone which has a greater surface area than a flat area of bone so generally you will find several muscles attached to an epicondyle because there is more space.

To control your elbow you actually have 16 muscles which cross the joint. There are four or sometimes five muscles that attach to the lateral epicondyle and four that attach to the medial epicondyle.

Lateral Epicondyle of Left Elbow

ELBOW LATERAL EPICONDYLITIS

In Elbow Lateral Epicondylitis it is the tendon of muscles on the outer elbow that may become inflamed or more likely undergo degenerative changes (generally through overuse or excessive strain) and painful whenever you use them.

The main muscles that attach to the lateral epicondyle are called :-

Extensor Carpi Radialis Brevis & Extensor Digitorum

TENNIS ELBOW LATERAL EPICONDYLITIS

Tenis elbow and lateral epicondylitis are one and the same thing with possible inflammation of the elbow tendons in the acute case, and more commonly, degeneration of the small tendons that connect these muscles to the lateral epicondyle. Tennis Elbow injuries are caused by repeated gripping tasks like DIY jobs and hitting numerous backhand volleys with bad technique. Also recently a very common cause of Tennis Elbow injury is playing the Nintendo Wii for hours. See my post on Wii Elbow.

REFERRED PAIN FROM NECK AND SHOULDER

Irritation of of the nerves in your neck from a disc bulge or some joint inflammation can cause pain to travel down your arm to the elbow and can feel like and present as Tennis Elbow.

Inflammation of soft tissues around the shoulder joint can refer pain down the arm to the elbow which can complicate the diagnosis of Tennis Elbow.

In addition there are a few sites in the arm where one of the the main nerves – the Radial Nerve – can get trapped or irritated and this specifically can replicate the pain and signs of Tennis Elbow!

Are you still sure you have Tennis Elbow?

Take my comprehensive FREE Assessment Tool HERE!

TENNIS ELBOW MUSCLES

These muscles are involved primarily in movements of the wrist and hand, but as they are attached to the humerus they cross both the wrist and elbow joints. In the body the muscles most susceptible to injury generally cross more than one joint. Think of the most common muscles to get injured and you get Hamstrings, Calf, Biceps etc – they all cross more than one joint.

The muscles attached to the lateral epicondyle are

1. Extensor Carpi Radialis Brevis
2. Extensor Digitorum
3. Supinator
4. Extensor Carpi Ulnaris

For More Information – see ESSENTIAL ANATOMY OF FOREARM MUSCLES 

or

TENNIS ELBOW – YOUR TOP 10 QUESTIONS ANSWERED

I want you to understand what Tennis Elbow actually affects, what you need to understand about the condition and then work out for yourself what you can do about it (that’s the DIY bit in DiyInjuryRehab.com).

You’ve probably read it all before about Tennis Elbow being an overuse injury that is caused by repetitive gripping tasks such as using a screwdriver or using power tools, that it affects between 1 and 4% of the population and that 30-40% of tennis players actually do get it!!

Well it’s all true! But I would like to take a slightly different approach. I am going to educate you to fix yourself!

Tennis Elbow can be quite persistent and can be troublesome for anything up to two years. It can become severe and in some cases requires surgery to resolve it! In 75% of cases it affects the elbow on the dominant hand side and this has serious implications for work and sport. It is important to get to grips with Tennis Elbow in the early stages and prevent it from becoming severe and chronic.

These posts on Tennis Elbow will help you understand what the condition involves and what you can do about it now to resolve it.
This post will explain:-

• anatomy of the elbow
• how the elbow moves
• what is tennis elbow?
• what causes tennis elbow?

Elbow Anatomy

There are three bones that make up your elbow joint.

First there’s the upper arm bone called the humerus which runs from your shoulder to your elbow.

Joining with the humerus at the elbow joint are the two forearm bones called the radius and the ulna.
If you stand with your arms by your sides and your palms facing forwards the ulna is the bone on the ‘inside’ nearest to your body.
It forms a ‘hinge’ joint with the humerus.

The radius lies on the outside of your forearm and has a button-like end which takes part in the elbow hinge.
It is also involved with palm up and palm down rotation of the forearm. (Pronation and Supination)

The radius and ulna are joined to each other just below the elbow and also just above the wrist joint.
These joints allow the radius to rotate around the ulna which stays stationary.
To demonstrate this bend your elbow to a right angle with your palm facing up – in this position the radius lies on the outside of the ulna at the elbow and the wrist.
Now if you turn your palm to face downwards the radius crosses over the ulna and now it is on the inside at the wrist (but still the outside at the elbow).
Click on the video for a demonstration.

If you feel the outside of your elbow you will find a distinctly sharp bony prominence which sticks out – this is called the lateral epicondyle. It is the lower part of your humerus bone. If you keep your finger on this bony lump and waggle fingers your will feel the muscles attached to this bump moving under your finger. 

Elbow Movements

As you can see from the video clip above the elbow movements are quite simple.

Flexion is bending of the elbow
Extension is straightening of the elbow
Pronation is when the palm faces down
Supination when the palm of the hand faces up

However none of the muscles that are used to produce these elbow movements are directly involved in Tennis Elbow.

What Is Tennis ELlbow?

It is thought that Acute Tennis Elbow consists of microscopic tears in the attachment of the muscle to the bone.
This tearing results in the stimulation of the repair process which increases collagen production and blood vessel growth.
This increase in blood vessels may explain the pain that is felt as well as a local increase in temperature.

However is is more commonly thought that even acute tendinitis is due to a sudden increase in stress which causes further problems for an already degenerated area of tendon.
The thinking is that the pain is produced by the new blood vessels and nerves at the repair site rather than from a local inflammatory response.

A key feature of chronic inflammation and degenerative changes is collagen production.
If too much collagen is formed, this can lead to a condition known as fibrosis.
As stated above collagen is necessary to replace the tissue lost during long term inflammation or degeneration, however the overproduction of collagen over time can lead to excessive scarring and functional shortening of the muscle interfering with it’s function.
In addition when your elbow is painful for a period of time the your brain adapts and you start to use the muscles in the arm differently and this can lead to problems elsewhere in the arm and neck.
These problems may well have to be corrected before you can use your elbow efficiently again and get rid of your pain – so it is always advisable to be assessed by a good physiotherapist (or other specialist) if you have chronic elbow pain.

Tennis Elbow Causes?

So you may be wondering why most tennis elbow pain seems to associated with gripping – you know that using a screwdriver, stripping wallpaper or practising a tennis backhand aggravates your pain. Well the reason takes a bit of explaining. 
The muscles that attach to the lateral epicondyle all are attached to the bones of the hand and they produce movements at the wrist and hand.

Movements at wrist:

      extension,                         flexion,                       radial deviation,             ulnar deviation.

The muscles associated with Tennis Elbow all produce extension of the wrist, and at least one from the group helps produce radial deviation, and one ulnar deviation.

To grip strongly you need to extend your wrist – this extension gives the muscles on the front of your forearm what is known as a mechanical advantage when producing gripping power.
Try gripping with your wrist fully flexed then the try again with your wrist extended.
It is much easier to generate power with your wrist extended isn’t it!
So although you don’t use the muscles on the back of your forearm to directly produce the grip strength in your hand you use them to help the muscles on the front of your forearm generate the power by positioning the wrist. 

I mentioned earlier that the muscles in the body that cross more than one joint are the ones most susceptible to injury. The simplest explanation for this is opposing movements can be simultaneously taking place at the two joints the muscle crosses.
This places complex movement patterns on the muscle which tries to do two things at the same time which makes it more prone to injury.
In the case of the Tennis Elbow muscles they are positioning the wrist and hand to allow you to get a strong grip- imagine using a screwdriver.
However at the same time you are frequently moving your elbow joint – remember these muscles are attached on the upper side of the elbow.
Trying to maintain the wrist position while moving at the elbow and pronating and supinating the forearm constantly changes the stress on these muscles.
Can you now start to understand why they get overused, are subject to microtrauma and degeneration, and get painful?

In addition to these stresses, raquet sports add further loads to these muscles.
Just imagine the extra load being applied by the impact of the ball on the raquet head in this picture!
The wrist extensors attached to the lateral epicondyle are having to stop the wrist from ‘breaking’ and keeping it firm to control the ball’s flight.
If you remember any of your school physics then you will recall that

EFFORT = LOAD X DISTANCE. 

Now think about the speed of the ball (loosely the Load = mass x acceleration) and look how far the ball is away from the wrist and start to calculate the increase in the ‘breaking’ force at the wrist!!

Be careful not to hit wet tennis balls – they weigh more and increase the load significantly!
Also your racquet needs to be strung appropriately for you. Increased tension in the strings increases the ‘forces’ generated in the racquet. These forces need to be controlled by the wrist and forearm.
It is essential that the grip of your racquet is appropriate to the size of your hand.
If you have any problems I would strongly advise seeking the advice of a professional tennis coach.

That is why you get Tennis Elbow with tennis backhands and also gripping activities, AND why avoiding gripping tightly will help your elbow to get better quicker!!

To summarise, you now should have an understanding of

• the anatomy of the elbow region
• movements at the elbow and forearm joints
• what Tennis Elbow is
• why gripping and raquet sports cause Tennis Elbow