Before turning to surgical intervention (of which a number of options exist for patients whose pain does not respond to conservative treatment6), the clinician may consider use of corticosteroid injections, which are relatively safe and usually have a short-term effect (ie, two to six weeks). Injection therapy for LE is usually considered appropriate for patients with chronic pain and disability that is not relieved by more conservative means, or who experience acute pain with functional impairment.7 Before performing corticosteroid soft-tissue injections, clinicians should consult the appropriate governing agency regarding this advanced practice privilege.
Patients who comply with orthotics and NSAID use and are able to avoid repetitive motion are most likely to see an enduring resolution of symptoms when steroid injections are administered as adjunct therapy. A review of the literature suggests no significant benefit from physical therapy or ultrasonography.8-10
Platelet-Rich Plasma Injections
Local injection of platelet-rich plasma is an alternative based on the understanding that platelets contain growth factors which aid in healing. This has been demonstrated as an effective treatment for LE.11,12 Whole blood obtained from the patient is centrifuged, with platelet-rich plasma then collected for local injection over the lateral epicondyle.
The cost of platelet-rich plasma therapy averages between $300 and $400 per injection (C. Whitney, personal communication, July 14, 2009). According to Mishra et al,12 one injection is ordinarily sufficient.
Patient Education
In-depth education prepares patients for long-term management of LE. Discussion explaining the causes, pathology, duration, and treatment may lead to better self-management for this chronic condition. Exacerbations are easily provoked by return to repetitive activities or direct trauma.
Clinicians who care for patients with LE are urged to emphasize the importance of complying with conservative therapies, avoiding repetitive activities, and adhering to ongoing conservative treatment measures. Follow-up is recommended six weeks after these treatment measures are begun; they should be continued if the patient’s symptoms are improving. Otherwise, further follow-up or referral to an orthopedic specialist can be made at the clinician’s discretion.
Conclusion
Lateral epicondylitis is a common elbow problem that can be diagnosed without difficulty, easily aggravated, and annoying for patients. Noncompliance with recommendations to use orthotics, avoid repetitive activities, and adhere to prescribed medication regimens is the most likely explanation for lack of improvement.
Whether or not your patient plays tennis, appropriate education and compliance with the agreed-on treatment support the optimal outcomes for this vexing condition. The ball is in their court.