Keywords: Lateral epicondylitis, Elbow pain, Physiotherapy, Special tests, Differential Diagnosis, Corticosteriod injection, repetitive strain, Surgery, lateral epicondylalgia
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Tennis elbow is the most common cause of pain of the elbow and forearm (Stephens, 1995). It effects approximately 3% of the adult population and is most prevalent in people aged 35-55 years old (Ahmad et al, 2013). Those who are in jobs that require repeated wrist extension are more vulnerable however it appears to effect men and woman equally (Geoffroy et al, 1994). Be sure to rule out cervical or neural origin of pain as this can present in a similar location.
Despite recent high quality evidence that corticosteriod injections may delay tendon healing this appears to have had little effect on clinical practice (Titchener et al, 2013). Inagaki (2013) found that 95% will heal spontaneously or by conservative management alone. This article aims to look briefly at some of the surrounding evidence relevant for us as healthcare professionals.
A little look at the evidence
A recent RCT (Coombes et al, 2013) compared 4 groups:
1.Corticosteroid injection (n = 43)
2.Placebo injection (n = 41)
3.Corticosteroid injection plus physiotherapy (n = 40)
4.Placebo injection plus physiotherapy (n = 41).
Researchers found that participants who had received a corticosteroid injection had an increased risk of recurrence at 1 year follow up compared to the placebo controls. Physiotherapy did not result in any significant difference at one year follow up (Coombes et al, 2013). So although the consensus seems to be that corticosteroid injections are a poor treatment for tennis elbow (BMJ, 2013) why is physiotherapy also having poor results?
So a few questions we need to ask ourselves with this result.
- Is physiotherapy useful in reducing pain in the short term enabling people to get back to work sooner?
- What does the ‘physiotherapy’ consist of and what treatments have an evidence base?
- Do we understand the true pathophysiology and are we treating it appropriately?
- Where are the gaps/grey areas in the research and where do we go next?
The pathophysiology of tennis elbow often involves osteotendinous part of the extensor muscles of the wrist at their origin (normally extensor carpi radialis brevis). As opposed to inflammatory cells, studies have shown degeneration of the tendon and the production of fibroblasts (Alfredson and Lorentzon, 2000) and therefore the old ‘lateral epicondylitis’ is no longer used in the description, lateral epicondylalgia is used instead (Waugh, 2005)
Prof Jill Cook (@ProfJillCook) is a leading researcher in tendinopathies and I would urge you to check out her recent podcast (Physioedge) which explains how tendons move through three stages. This continuum is described in a 2009 paper and discusses reactive, disrepair and degenerative stages in the continuum. Tennis elbow when it appears to us in clinic is likely to be in a degenerative phase and often occurs following chronic overloading. This results in disorganisation of the collagen, increases in vascularity, neuronal ingrowth and advanced break down of the matrix (Cook et al, 2009), which reduces its ability and efficiency to deal with loading.
There are many theories of what may be contributing to the pain, which include vascular changes, biomedical changes, tenocyte changes, biochemical changes, cell changes, ion changes and central mechanisms within the spinal cord and brain (Rio et al, 2013).
So what does the evidence say on treatment?
“This study Some commonly used injection therapies can be considered treatment candidates for lateral epicondylalgia, such as botulinum toxin, platelet-rich plasma and autologous blood injection, but corticosteroid is not recommended. Hyaluronate injection and prolotherapy might be more effective, but their superiority must be confirmed by more research. The peppering technique is not helpful in injection therapies.“
(Dong et al, 2016)
(Nagrale et al , 2009)
Bisset et al. found that corticosteroid injections were statistically and clinically superior at six weeks but significantly worse at 52 weeks compared to wait-and-see and physiotherapy.
(Bisset et al, 2007)
“Deficits in sensory and motor systems present bilaterally in unilateral tendinopathy. This implies potential central nervous system involvement. This indicates that rehabilitation should consider the contralateral side of patients.”
“Corticosteroid injection is beneficial in the short term for the treatment of tendinopathies but may be worse than other treatments in the intermediate and long terms. No clear evidence of benefit of other injections was shown, except for sodium hyaluronate in the short and long term.”
“ Insufficient evidence to support the use of acupuncture to achieve long-term results for lateral epicondyle pain. However, the results did indicate that acupuncture provided a short-term relief and side effects were low”
(Green et al, 2002)
One study by Haker et al (1991) found ultrasound to be no more superior than a placebo when used 3 x weekly on a pulsed setting. In the absence of evidence for a biological rationale for the use of therapeutic ultrasound and these findings they were unable to recommend ultrasound for lateral epicondylagia.
(Baker et al, 2001)
“The taping technique, as applied in this study demonstrates an impressive effect on wrist extension force and grip strength of patients with TE. Elbow taping also reduces pain at the lateral aspect of the elbow in these patients”
Limitations: Small sample size, no control.
So what should we be doing?
Nilsson et al (2012) found that some patients at 2 years were still experiencing pain and reduced function therefore a sit and wait approach may not be acceptable. They advised that patients should be seen by a physiotherapist or occupational therapist to offer a structured home program.
Below is a huge generalization and you should look at the studies individually, their population sizes and stage of tendon degeneration to fit relevant studies to your individual patient.
Every patient is different however a with a typical presentation you may expect to find ……
- Restore ROM
- Decrease pain
- Improve function
- To restore normal tendon integrity
- Refer on as appropriate
- Pain in lateral elbow region +/- referral.
- Degeneration of the tendon and disruption of the matrix.
- Pain with resisted wrist extension.
- Secondary trigger points and muscle spasm
- Reduced muscle strength wrist extension.
- Reduced function
- Soft tissue mobilisations
- Manual therapy
- Strengthening(eccentric) exercises.
- Deep transverse frictions
- Ultrasound for TRP within muscle
References are not consistently cited in Havard system. Please use other tool to check your references against if reproducing.
Ahmad Z, Siddiqui N, Malik SS, Abdus-Samee M, Tytherleigh-Strong G, Rushton N. Lateral epicondylitis: a review of pathology and management. The bone & joint journal. 2013;95-B(9):1158-64. Epub 2013/09/03.
Alfredson H, Lorentzon R. Chronic Achilles tendinosis: recommendations for treatment and prevention. Sports Med, 2000. 29(2): 135-46.
Aspenberg P. [Local corticosteroid injections for tennis elbow is a Dobeln medicine. A meta analysis shows short-term benefits, but adverse effects in the long run]. Lakartidningen. 2012;109(48):2203-4. Epub 2013/01/22. Lokal kortisoninjektion vid tennis- armbage ar en dobelnsmedicin. Metaanalys visar kortsiktig nytta, men skadlig inverkan pa langre sikt.
Baker KG, Robertson VJ, Duck FA. A review of therapeutic ultrasound: biophysical effects. Phys Ther, 2001. 81(7): 1351-8.
Bisset L, Smidt N, Van der Windt DA, Bouter LM, Jull G, Brooks P, Vicenzino B. Conservative treatments for tennis elbow do subgroups of patients respond differently? Rheumatology (Oxford), 2007. 46(10): 1601-5.
Corticosteroid injections are a poor treatment for tennis elbow. BMJ (Clinical research ed). 2013;346:f748. Epub 2013/02/08.
Geoffroy P, Yaffe MJ, Rohan I. Diagnosing and treating lateral epicondylitis. Canadian family physician Medecin de famille canadien. 1994;40:73-8. Epub 1994/01/01.
Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft W. Acupuncture for lateral elbow pain. Cochrane Database Syst Rev, 2002(1): CD003527
Haker E, Lundeberg T. Pulsed ultrasound treatment in lateral epicondylalgia. Scand J Rehabil Med, 1991. 23(3): 115-8.
Inagaki K. Current concepts of elbow-joint disorders and their treatment. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association. 2013;18(1):1-7. Epub 2013/01/12.
Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the ”tendinitis” myth. BMJ, 2002. 324(7338): 626-7.
Nilsson, P., Baigi, A., Sward, L., Moller, M. and Mansson, J. (2012) Lateral epicondylalgia: a structured programme better than corticosteroids and NSAID. Scand J Occup Ther. Sep;19(5):404-10. doi: 10.3109/11038128.2011.620983.
Peterson M, Elmfeldt D, Svardsudd K. Treatment practice in chronic epicondylitis: a survey among general practitioners and physiotherapists in Uppsala County, Sweden. Scand J Prim Health Care, 2005. 23(4): 239-41.
Stephens G. Lateral Epicondylitis. J Manual Manip Ther. 1995;3(2):50-8
Tichener, A., Brooker, S., Bhamber, N., Tambe, A. and Clark, D. (2013) Corticosteroid and platelet-rich plasma injection therapy in tennis elbow (lateral epicondylalgia): a survey of current UK specialist practice and a call for clinical guidelines. Br J Sports Med. doi: 10.1136/bjsports-2013-092674. [Epub ahead of print]
Waugh EJ. Lateral epicondylalgia or epicondylitis: What’s in a name? J Orthop Sports Phys Ther 2005;35:200–202.
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