9 responses to “Lateral Epicondyle Tendinopathy (Tennis Elbow) Toolkit”

  1. For years I injected lateral epicondyles with cortisone but noted exactly the findings found in the research- good initial results but poor results over time. I thought that the pain relief allowed patients to continue doing the activities that got them into trouble in the first place. I stared switching to physio and saved injections for the treatment failures after at least 6 weeks of physio. Results were much better.

  2. This article does not mention infra red as a physio option. I have found that this treatment 2-3 minutes/ session, 2-3 times a week for up to 2-3 weeks does work very well.
    Any comments?

  3. Physiotherapy really works in pain management, It’s my personal experience and it helps in fast recovery. I like your post, little complicated but very nice.

  4. Thank you for your comments. The primary intention in developing the toolkit was to present a guide for treatment of lateral epicondyle tendinopathy based on the best evidence available. This involved an extensive literature search for the management of this condition. The literature search did not identify studies specific to infrared radiation for LET. There is, of course, evidence for the use of infra-red laser for tendinopathies. There are two references (from the same institution) reporting a study that used hyperthermia cause by microwave heating to treat patellar or achilles tendinopathies, or supraspinatus tendinopathy, which showed benefit. This is not to say that infrared radiation is ineffective in the treatment of lateral epicondyle tendinopathy, rather that we could find no evidence for effectiveness specifically for it, and so we were not able to add this modality as a treatment option in the toolkit.

  5. I have also found that specific exercises are effective and have used injections for persistent symptoms that do often reoccur. What is the place for surgical treatment?

  6. I would agree with the conclusions of this article regarding the use of corticosteroid. The toolkit, while helpful, has some weaknesses. It ignores the natural history of the condition and appears to promote interventions which to date have not been proven or have been disproven. For example shock wave and PRP appear to be ineffective in the (limited) studies to date. NSAID’s may have a role but one must balance their SE’s. Bracing/straps and other devices have yet to be proven effective in RCT’s.

    Surgery is now often done through a percutaneous or arthroscopic or mini-open technique. The technique described in the toolkit has largely been abandoned. Neurectomy should also be avoided. Surgery can be effective for refractory cases but other disorders also need to be ruled out (for example supinator syndrome)

  7. Good article : exercising and stretching and avoiding the actions that brought up on the inflammation

  8. Dear Dr Kendall,

    We appreciate hearing that the surgical technique described in the toolkit has been largely abandoned, and we will be sure to update this in future versions. We apologise for not making greater effort to contact local surgeons and find out the state of current practice.

    We would like to clarify, though, that the toolkit DOES NOT promote PRP or extracorporeal shockwave therapy (ESWT) as your post suggests.

    The section of the toolkit which dealt with PRP states “A small amount of evidence suggests that PRP injection is no more effective than placebo.” Most clinicians would be discouraged by this statement.

    The section summarizing the take-home message for ESWT stated “Consider NOT using ESWT in the acute stage…” Again, this appears to be the opposite message than the one taken by Dr Kendall (discouraging, rather than promoting)

    For patients with chronic lateral elbow tendinopathy, we stated that for those patients who have failed other conservative measures one could CONSIDER using ESWT, but that patients should be informed that this is an experimental approach (i.e. no conclusive evidence of benefit).

    Although it is not our place as physiotherapists to comment on medical prescriptions, we agree that the scientific literature suggests NSAIDs may play a role in acute symptom relief, dependent on the natural history of the condition. Based on a double-blind RCT of topical NSAID (niflumic acid) in patients with acute tendinopathies of the upper and lower extremities (< 1 month duration), one can expect significant pain relief within 1 week in most patients (Dreiser et al 1991), but this conclusion should be made with caution given some methodological problems with this RCT. There is no apparent long-term benefit of Naproxen compared to placebo for chronic lateral elbow tendinopathy, based on a metanalysis by Smidt et al 2005.

    Perhaps the situation with NSAIDs is similar to bracing – acute pain-relief has been demonstrated, but there is no evidence yet of long-term effects (Bisset et al 2014).

    Thank you for your comments. For a general discussion on the natural history of tendinopathies, please see our paper "Tendons: Time to Revisit Inflammation": http://bjsm.bmj.com/content/early/2013/03/08/bjsports-2012-091957.full

    Alex Scott

    Bisset et al. Immediate effects of 2 types of braces on pain and grip strength in people with lateral epicondylalgia: a randomized controlled trial. J Orthop Sports Phys Ther. 2014 Feb;44(2):120.

    Dreiser et al. A double blind, placebo controlled study of niflumic acid gel in the treatment of acute tendinitis. European J Rheumatol Inflamm. 1991 11(2), 38-45.

    Smidt et al. A comparison of two primary care trials on tennis elbow: issues of external validity. Annals of Rheumatic Diseases 2005;64:1406–1409.

  9. Good exercises. Would be helpful if there was a you tube link to demonstrate the exercises to the patient as well as the print out sheet for those who need the dynamic visual clues.

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