Alison Hoens (biography and disclosures) and Dr. Alex Scott (biography and disclosures)
Frequently asked questions I’ve noticed
Should I recommend that a patient with tennis elbow (1) receive a corticosteroid injection? (2) wear a brace? (3) do specific exercises? (4) see a physiotherapist?
Most doctors, and many patients, are aware that tendinopathy of the lateral epicondyle can be a difficult problem to resolve. There are multiple options for management including: oral medications, injections, exercise, braces, ultrasound, LASER and shockwave therapy. Patients have a greater awareness of these options as they trawl the internet looking for an answer to their pain. When a patient asks your opinion about what is the best option and why, it is understandably difficult, given the vast quantity of literature that is scattered throughout many journals and online resources, to respond with confidence.
Data that answer these questions
There is a growing body of evidence demonstrating that despite an initial improvement in pain, patients who receive corticosteroid injection have a worse long-term outcome than those who do not receive a corticosteroid injection 1,2, 3,4. Indeed, in February 2013 the Journal of the American Medical Association published a clinical trial by Coombes et al entitled “Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondyle tendinopathy: a randomized controlled trial” 4. Patients with chronic tendinopathy randomly received corticosteroid injection (n = 43), placebo injection (n = 41), corticosteroid injection plus physiotherapy (n = 40), or placebo injection plus physiotherapy (n = 41). Patients who received corticosteroid injection had a greater rate of recurrence in their condition at 1 year (54% vs 12% in the placebo injection group), whether or not they received physiotherapy treatment. This is the key finding of the study – although corticosteroids led to an early (at 4 weeks) reduction in pain, the patients were 4 or 5 times more likely to be worse off long-term. By contrast, in the group which received placebo injections, those who received physiotherapy experienced a substantial improvement in pain after 4 weeks, compared to those receiving placebo injection alone. In this clinical trial, physiotherapy treatment consisted of a previously described combination of specific exercises and manual therapy2.
Given the mounting evidence regarding the longterm worse outcomes with corticosteroid injection, it was important to identify alternatives to injection and the evidence regarding the effectiveness of these alternatives. Consequently, a team of tendon researchers and clinicians undertook a rigorous evaluation of the literature and developed a freely accessible toolkit which summarizes the literature on interventions for tennis elbow. The toolkit can be found at http://physicaltherapy.med.ubc.ca/physical-therapy-knowledge-broker/lateral-epicondyle-tendinopathy-let-toolkit/.
Although initially designed for and by physiotherapists, this toolkit is a helpful resource for general practitioners to guide their patients who have tendinopathy of the lateral epicondyle through the myriad of treatment options available.
The Lateral Epicondyle Tendinopathy Toolkit is comprised of the following components:
Summary of the Evidence for Physical Therapy Interventions – commonly used to manage acute and chronic tendinopathy of the lateral epicondyle including: manual therapy, exercise, Low Level Laser Therapy, Ultrasound, Extracorporeal Shock Wave Therapy, Iontophoresis using Dexamethasone, Iontophoresis using NSAID or Lidocaine, Orthotic devices, and taping, and includes relevant outcome measures.
Treatment Algorithm – to assist clinicians in ascertaining when to incorporate specific interventions into the management of Lateral Epicondyle Tendinopathy.
Appendices – containing more detailed information on: methods and outcomes reported in each article referenced; manual therapy techniques; specific exercises; LASER dosage calculation; specific braces, splints and taping; outcome measures; and common medical and surgical interventions.
Of particular relevance for general practitioners is the summary of the evidence. This resource provides, in a standardized format, a summary of clinical research evidence, expert opinion, take home message and clinical implication. This permits the physician to quickly obtain a ‘snapshot’ of the support for/against each intervention. If more information is required, appendix A provides more details on each article that was used to inform the summary statements. Physicians may also appreciate viewing Appendix C which provides photos and descriptions of standardized exercise protocols that have demonstrated effectiveness in the treatment of tennis elbow. This can be printed and provided as a handout to patients.
*Note: there is a similar toolkit available for clinical decision-making regarding the management of acute and chronic Achilles tendinopathy (http://physicaltherapy.med.ubc.ca/physical-therapy-knowledge-broker/tendinopathy-toolkit/).
Practice tips
The Lateral Epicondyle Tendinopathy Toolkit is an excellent resource for physicians looking to quickly advise patients on interventions to manage both acute and chronic tennis elbow. Relevant key practice tips for general practitioners include:
- Although corticosteroid injections may initially result in a reduction of symptoms (particularly pain) they are associated with a dramatically greater recurrence rate 1, 2, 3, 4.
- It is strongly recommended for patients with chronic lateral epicondyle tendinopathy to undertake a specific exercise regime5, 6,7. Appendix C of the toolkit (http://physicaltherapy.med.ubc.ca/files/2013/07/Appendix-C.-Lateral-Epicondyle-Tendinopathy-Details-of-Exercise-Prescription-June-2013.pdf) provides clinicians with the parameters for evidence-based exercise programs.
- Referral to physiotherapists for manual techniques for the elbow and cervical spine are particularly helpful in chronic lateral epicondyle tendinopathy 8, 9, 10, 11. The Physiotherapy Association of BC provides an online database to search physiotherapists in BC by area of expertise and geographical location – ‘Find a Physio’ at http://bcphysio.org/
- Low Level Laser Therapy and Ultrasound, at recommended dosages, may be beneficial for both acute and chronic stages 12, 13, 14, 15
- Extracorporeal shock wave therapy should be avoided in the acute stage but may be considered for management of chronic tennis elbow which has been unresponsive to other conservative interventions 16, 17,18, 19
- Tennis elbow braces may be considered for the management in the chronic stage19, 20
References (Links might require login with CPSBC or UBC)
- Coombes B et al. Efficiency and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of RCTs. LANCET. 376(9754): 1751-67. Nov 2010. (View with CPSBC)
- Vicenzino B: Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. Manual therapy 2003, 8(2):66-79. (View with CPSBC or UBC)
- Snyder K, Evans T. Effectiveness of corticosteroids in treatment of lateral epicondylosis. Jour Sports Rehab. 21(1): 83-88. Feb 2012. (Request from CPSBC, view with UBC)
- Coombes B et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013 Feb 6;309(5):461-9. (Request from CPSBC, view with UBC)
- Peterson M, Butler S, Eriksson M, Svardsudd K. A randomized controlled trial of exercise versus wait-list in chronic tennis elbow (lateral epicondylosis). Uppsala Journal of Medical Science. 2011; 116: 269-279. (Request from CPSBC, view with UBC)
- Stasinopoulos D, Stasinopoulos I. (2006) Comparison of effects of cyriax physiotherapy, a supervised exercise programme and polarized polychromatic non-coherent light (bioptron light) for the treatment of lateral epicondylosis. Clinical Rehabilitation. 20(1): 12-23. (View with CPSBC or UBC)
- Tyler T, Thomas G, Nicholas S, McHugh M. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. Journal of Shoulder and Elbow Surgery. Sep 2010; 19(6): 917-922. (View with CPSBC or UBC)
- Vicenzino, B. et al. Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia. Manual Therapy. Nov 2001; 6(4): 205-212. (View with CPSBC or UBC)
- Bisset L, Paungmali A, Vicenzino B, Beller, E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine. 2005; 39, 411-422. (Request from CPSBC, view with UBC)
- Cleland JA, Whitman JM, Fritz, JM. Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis (including commentary by Vicenzino B.) Journal of Orthopaedic & Sports Physical Therapy. 2004; 34(11): 713-724. (Request from CPSBC)
- Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain. Nov 1996; 68(1): 69-74. (View with CPSBC or UBC)
- Tumilty S, Munn J, McDonough S, Hurley D A, Basford J R, & Baxter G D. Low level laser treatment of tendinopathy: a systematic review with meta-analysis. Photomedicine and Laser Surgery. 2010; 28(1): 3-16. doi:10.1089/pho.2008.2470. (Request from CPSBC, view with UBC)
- Bjordal J M, Lopes-Martins R A B, Joense J, Couppe C, Ljunggren A E, Stergioulas A, & Johnson M I. A systematic review with procedural assessments and meta-analysis of Low Level Laser Therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskeletal Disorders. 2008; 9(75). doi:10.1186/1471-2474-9-75. (View article)
- Lam L K Y, & Cheing G L. Effects of 904-nm low-level laser therapy in the management of lateral epicondylitis: a randomized controlled trial. Photomedicine and Laser Surgery. 2007; 25(2): 65-71. doi:10.1089/pho.2006.2047
- Trudel D, Duley J, Zastrow I, Kerr E W, Davidson R, & MacDermid J C. Rehabilitation for patients with lateral epicondylitis: a systematic review. Journal of Hand Therapy. 2004; 17(2): 243-266. doi:10.1197/j.jht.2004.02.011 (View with CPSBC or UBC)
- Gunduz R, Malas F U, Borman P, Kocaoglu S, & Ozcakar L. Physical therapy, corticosteroid injection, and extracorporeal shock wave treatment in lateral epicondylitis. Clinical and ultrasonographical comparison. Clinical Rheumatology. 2012; 31(5): 807-812. doi:10.1007/s10067-012-1939-y. (View with CPSBC or UBC)
- Rompe J, Decking J. Schoeliner S, Thies C. Repetitive low-energy shock wave therapy for treatment of chronic lateral epicondylitis in tennis layers. American Journal of Sports Medicine. 2004; 32(3): 734-43.(Request from CPSBC)
- Buchbinder R, Green S, Youd J, et al. Systematic review of the efficiency and safety of shock wave therapy for lateral elbow pain. Journal of Rheumatology. 2006; 33(7): 1351-63. (Request from CPSBC)
- Rompe J, Muffulli N. Repetitive shock wave therapy for lateral elbow tendinopathy (tennis elbow): a systematic and qualitative analysis. British Medical Bulletin. 2007; 83(1): 355-78. (View article)
- Struijs PA, Smidt N, Arola H, Dijk CN, Buchbinder R, Assendelft WJ. Orthotic devices for the treatment of tennis elbow. Cochrane Database of Systematic Reviews. (1):CD001821, 2002. (View with CPSBC or UBC)
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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.
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?
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.
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.
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?
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)
Good article : exercising and stretching and avoiding the actions that brought up on the inflammation
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.
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.