Tennis elbow, or lateral epicondylitis (LE) is the most frequent cause of elbow pain with approximately 1% to 3% of the population being diagnosed in their lifetime.1-5 It usually manifests from repetitive loading of the extensor muscles of the forearm resulting in a degenerative process of the common extensor origin muscles and tendon, with the most common sites of focal degeneration being the deep and anterior fibres of extensor carpi radialis brevis (ECRB) component of the CEO.4,5,11 The condition is particularly common in 35 to 50 year olds in the workforce and can produce significant disability affecting work productivity and activities of daily living. Smokers, manual workers and tennis players have an increased risk, 1,2,4,11 with an increasing number of office workers being affected.
Diagnosis generally includes a history of repetitive wrist extension movements, changes in workload and potential sources of trauma. Physical examination should reproduce pain in the area of the lateral epicondyle in at least one of three ways: palpation of the lateral epicondyle, resisted extension of the wrist, index or middle finger, or firm grip.11 Imaging may be useful in confidently excluding a diagnosis of LE11 as both US and MRI demonstrate high sensitivity. Caution should be used however, with limited specificity in diagnosing tendinopathies.11
Management strategies for LE include physiotherapy, wait and see, medication, bracing, injection therapies and surgical interventions.1,2,6,7 Principles of treatment include controlling pain, preserving movement, improving grip strength, returning to daily activities and preventing further decline.1 70% to 80% of patients recover in the first year and as such conservative treatment with rest and physiotherapy is recommended before considering invasive treatment.2,6,7 Exercise and manual therapy are at the core of rehabilitation through the implementation of appropriate functional tasks, graded increase of load in the wrist extensors and motor control exercises.11
Physiotherapy management also focuses on reassurance about outcomes, education on self-management and strategies to avoid aggravation.11
Two well designed RCTs9,10 found that steroid injections caused adverse outcomes compared to other forms of management for LE. A recent systematic review8 on the use of PRP to treat LE indicated that PRP may provide a short-term benefit over other forms of non-operative treatment, but the long-term efficacy has not been demonstrated. Current best evidence the use of PRP for the treatment of chronic LE is not supported over other treatments.
Evidence Based Approach
Our evidence based approach at BPC takes into account the numerous factors that can affect the course of LE. These factors include: state of tendon pathology, severity of pain and disability, central sensitisation, concomitant neck and shoulder pain, associated neuromuscular impairments, sport, work related and psychological factors.
The complexity to LE requires a comprehensive examination and an intervention strategy that deals with all the contributing issues. This is the strength of Physiotherapy management of a condition that can be very disabling and challenging to treat.
M. Musc & Sports Physiotherapy
APA Titled Musc & Sports Physiotherapist
1. Ahmad Z, Siddiqui N, Malik SS, et al. Lateral epicondylitis: a review of pathology and management. Bone Joint J. 2013;95-B:1158-64. doi:10.1302/0301-620X.95B9
2. Behrens SB, Deren ME, Matson AP, et al. A review of modern management of lateral epicondylitis. Phys Sports Med 2012;40:34-40. doi:10.3810/psm.2012.05.1963
3. Gosens T, Peerboms JC, van Laar W, et al. Ongoing positive effects of platelet-rich plasma versus corticosteriod injection in lateral epicondylitis: a double-blind randomised controlled trial with 2-year follow-up. Am J Sports Med 2011;39:1200-08. doi:10.1177/0363546510397173
4. Jindal N, Gaury Y, Banshiwal RC, et al. Comparison of short term results of single injection of autologous blood and steroid injection in tennis elbow: a prospective study. J Orthop Surg Res 2013;8:10-6. doi:10.1186/1749-799X-8-10
5. Raeissadat SA, Sedighipour L, Rayegani SM, et al. Effect of platelet-rich plasma (PRP) versus autologous whole blood on pain and function improvement in tennis elbow: a randomised control trial. Pain Research Treatment 2014;2014:191525-8. doi:10.1155/2014/191525
6. Smidt N, Van der Windt DA, Assendelft WJ, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62. doi:10.1016/S0140-6736(02)07811-X
7. Tosti R, Jennings J, Sewards M. Lateral Epicondylitis of the elbow. Am J Med 2013;126:357.e1-357.e6. doi:10.1016/j.amjmed.2012.09.018
8. de Vos RJ, Windt J, Weir A. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med 2014;48:952-6. doi:10.1136/bjsports-2013-093281
9. Coombes BK, Bisset L, Brooks P, et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA 2013;309:461-9. doi:10.1001/jama.2013.129
10. Smidt N, van der Windt DAWM, Assendelft WJJ, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62. Retrieved: http://www.thelancet.com
11. Coombes, B.K., Bisset, L., & Vicenzino, B. (2015). Management of lateral elbow tendinopathy—one size does not fit all. Journal of Orthopaedic and Sports Physical Therapy, Epub 17 Sept 2015, 1-38. doi:10.2519/jospt.2015.5841
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