Lateral epicondylalgia: a musculoskeletal physiotherapy perspective

doi:10.1016/S1356-689X(02)00157-1

Manual Therapy

Volume 8, Issue 2, May 2003, Pages 66-79

https://doi.org/10.1016/S1356-689X(02)00157-1 Get rights and content

Abstract

Tennis elbow or lateral epicondylalgia (LE) is a challenging musculoskeletal condition to treat. This is largely due to the lack of research-based evidence of the clinical efficacy of the myriad of treatment approaches espoused in the literature. In view of this, successful rehabilitation of LE is based on choosing treatments that address the physical impairments found during clinical examination. The primary physical impairment in LE is a deficit in grip strength predominately due to pain and its consequences on motor function. Hence the mainstay of successful management of this condition is therapeutic exercise, providing it is not pain provocative. Adjunctive procedures such as manipulative therapy and sports taping techniques have recently been shown to provide substantial initial pain relief. Early relief of pain in the rehabilitation program helps accelerate recovery and most importantly motivates the client to persist with the therapeutic exercise program. The manipulative therapy and taping treatments presented in this masterclass warrant consideration in the clinical best practice management of LE, and serve as a model for other similar musculoskeletal conditions.

Section snippets

INTRODUCTION

Pain over the lateral humeral epicondyle which manifests during activities involving the hand in gripping or manipulating an object, such as that required when lifting a tea cup, shaking hands, dressing and desk or house work, will to most musculoskeletal health care practitioners signal the provisional diagnosis of ‘tennis elbow’ or more correctly lateral epicondylalgia (LE) (Vicenzino & Wright 1996). The cardinal physical signs of LE are pain to direct palpation over the lateral epicondyle

AETIOLOGY PERSPECTIVE

The aetiology of LE has not been fully elucidated but on current evidence it would appear that the condition in its chronic form is not one of acute inflammation. Studies conducted on biopsy material taken at the time of surgical treatment for LE have identified a lack of inflammatory markers (Ljung et al. 1999); instead, degenerative changes in connective tissue have been reported (Nirschl 1989; Regan et al. 1992; Verhaar et al. 1993). Degenerative changes have also been shown in other chronic

EVIDENCE-BASED PRACTICE PERSPECTIVE

The numerous treatments for LE described in the literature mirror the unknown elements of the condition's aetiology and underscores the impression that it is a difficult condition to manage successfully. Labelle et al. attempted a meta-analysis of published research findings on the treatments for this condition and reported that it was not possible, mainly due to the poor methodological quality of the research (Labelle et al. 1992). Since Labelle's paper, several Cochrane reviews have been

A MUSCULOSKELETAL PHYSIOTHERAPY PERSPECTIVE

Pain relief and restoration of muscle condition are primary objectives of rehabilitation. Restoration of muscle condition is best effected through a progressive resistance exercise program of the upper limb muscles, concentrating on the extensors of the wrist and hand (Pienimaki et al., 1996, Pienimaki et al., 1998). Pienimaki et al. (1996) studied the clinical efficacy of a progressive and slowly graduated program of strengthening and stretching exercises in 39 sufferers of chronic LE who had

Conclusion

Currently the recommended approach to clinical manual therapy management of LE is based on the findings from physical examination and matching the treatment approach to the deficits highlighted in the clinical examination. Essentially, therapeutic exercise forms the mainstay of the program. Manual therapy and sports tape are useful adjunctive therapies to achieve rapid pain relief that allow for effective and timely physical conditioning of the affected muscles.

References (48)

Abbott JH 2001 Mobilization with movement applied to the elbow affects shoulder range of movement in subjects with...
Abbott JH, Patla CE, Jensen RH 2001 The initial effects of an elbow mobilization with movement technique on grip...
Alfredson H, Ljung BO, Thorsen K, Lorentzon R 2000 In vivo investigation of ECRB tendons with microdialysis...
Allander E 1974 Prevalence, incidence and remission rates of some common rheumatic diseases or syndromes. Scandinavica...
Assendelft WJJ, Hay EM, Adshead R, Bouter LM 1996 Corticosteroid injections for lateral epicondylitis: a systematic...
Buchbinder R, Green S, Bell S, Barnsley L, Smidt N, Assendelft WJJ 2002a Surgery for lateral elbow pain (Cochrane...
Buchbinder R, Green S, White M, Barnsley L, Smidt N, Assendelft WJJ 2002b Shock wave therapy for lateral elbow pain...
Chiang HC, Ko YC, Chen SS, Yu HS, Wu TN, Chang PY 1993 Prevalence of shoulder and upper-limb disorders among workers in...
Elvey R 1986 Treatment of arm pain associated with abnormal brachial plexus tension. Australian Journal of...
Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft WJJ 2002a Acupuncture for lateral elbow pain...

Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft WJJ 2002b Non-steroidal anti-inflammatory drugs...

Gunn C, Milbrandt W 1976 Tennis elbow and the cervical spine. Canadian Medical Association Journal 114:...

Kelley JD, Lombardo SJ, Pink M, Perry J, Giangarra CE 1994 Electromyographic and cinematographic analysis of elbow...

Khan K, Cook J 2000 Overuse tendon injuries: where does the pain come from? In: Dilworth Cannon W, DeHaven K (eds)...

Khan KM, Cook JL, Maffulli N, Kannus P 2000 Where is the pain coming from in tendinopathy? It may be biochemical, not...

Labelle H, Guibert R, Joncas J, Newman N, Fallaha M, Rivard C 1992 Lack of scientific evidence for the treatment of...

Ljung BO, Forsgren S, Friden J 1999 Substance P and calcitonin gene-related peptide expression at the extensor carpi...

MacDermid J 2001 Outcome evaluation in patients with elbow pathology: issues in instrument development and evaluation....

McArdle W, Katch F, Katch V 1996 Exercise Physiology. Williams Wilkins,...

McConnell J 2000 A novel approach to pain relief pre-therapeutic exercise. Journal of Science and Medicine in Sport 3:...

McLean S, Naish R, Reed L, Urry S, Vicenzino B 2002 A pilot study of the manual force level required to produce...

Mulligan B 1999 Manual therapy—‘NAGS’, ‘SNAGS’, ‘MWMS’, etc. Plane View Services,...

Murtagh J 1988 Tennis elbow. Australian Family Physician 17:...

Nirschl R 1989 Patterns of failed healing in tendon injury. In: Leadbetter W, Buckwalter J, Gordon S (eds)...

Cited by (87)

Comparing the efficacy of blind vs. ultrasound-guided injections in Lateral Epicondylitis: A prospective analysis
2024, Journal of King Saud University - Science
Lateral epicondylitis is a relatively common non-traumatic elbow disorder. It is a painful musculoskeletal condition that usually follows forceful repetitive pronation and supination. The aim of this study was to evaluate the advantages of ultrasound-guided injection in patients of Lateral Epicondylitis in comparison to non-image-guided blind injections. This comparative observational study was conducted on sixty patients who had clinical diagnosis of Lateral Epicondylitis. They were divided into two groups of thirty each (randomization done on odd even manner), one group underwent US-guided injections and the other group underwent the blind procedure by a specialist. Pain relief using the Visual Analog Scale (VAS) {score of 0–10} was recorded before the procedure, immediately after the procedure, one-week post-procedure, and six weeks post-procedure. Demographic characteristics, chief complaints, duration of symptoms, previous treatment taken, and complications post-procedure were gathered and compared between the two groups. All patients in both groups finished the period of study. Significant improvement in pain score and tenderness was found in both groups immediately after the injection, one-week post-procedure, and after six weeks post-procedure when compared to the baseline value (p value < 0.05). The US-guided group showed a better reduction in VAS scores immediately after the procedure and one-week post-procedure as compared to patients who were given blind injections, however no statistical difference was found at six weeks follow up. This study shows that US-guided injection relatively improves elbow pain and functional activities early and more effectively than blind/non-image-guided injections, although such results fade as time passes by.
Risk factors associated with atraumatic posterolateral rotatory instability
2021, JSES International
Traumatic posterolateral rotatory instability after elbow dislocation or fracture dislocation has been well described. However, few reports cover atraumatic posterolateral rotatory instability as a cause of lateral-sided elbow pain. We assessed the risk factors and epidemiology of atraumatic posterolateral rotatory instability in a case-control study.
A retrospective review of all patients treated operatively for atraumatic posterolateral rotatory instability during a 6-year period was compared with a group of patients with extensor carpi radialis brevis tendinopathy without instability treated during the same time period. Bivariate and multiple logistic regression statistical analyses were used to investigate the following risk factors: gender, age, hand dominance, diabetes, smoking, body mass index, corticosteroid injection history, and duration of symptoms. Disabilities of the Arm, Shoulder, and Hand and pain scores were obtained preoperatively and postoperatively.
Thirteen patients with atraumatic posterolateral rotatory instability were compared with 12 patients with extensor carpi radialis brevis tendinopathy. Multivariate analysis revealed patients with atraumatic posterolateral rotatory instability were more likely to have multiple corticosteroid injections (P = .05) and present with a longer duration of symptoms (P = .03). Postoperative pain scores improved in both groups.
Atraumatic posterolateral rotatory instability should be considered in the differential diagnosis of lateral elbow when patients present with a protracted clinical course. Statistically, posterolateral rotatory instability patients more often present with a history of multiple corticosteroid injections.
Therapeutic tape use for lateral elbow tendinopathy: A survey of Australian healthcare practitioners
2020, Musculoskeletal Science and Practice
Lateral elbow tendinopathy (LET) is a common musculoskeletal condition that can be treated with therapeutic tape. However, little is known of taping practices for LET in a clinical setting.
To examine Australian healthcare practitioners’ taping techniques, clinical reasoning, and information sources regarding therapeutic tape use for LET.
Cross-sectional survey.
An anonymous online survey was distributed between September 2018 and February 2019. Respondents answered questions about demographics, frequency of tape use, techniques, reasons for application, factors influencing clinical decision-making, and information sources, related to tape for LET.
188 Australian healthcare practitioners completed the survey. The majority of respondents were physiotherapists (n = 132, 70%) with the remainder of respondents being chiropractors (21%), myotherapists (3%), exercise physiologists (3%), or osteopaths (3%). 51% of respondents use tape as part of their management for LET at least half the time. The most popular taping technique used is a transverse band of rigid tape across the forearm (n = 78, 55% of respondents who use tape). The most common reasons for tape application are to reduce pain during occupational tasks (n = 123, 65%), and during sport/hobbies (n = 101, 54%). Respondents predominately rely on experience and patient preference to guide tape use. 63% of all respondents (n = 118) sought information about tape from professional development courses.
A wide range of tape techniques are used to treat LET, despite limited evidence for efficacy. Justification for tape is largely based on experience and patient preference; with information mostly gained from professional development courses. More research is required to understand the relationship between the evidence and clinical use of tape to treat LET.
Evaluating the immediate effect of forearm and wrist orthoses on pain and function in individuals with lateral elbow tendinopathy: A systematic review
2020, Musculoskeletal Science and Practice
Lateral elbow tendinopathy is associated with pain during gripping, with forearm/wrist orthoses prescribed for treatment.
To investigate the immediate effects of forearm and/or wrist orthoses on outcome measures of pain and function in individuals with lateral elbow tendinopathy.
Systematic review
Four electronic databases were searched to identify randomised controlled trials reporting the immediate effects of forearm and/or wrist orthoses on pain and function in individuals with lateral elbow tendinopathy. The quality of evidence was rated from high to very low, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) for the primary outcomes. Where possible, standardised mean difference (SMD) and 95% confidence intervals were calculated to compare post measures between forearm and/or wrist orthoses and control/placebo conditions.
The search revealed 1965 studies, of which, seven randomised crossover trials were included. Using the GRADE approach there was low quality evidence revealing a significant decrease in pain during contraction (SMD range −0.65 to −0.83) with forearm orthoses compared to a control/placebo condition. Low quality evidence revealed improvements in pain-free grip strength with the use of a forearm orthosis (SMD range 0.24–0.38), but not maximal grip strength (SMD range 0.14–0.15). Low quality evidence revealed a static wrist orthosis did not improve pain-free grip strength (SMD -0.08) or maximal grip strength (SMD -0.22).
There is low quality evidence that forearm orthoses can immediately reduce pain during contraction and improve pain-free grip strength but not maximal grip strength in individuals with lateral elbow tendinopathy.
Sticking to the facts: A systematic review of the effects of therapeutic tape in lateral epicondylalgia
2019, Physical Therapy in Sport
Citation Excerpt :
One commonly used treatment option is therapeutic tape (Bateman et al., 2018). Therapeutic tape has been proposed to alleviate pain (Vicenzino, 2003; Vicenzino et al., 2003), improve muscle load and function (Vicenzino et al., 2003), and restore efficient movement patterns (Vicenzino, 2003). At present, there are two main types of tape used to treat LE.
To systematically identify, appraise, and examine evidence regarding the effects of therapeutic tape on pain and function in individuals with lateral epicondylalgia (LE).
Five electronic databases were systematically searched up to March 2018. Full-text, peer-reviewed, English-language studies were included if they had an LE population, a standalone tape condition, and an outcome related to pain or function.
Eight out of 2022 screened studies were included. Three studies demonstrated immediate (i.e. within 1 h) improvements in pain and pain-free grip strength following diamond deloading rigid tape. One study reported immediate improvements in proprioception following transverse rigid tape. The immediate effects of longitudinal kinesiotape were inconsistent. One study reported improvements in pain and pain-free grip strength, while another study reported no effect on pain, strength, or muscle activity. Two studies examined short-term (i.e. within six weeks) kinesiotape application. One study reported two weeks of longitudinal kinesiotape improved pain and maximum grip strength. The other study reported one week of diamond kinesiotape improved patient-reported pain and function, but not maximum grip strength.
In individuals with LE, diamond deloading rigid tape may immediately improve pain and strength. There is conflicting evidence regarding kinesiotape effects in both immediate and short-term timeframes.
The immediate sensorimotor effects of elbow orthoses in patients with lateral elbow tendinopathy: a prospective crossover study
2019, Journal of Shoulder and Elbow Surgery
Counterforce orthoses are used to manage lateral elbow tendinopathy, and their effectiveness in improving motor function has been documented. Little is known about the impact of bracing on sensory function. The objective of this study was to investigate the immediate effectiveness of 2 counterforce orthoses in improving the sensorimotor abilities of the hand in patients with lateral elbow tendinopathy.
In this crossover, randomized controlled trial, elbow proprioception, pain severity, pain-free grip strength, and finger dexterity were measured in 50 participants with a diagnosis of lateral elbow tendinopathy. Outcomes were measured in 3 randomized conditions (no brace, forearm band, or elbow sleeve). Data were analyzed using 1-way repeated-measures analysis of variance for each outcome measure.
Better scores were observed with the forearm band, as compared with no orthosis, for multiple outcomes including joint position reproduction score at 70° of elbow flexion (P = .006), pain (P < .001), grip strength (P = .01), and dexterity (P < .001). The elbow sleeve yielded better scores than no orthosis for the following outcomes: joint position reproduction score at 110° (P < .001), pain (P < .001), and grip strength (P = .012). No statistically significant difference was found between the orthoses' effects on pain reduction and grip strength (P > .05). The forearm band showed better scores on joint position reproduction at 70° compared with the elbow sleeve (P = .006), whereas the elbow sleeve showed better scores at 110° (P < .001).
Our results support the mechanisms occurring with the use of either of the described orthotic interventions. Future randomized trials with longer-term outcomes that include sensorimotor mechanisms might enhance our understanding of the comparative effectiveness.

View all citing articles on Scopus

View full text

MasterclassLateral epicondylalgia: a musculoskeletal physiotherapy perspective