Physical Medicine and Rehabilitation for Lateral Epicondylitis Treatment & Management
- Author: Consuelo T Lorenzo, MD; Chief Editor: Stephen Kishner, MD, MHA more...
Acutely, the goals of treatment are to reduce pain and inflammation. Anti-inflammatory modalities include ice, ultrasonography, and iontophoresis. Iontophoresis with topical nonsteroidal anti-inflammatory drugs (NSAIDs) has been shown to help reduce pain. The use of iontophoresis with corticosteroids is not supported. A wrist splint used during activities can be helpful, because it places the extensor muscles in a position of rest and prevents maximal muscle contraction. Counterforce bracing (tennis elbow strap) is another orthotic alternative that can be used to unload the area of muscle origin at the elbow. A splint or brace should not be used in isolation but should be employed only as an adjunct to modalities and exercise/stretching.[11, 12]
Deep-tissue and friction massage help to release underlying adhesions and promote improved circulation to the area. However, a study by Olaussen et al suggested that results from a physical therapy program for lateral epicondylitis consisting of deep transverse friction massage, Mills manipulation, stretching, and eccentric exercises do not significantly differ from those associated with a wait-and-see approach to the condition.
In the subacute stage, emphasis is placed on the restoration of function of the involved muscle group. Flexibility, strength, and endurance of the wrist extensor muscle group can be achieved through a graded program. ROM for wrist flexion/extension and pronation/supination should be achieved prior to proceeding with a strengthening program. Strength and grip training should progress from isometric to concentric to eccentric contractions of the forearm muscles, especially the wrist extensors.[14, 15]
Jafarian et al compared 3 common types of orthoses for their effect on grip strength in patients with lateral epicondylitis. In a randomized, controlled laboratory study in 52 patients, maximum and pain-free grip strength were assessed, with patients wearing an elbow strap orthosis, an elbow sleeve orthosis, a wrist splint, or a placebo orthosis. Use of either the elbow strap or sleeve orthosis resulted in an immediate and equivalent increase in pain-free grip strength (p < 0.02); consequently, the researchers suggested that either of these types of orthosis may be used. The wrist splint provided no immediate improvement in either pain-free or maximum grip strength.
In chronic refractory cases of lateral epicondylitis, scapular stabilization should be addressed to prevent overuse of the wrist extensors during activities. Sports-specific training should also be included in the rehabilitation program, if appropriate.
A study by Knutsen et al indicated that independent risk factors for failure of nonoperative treatment of lateral epicondylitis include previous injection, prior orthopedic surgery, the presence of radial tunnel syndrome, symptom duration of more than 12 months, and the submission of a workers’ compensation claim. The study involved 580 patients who were treated for lateral epicondylitis, including 92 who were managed with surgery a mean 6 months after their initial visit to a tertiary care center.
As activities are resumed, the patient's vocational and avocational pursuits must be considered. Job and recreational tools and/or equipment may need to be modified, especially if repetitive gripping is required. Gradual resumption of activities is recommended to improve tolerance and prevent recurrence.
The so-called radial tunnel syndrome should be considered for refractory cases of lateral epicondylitis. Criteria for diagnosis of radial tunnel syndrome are controversial in the literature. There exist cases of posterior interosseous nerve palsy associated with weakness in muscles that are innervated by that nerve. However, syndromes of forearm pain without associated weakness in muscles that are innervated by the posterior interosseous nerve are also seemingly labeled as radial tunnel syndrome.
Electrodiagnostic studies should be helpful in demonstrating nerve injury in cases of radial tunnel syndrome, thereby differentiating this entity from a forearm pain syndrome. In compression of the posterior interosseous nerve, patients report pain at the lateral aspect of the elbow and weakness in the wrist and hand, but no sensory symptoms. Electrodiagnostic findings in posterior interosseous nerve compression may include denervation in radial-supplied muscles distal to the supinator, and possibly slowing across the area of entrapment. Surgical intervention for radial tunnel syndrome or persistent tennis elbow should be approached with caution and only after a thorough workup and extensive conservative management.
For cases of refractory lateral epicondylitis, surgical resection of the lateral extensor aponeurosis might be considered.[19, 20]
An orthopedic hand specialist may be consulted.
Topical NSAIDs may provide short-term pain relief, but evidence is conflicting on the use of oral NSAIDs.
If a patient does not seem to be responding to conservative care, a steroid injection about the lateral epicondyle using local anesthetic can be performed.[9, 21, 22, 23, 24, 25, 26] However, the role of corticosteroid injection in tendinopathy remains controversial. Most lateral epicondylitis is degenerative rather than inflammatory, and injecting steroid around a tendon can inhibit collagen repair; therefore, steroid injections should be used on a limited basis. Additionally, injecting a corticosteroid directly into a tendon can be deleterious. Nonetheless, steroid injections in some cases can bring about dramatic, albeit short-term, relief. When employing steroid injections, the following steps should be taken:
Palpate the lateral epicondyle to locate the painful area (usually inferior and radial to the lateral epicondyle).
Using a 25- or 30-gauge needle, inject 0.5-1 mL of triamcinolone (20 mg/mL) and 1-2 mL of 1% lidocaine. Infiltrate the area, distributing small aliquots of medication in a fanlike fashion. To avoid tissue rupture, take care not to inject directly into the origin of the extensor muscle group.
Heavy lifting or repetitive activity by the patient should be minimized for 48-72 hours after the injection.
A prospective, randomized controlled, double-blinded study of 24 subjects concluded that both prolotherapy and corticosteroid therapy appeared to provide patients with long-term benefits. However, the study's small sample size prohibits determining whether one therapy is better than the other; larger, controlled trials are necessary.
Platelet-rich plasma has been used to treat chronic epicondylitis and has been shown to be more efficacious than corticosteroid injection, with improvement on both VAS and DASH scores at 2 year follow-up.
Other substances used for injection include local anesthetics and botulinum toxin. However, studies have provided conflicting evidence as to whether botulinum toxin injection has positive long-term benefits for lateral epicondylitis.[29, 30, 31]
Other types of treatment have included acupuncture and extracorporeal shockwave therapy.[32, 33, 34, 35] However, there is insufficient evidence to support acupuncture as a treatment for epicondylitis. Likewise, reviews of trials using shockwave therapy have found reasons not to support this as a treatment option.
Sheon RP. Repetitive strain injury. 1. An overview of the problem and the patients. The Goff Group. Postgrad Med. 1997 Oct. 102(4):53-6, 62, 68. [Medline].
Sheon RP. Repetitive strain injury. 2. Diagnostic and treatment tips on six common problems. The Goff Group. Postgrad Med. 1997 Oct. 102(4):72-8, 81, 85 passim. [Medline].
Nadler S, Nadler JM. Cumulative trauma disorders. DeLisa JA, Gans BM, eds. Rehabilitation Medicine: Principles and Practice. 3rd ed. Philadelphia, Pa: Lippincott-Raven; 1998. 1661-76.
Khan KM, Cook JL, Taunton JE. Overuse tendinosis, not tendinitis. Phys Sportsmed. 2000. 28:38-48.
O'Connor FG, Howard TM, Fieseler CM. Managing overuse injuries. A systematic approach. Phys Sportsmed. 1997. 25:88-113.
Yassi A. Repetitive strain injuries. Lancet. 1997 Mar 29. 349(9056):943-7. [Medline].
Downs DG. Nonspecific work-related upper extremity disorders. Am Fam Physician. 1997 Mar. 55(4):1296-302. [Medline].
Torp-Pedersen TE, Torp-Pedersen ST, Qvistgaard E, et al. Effect of glucocorticosteroid injections in tennis elbow verified on colour Doppler ultrasound: evidence of inflammation. Br J Sports Med. 2008 Mar 4. [Medline].
Laban MM, Pai R. Lateral Epicondylitis of the Elbow Use of Magnetic Resonance Imaging in Predicting Clinical Recovery. Am J Phys Med Rehabil. 2013 Jul 27. [Medline].
Altan L, Kanat E. Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices. Clin Rheumatol. 2008 Mar 26. [Medline].
Hoogvliet P, Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med. 2013 May 24. [Medline].
Olaussen M, Holmedal O, Mdala I, Brage S, Lindbaek M. Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial. BMC Musculoskelet Disord. 2015 May 20. 16:122. [Medline].
Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006 Nov 4. 333(7575):939. [Medline]. [Full Text].
Bisset L, Paungmali A, Vicenzino B, et al. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005 Jul. 39(7):411-22; discussion 411-22. [Medline].
Jafarian FS, Demneh ES, Tyson SF. The immediate effect of orthotic management on grip strength of patients with lateral epicondylosis. J Orthop Sports Phys Ther. 2009 Jun. 39(6):484-9. [Medline].
Knutsen EJ, Calfee RP, Chen RE, Goldfarb CA, Park KW, Osei DA. Factors Associated With Failure of Nonoperative Treatment in Lateral Epicondylitis. Am J Sports Med. 2015 Jun 29. [Medline].
Rosenbaum R. Disputed radial tunnel syndrome. Muscle Nerve. 1999 Jul. 22(7):960-7. [Medline].
Baker CL Jr, Baker CL 3rd. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med. 2008 Feb. 36(2):254-60. [Medline].
Dunn JH, Kim JJ, Davis L, et al. Ten- to 14-year follow-up of the Nirschl surgical technique for lateral epicondylitis. Am J Sports Med. 2008 Feb. 36(2):261-6. [Medline].
Genovese MC. Joint and soft-tissue injection. A useful adjuvant to systemic and local treatment. Postgrad Med. 1998 Feb. 103(2):125-34. [Medline].
Rifat SF, Moeller JL. Site-specific techniques of joint injection. Useful additions to your treatment repertoire. Postgrad Med. 2001 Mar. 109(3):123-6, 129-30, 135-6. [Medline].
Tonks JH, Pai SK, Murali SR. Steroid injection therapy is the best conservative treatment for lateral epicondylitis: a prospective randomised controlled trial. Int J Clin Pract. 2007 Feb. 61(2):240-6. [Medline].
Lewis M, Hay EM, Paterson SM, et al. Local steroid injections for tennis elbow: does the pain get worse before it gets better?: Results from a randomized controlled trial. Clin J Pain. 2005 Jul-Aug. 21(4):330-4. [Medline].
Roberts WO. Lateral epicondylitis injection. Phys Sportsmed. 2000. 28:93-4.
Küçüksen S, Yilmaz H, Salli A, Ugurlu H. Muscle Energy Technique Versus Corticosteroid Injection for Management of Chronic Lateral Epicondylitis: Randomized Controlled Trial With 1-Year Follow-up. Arch Phys Med Rehabil. 2013 Jun 22. [Medline].
Carayannopoulos A, Borg-Stein J, Sokolof J, Meleger A, Rosenberg D. Prolotherapy versus corticosteroid injections for the treatment of lateral epicondylosis: a randomized controlled trial. PM R. 2011 Aug. 3(8):706-15. [Medline].
Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis: A Double-Blind Randomized Controlled Trial With 2-year Follow-up. Am J Sports Med. 2011 Jun. 39(6):1200-8. [Medline].
Hayton MJ, Santini AJ, Hughes PJ, et al. Botulinum toxin injection in the treatment of tennis elbow. A double-blind, randomized, controlled, pilot study. J Bone Joint Surg Am. 2005 Mar. 87(3):503-7. [Medline].
Wong SM, Hui AC, Tong PY, et al. Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2005 Dec 6. 143(11):793-7. [Medline]. [Full Text].
Placzek R, Drescher W, Deuretzbacher G, et al. Treatment of chronic radial epicondylitis with botulinum toxin A. A double-blind, placebo-controlled, randomized multicenter study. J Bone Joint Surg Am. 2007 Feb. 89(2):255-60. [Medline].
Haake M, König IR, Decker T, et al. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis: a randomized multicenter trial. J Bone Joint Surg Am. 2002 Nov. 84-A(11):1982-91. [Medline].
Pettrone FA, McCall BR. Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg Am. 2005 Jun. 87(6):1297-304. [Medline].
Dingemanse R, Randsdorp M, Koes BW, Huisstede BM. Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: a systematic review. Br J Sports Med. 2013 Jan 18. [Medline].
Ilieva EM, Minchev RM, Petrova NS. Radial shock wave therapy in patients with lateral epicondylitis. Folia Med (Plovdiv). 2012 Jul-Sep. 54(3):35-41. [Medline].