eMedicine Specialties > Sports Medicine > Upper Limb
Lateral Epicondylitis: Treatment & Medication
Updated: Jul 23, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
There are numerous treatment options, but no one single treatment is completely effective.
Watchful waiting
Smidt et al noted a greater improvement in pain symptoms from lateral epicondylitis at 52 weeks when employing watchful waiting relative to the administration of corticosteroid injections.5 In addition, watchful waiting was about equally as effective as physiotherapy at 52 weeks. However, corticosteroid injections were significantly better than both watchful waiting and physiotherapy at 6 weeks.5
Nonsteroidal Anti-inflammatory Drugs (NSAIDS)
Topical NSAIDS such as diclofenac may offer some short-term relief.6,7 In a study with oral diclofenac, this agent improved short-term pain and function, but there was no difference noted when comparing naproxen and placebo for pain reduction in lateral epicondylitis. Corticosteroid injection demonstrated greater benefit at 4 weeks when compared with NSAIDS, but no long-term differences were seen.
Corticosteroid injection
One study demonstrated administering a corticosteroid injection as having superior efficacy in pain relief at 6 weeks when compared with physiotherapy that consisted of ultrasound, massage, and exercise. However, the authors noted that corticosteroid injection was not as effective as physiotherapy at 12 weeks.5 Smidt et al found that administering a corticosteroid injection decreased pain in lateral epicondylitis at 6 weeks but not beyond that period.
In another study, when corticosteroid injection was compared with arm bracing, the use of a corticosteroid injection demonstrated decreased pain at 2 weeks, but there was no difference noted at 6 weeks.8 There was also no significant difference noted in the type of steroid that was injected.
In summary, administering a corticosteroid injection is effective in reducing pain from lateral epicondylitis in the short term, but this procedure may not be as effective in the long term.
Counterforce Bracing
Counterforce braces are used in an attempt to reduce the tension forces on the wrist extensor tendons, and these orthotics may be superior to lateral epicondyle bandages in reducing resting pain.9 The brace should be applied firmly approximately 10 cm distal to the elbow joint. Use of a counterforce brace may decrease pain and increase grip strength at 3 weeks in individuals with lateral epicondylitis.10 However, some authors believe that no firm conclusions can be drawn from the use of orthotics in the treatment of lateral epicondylitis.11 Counterforce braces are possibly inferior in the treatment of lateral epicondylitis when compared with topical NSAIDS and corticosteroid injections.
Jafarian et al compared 3 common types of orthoses for their effect on grip strength in patients with lateral epicondylosis.12 In a randomized controlled laboratory study in 52 patients, maximum and pain-free grip strength were assessed with the patient wearing an elbow strap orthosis, an elbow sleeve orthosis, a wrist splint, or a placebo orthosis. Use of the elbow strap and sleeve orthoses resulted in an immediate and equivalent increase in pain-free grip strength (P <0.02); consequently, the researchers suggest that either of these types of orthosis may be used.12 The wrist splint provided no immediate improvement in either pain-free or maximum grip strength.
Extracorporeal Shock Wave Therapy (ECSWT)
There has been no significant benefit demonstrated in using ECSWT to treat patients with lateral epicondylitis.13
Laser Therapy
Low-level laser treatments have not been proven to be an effective method to treat patients with pain from lateral epicondylitis.14
Acupuncture
Systemic reviews and meta-analyses have demonstrated some evidence of short-term improvement in pain reduction at 2 to 8 weeks in patients suffering from lateral epicondylar pain.11,15 However, other studies demonstrated insufficient evidence to recommend its use.7
Autologous Blood
Autologous blood injections are thought to initiate an inflammatory process and promote improved healing of degenerative tissue via the relatively atraumatic injection itself or via mediators in the blood. Edwards and Calandruccio studied 28 people in whom conservative therapy had failed to resolve symptoms from their lateral epicondylitis.16 The study demonstrated 79% (22 of 28) of the patients had a reduction in pain over 9.5 months after autologous blood injection therapy.16 Most often, this occurred after only one injection. However, this study is limited as it lacked a control group.
Another study demonstrated significantly reduced pain when treating chronic elbow tendinosis with buffered platelet rich plasma. Mishra and Pavelko evaluated 140 patients with elbow epicondylar pain; 20 patients continued to consider surgical intervention after conservative therapy failed to resolve their symptoms.17 These patients were then administered either a single percutaneous injection of platelet-rich plasma or bupivacaine (control group). At 8 weeks after therapy, the authors demonstrated a 60% pain improvement in the group who received the platelet-rich plasma compared with a 16% pain improvement in the control group.17 At 6 months and final follow-up (mean, 25.6 mo; range, 12-38 mo), the patients who had received the platelet-rich plasma continued to report significant pain reduction.
Botulism Toxin (BTX)
In a study by Wong et al, the authors demonstrated that an injection of BTX decreased patients' pain from lateral epicondylitis at 4-12 weeks when compared with saline injection; however, there was an increased incidence of side effects in the BTX treated group, which included digit paresis and weakness of finger extension.18 In addition, the trial was small (60 patients), most of the patients were women, and the blinding of the study may have been affected by some of the patients possibly knowing which treatment they received (4 patients experienced digit paresis and may have correctly deduced they'd received the BTX injection).
A study by Placzek et al also demonstrated improvement in painful symptoms arising from lateral epicondylitis when BTX injections were used compared with saline.19 However, another randomized controlled trial demonstrated no significant difference when comparing injections of BTX and saline in the treatment of lateral epicondylitis.20
Topical Nitrates
Topical nitrates are thought to stimulate collagen synthesis and improve healing. Paolini et al demonstrated that application of topical nitrates to be an effective method of treating pain from lateral epicondylitis.21
Acute Phase
Rehabilitation Program
Physical Therapy
Strength training, exercise, and stretching have been shown to decrease pain in patients with lateral epicondylitis.11 It is important to have the patients progress from concentric to eccentric exercises and then stress eccentric exercises when the individual is able to tolerate them. NSAID iontophoresis is also an effective method of treating pain from lateral epicondylitis, but corticosteroid iontophoresis has not been shown to be effective.11 Occupational therapy can be employed in an attempt to modify the workplace environment to eliminate aggravating activities.
Ultrasound (US) therapy has demonstrated modest pain reduction,11,14 although US- and color Doppler-guided intratendinous injections with polidocanol in the extensor origin have shown promising clinical results,22 and there is insufficient evidence to support the use of transverse friction, soft-tissue therapy in the treatment of lateral epicondylitis.23
Recovery Phase
Surgical Intervention
Surgical intervention is only indicated after 6 months of conservative care has failed to relieve the patient's symptoms. A long-term, follow-up study (mean, 130 mo; range, 106-173 mo) of arthroscopic treatment of recalcitrant lateral epicondylitis by Baker and Baker demonstrated that arthroscopic removal of pathologic tendinosis tissue can be a successful treatment strategy in such cases.24
It is important that each case is evaluated individually, because some patients may have multiple relapses or lack progression through therapy. These patients may opt for surgery after a shorter trial of conservative care.
Medication
Medical intervention is geared toward the joint goals of decreasing inflammation and providing analgesia. The major concern with all the drugs used is their effect on the gastrointestinal (GI) tract with long-term use. Renal function must also be monitored with long-term NSAID use. Long-term corticosteroids have a myriad of side effects, which are beyond the scope of this article.
Related eMedicine topics:
Corticosteroid-Induced Myopathy
Therapeutic Injections for Pain Management
Toxicity, Nonsteroidal Anti-inflammatory Agents
Nonsteroidal anti-inflammatory drugs
NSAIDs are used to help reduce inflammation and are used as analgesics. Multiple drugs are in this class and every physician should be aware of drugs in each subclass because some patients respond better to one subclass than another. A few of the medications are named not to belabor the wide variety of choices available.
Diclofenac (Cataflam, Voltaren)
Designated chemically as 2-[(2,6-dichlorophenyl) amino] benzeneacetic acid, monosodium salt, with an empirical formula of C14 H10 Cl2 NO2 NA. One of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacologic studies. Believed to inhibit the enzyme cyclooxygenase, which is essential in the biosynthesis of prostaglandins. Can cause hepatotoxicity; hence, liver enzymes should be monitored in the first 8 weeks of treatment.
Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. The delayed-release, enteric-coated form is diclofenac sodium, and the immediate release form is diclofenac potassium. Has a relatively low risk for bleeding GI ulcers.
Adult
25 mg PO bid/tid; if well tolerated, increase by 25 or 50 mg at weekly intervals until satisfactory response is obtained or a total daily dose of 150-200 mg PO is reached; higher doses generally do not increase effectiveness
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; do not administer into the CNS or give to patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and those at high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases the risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if there is persistent leukopenia, granulocytopenia, or thrombocytopenia
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400-600 mg PO q4-6h prn
Pediatric
Not usually recommended for pain control; however, often taken by adolescents in OTC form
Probenecid may increase the concentrations and possibly the toxicity of NSAIDs; may decrease the effect of concurrently administered loop diuretics; PT duration may increase when administered concurrently with anticoagulants; closely monitor PT duration and instruct patients to watch for signs and symptoms of bleeding; H2 antagonists and Carafate (active ingredient sucralfate) may decrease the risk of GI ulcer when administered concurrently with NSAIDs
Documented hypersensitivity to aspirin, iodides, or other NSAIDS
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with renal impairment, hepatic or cardiac dysfunction, and decreased hemoglobin; monitor serum electrolytes in long-term use (>3 mo); caution in the presence of peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and high risk of bleeding
Naproxen and naproxen sodium (Aleve, Naprelan, Naprosyn)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which is responsible for prostaglandin synthesis.
Available in many dosages and delivery systems. Oral suspension is available at a dose of 125 mg/5 mL. Fairly inexpensive and has a similar therapeutic profile to the other NSAIDs.
Adult
Naproxen: 375 mg and 500 mg PO bid with food
Naproxen sodium: 275 mg PO qid or 550 mg PO bid with food
Pediatric
Suspension: 10 mg/kg/d PO divided bid
Probenecid may increase the toxicity of NSAIDs; coadministration with ibuprofen may decrease the effects of loop diuretics; coadministration with anticoagulants may prolong PT duration (watch for signs of bleeding); NSAIDs may increase serum lithium levels and the risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity).
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion, risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrant further evaluation and may require discontinuation of drug.
Cyclooxygenase 2 (COX-2) inhibitors
Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.
Celecoxib (Celebrex)
Primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus the incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased when compared with nonselective NSAIDs. Seek the lowest dose for each patient.
Neutralizes circulating myelin antibodies through anti-idiotypic antibodies; downregulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; may increase CSF IgG (10%).
Has a sulfonamide chain and is primarily dependent upon cytochrome P450 enzymes (a hepatic enzyme) for metabolism.
Adult
200 mg PO qd or bid
Pediatric
Not usually recommended for pain control
Probenecid may increase the concentrations and possibly the toxicity of NSAIDs; may decrease the effect of concurrently administered loop diuretics; PT duration may increase when administered concurrently with anticoagulants; closely monitor PT duration and instruct patients to watch for signs and symptoms of bleeding
Documented hypersensitivity to aspirin, sulfa-based drugs, or other NSAIDS
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with renal impairment, hepatic or cardiac dysfunction, and decreased hemoglobin values; monitor serum electrolytes in long-term use (>3 mo); caution in the presence of peptic ulcer disease, recent GI bleeding or perforation, or renal insufficiency.
Corticosteroids
Corticosteroids are some of the strongest anti-inflammatory agents available. The injectable preparations make it possible to deliver the drug directly to the joint in a concentrated dose while greatly decreasing the systemic effects.
Triamcinolone acetonide (Amcort, Aristospan Intra-Articular)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult
2.5-40 mg (10 mg/mL or 40 mg/mL formulations) intra-articularly; repeat prn
Pediatric
Not established
Coadministration with barbiturates, phenytoin, and rifampin decreases the effects of triamcinolone.
Documented hypersensitivity; fungal, viral, and bacterial skin-infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Multiple complications including severe infections, hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, or growth suppression may occur; abrupt discontinuation of glucocorticoids may cause adrenal crisis.
Betamethasone (Celestone Soluspan)
Author's drug of choice for intra-articular injections. Preparation does not crystallize if used with paraben-free anesthetic preparations.
Adult
1 mL (6 mg/mL) mixed with 1 mL of 2% lidocaine and 1 mL of 0.5% Marcaine
Pediatric
Not established
Effects decrease with the coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases the effect of salicylates and vaccines used for immunization
Documented hypersensitivity; systemic fungal infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increases the risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use
Vasodilators
Vasodilators may stimulate collagen synthesis and improve healing. These agents may also effectively treat pain.
Nitroglycerin (Nitro-Dur)
Causes relaxation of vascular smooth muscle by stimulating intracellular cyclic guanosine monophosphate production.
The dosages available include 0.1mg/h, 0.2mg/h, 0.3mg/h, 0.4mg/h, 0.6mg/h, 0.8mg/h per patch
Adult
May cut a 0.2mg/h patch into quarters and place on the point of maximal tenderness for 24 h; the typical duration of treatment varies, but may take up to 3-4 mo
Pediatric
Not established
Aspirin may increase nitrate serum concentrations; marked symptomatic orthostatic hypotension may occur with coadministration of calcium channel blockers (dose adjustment of either agent may be necessary); vasodilating effects may be additive when coadministered with other vasodilators.
Documented hypersensitivity; severe anemia, shock, postural hypotension, head trauma closed-angle glaucoma, or cerebral hemorrhage
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Flushing, severe headache disorder, nausea, nervousness, orthostatic hypotension, tachyarrhythmia, vomiting, erythema, skin irritation, allergic reactions, blurred vision, dermatitis due to topical drug, skin rash, xerostomia; severe hypotension, particularly with upright posture, may occur with even small doses of nitroglycerin, particularly in the elderly (use with caution); hypotension induced by nitroglycerin may be accompanied by paradoxical bradycardia and increased angina pectoris; elderly patients may be more susceptible to hypotension and may be at greater risk of falling at therapeutic doses; nitrate therapy may aggravate angina caused by hypertrophic cardiomyopathy, particularly in the elderly; aspirin may increase nitrate serum concentrations; marked symptomatic orthostatic hypotension may occur with coadministration of calcium channel blockers (dose adjustment of either agent may be necessary)
Neuromuscular Blocker Agent, Toxin
Neuromuscular blocker agents have been shown to decrease pain.
Botulinum Toxin Type A (Botox)
Botulinum neurotoxin is produced by the gram-negative anaerobic bacterium Clostridium botulinum. This agent acts by interrupting signal transmission within the peripheral and sympathetic nervous system, leaving sensory transmission intact. Botulinum toxins block acetylcholine release, causing a chemical denervation.
Adult
Dose expressed in mouse units; many studies have used the European version of botulinum toxin called Dysport, which is 4 times stronger than the commercial preparations used in United States; the dose commonly used in studies is 60 Dysport U mixed with 0.6 mL of NaCl; inject 2-4 cm distal to the lateral epicondyle
Pediatric
Not indicated
Coadministration of botulinum toxin and aminoglycosides or other agents that interfere with
neuromuscular transmission (eg, curare-like nondepolarizing blockers, lincosamides, polymyxins,
quinidine, magnesium sulfate, anticholinesterases, succinylcholine chloride) should only be performed
with caution, as the effect of the toxin may be potentiated.
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
The most serious adverse events reported after treatment with botulinum toxin include rare
spontaneous reports of death, sometimes associated with anaphylaxis, dysphagia, pneumonia,
and/or other significant debility; adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes, have been reported (some patients had risk factors including preexisting cardiovascular disease); onset or recurrent seizures have also been reported in patients predisposed to these events; treat patients with diseases of the neuromuscular junction with caution because the underlying generalized weakness may be augmented, and local weakness at the injection site may be more than otherwise anticipated; unwanted weakness, nausea, fatigue, malaise, flulike symptoms, rashes, pain, edema, erythema, ecchymosis, headache, and hyperesthesia can be noted after administration of botulinum toxin.
More on Lateral Epicondylitis |
| Overview: Lateral Epicondylitis |
| Differential Diagnoses & Workup: Lateral Epicondylitis |
 Treatment & Medication: Lateral Epicondylitis |
| Follow-up: Lateral Epicondylitis |
| References |
| « Previous Page | Next Page » |
References
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Further Reading
Keywords
tennis elbow, lateral elbow stress syndrome, wrist extensor tendonitis, lateral elbow overuse syndrome, elbow and forearm overuse injuries, coffee cup sign, coffee-cup sign
