Lateral Epicondylitis Treatment & Management

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]

In 2006, Bisset et al investigated treating lateral epicondylitis with physiotherapy, corticosteroid injection, or watchful waiting in 198 individuals with symptoms for greater than 6 weeks.^[1] Outcomes were global improvement in symptoms, pain-free grip force, and assessment of severity of complaints. There were significant reductions in all outcomes measured for corticosteroid injections over watchful waiting at 6 weeks. In the corticosteroid group, 78% reported success, versus 27% for those in the watchful waiting group. Corticosteroid injections also outperformed physiotherapy at 6 weeks, with 65% of the physiotherapy group having success versus 78% of the corticosteroid group. Physiotherapy was superior to watchful waiting at 6 weeks. However, the improvement in symptoms with corticosteroid injections was not sustained at 52 weeks.

At 52 weeks, the injection group was significantly worse on all outcomes compared with the physiotherapy group and worse on 2 of 3 measures compared with watchful waiting. Finally, at 52 weeks, there was not much of a difference in comparing physiotherapy to watchful waiting. Fifty-nine of 63 much improved or completely recovered in the physiotherapy group, versus 56 of 62 in the watchful waiting group. This study again elucidates that corticosteroid injections may have some benefit in the short term, but the long-term benefits are definitely lacking in the treatment of lateral epicondylitis. Physiotherapy demonstrated improvement versus watchful waiting at 5 weeks, with only slight improvement at 52 weeks.^[1]

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.

A study by Gosens et al compared corticosteroid with platelet-rich plasma (PRP) injections in patients who had refractory lateral epicondylitis symptoms for longer than 6 months. Primary outcome measures were pain and daily use of the elbow. One hundred patients blindly received either PRP or corticosteroid injection, followed by a similar standard rehabilitation protocol. Success was defined as a 25% reduction in pain on a visual analog scale (VAS) score or on a disabilities of the arm, shoulder, and hand (DASH) score.

At 4 weeks, the corticosteroid injection group reported a 32.8% improvement in VAS scores and a 25.8% improvement in DASH scores. At 4 weeks, the PRP group had a 21% improvement in VAS scores and a 15.7% improvement in DASH scores. Both had similar improvements at 8 weeks. The PRP group had a greater and more sustained symptom improvement; the individuals were followed for longer period of time. At 12 weeks, the PRP group demonstrated a 44.8% improvement in VAS and a 43% improvement in DASH scores. At 12 weeks, the corticosteroid group reported improvements of 32.8% in VAS and 29.8% in DASH scores. These trends continued at 6 months, 12 months, 1 year, and 2 years. The PRP group continued to show improvement in VAS and DASH scores at 6 months, 12 months, and 2 years. The corticosteroid group had less successful symptom resolution the longer the individuals were followed.^[9]

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.^[10] 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.^[11] However, some authors believe that no firm conclusions can be drawn from the use of orthotics in the treatment of lateral epicondylitis.^[12] 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.^[13] 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.^[13] The wrist splint provided no immediate improvement in either pain-free or maximum grip strength.

A study in 2008 by Altan and Kanat compared treating 50 individuals with symptoms of lateral epicondylitis for less than 12 months with either a typical counterforce forearm brace versus treatment with a 10-15° dorsiflexion wrist splint.^[2] Parameters of pain at rest and with extension, sensitivity, hand grip strength, and a subjective response to treatment were measured at baseline, 2 weeks, and 6 weeks. No formal physical therapy or home exercise program was recommended. The counterforce brace group demonstrated significant reduction in pain at rest and during movement at 2 weeks, while sensitivity and grip strength were not changed at 2 weeks.

At 6 weeks, significant improvement was noted in all parameters with the implementation of counterforce bracing. The wrist splint group demonstrated improvement in all parameters measured at 2 and 6 weeks except for sensitivity at 2 weeks. Comparison of the 2 groups showed significant improvement in resting pain at 2 weeks for the wrist splint group over the counterforce brace group. No other significant differences were noted between the 2 groups. This study was limited by lack of a control group. In summary, all patients improved with either counterforce elbow bracing or wrist splint bracing at 2 and 6 weeks. Wrist splint bracing, however, demonstrated an advantage on some measured subjective and objective parameters.^[2]

In 2009, a study looked at the immediate effect on grip strength in treating lateral epicondylitis with 3 different kinds of orthoses, a counterforce elbow strap, a counterforce elbow sleeve, and a wrist splint versus a placebo control brace proximal to the elbow. This involved 52 subjects with symptoms of a mean duration of 18 weeks. The counterforce strap and sleeve provided an improvement in pain free grip strength; however, there were no differences between the 2 counterforce braces. The wrist splint did not change pain free grip strength compared with placebo.^[3]

Extracorporeal shock wave therapy (ECSWT)

There has been no significant benefit demonstrated in using ECSWT to treat patients with lateral epicondylitis.^[14]

Ultrasound-guided percutaneous radiofrequency thermal lesioning

In August of 2011, Lin et al published a study looking at a novel method of treating chronic refractory lateral epicondylitis with ultrasound-guided percutaneous radiofrequency thermal lesioning (RTL).^[4] They enrolled 34 patients (35 elbows) with symptoms of lateral epicondylitis for greater than 6 months in whom previous interventions had failed. Patients were examined at baseline and then at 1, 3, and 6 months after the index procedure. Outcomes measures were VAS at rest and activity, QuickDASH scores, and the Modified Mayo Clinic Performance Index (MMCPI) for the elbow.

Significant pain reductions were noted at the 1, 3, and 6 months of follow up. Grip strength improved significantly at 3 and 6 months of follow up but not significantly at the 1 month of follow up. DASH and MMCPI scores improved significantly at all follow-up measurements. Eighty-five percent of the patients reported pain relief at the 1-month follow-up. Ninety-one percent of the subjects reported good-to-excellent satisfaction results at 6 months. Five patients needed a repeat procedure because of unsatisfactory symptom relief, and, of these, 4 reported satisfactory results after the second procedure. No change was noted on ultrasound in the thickness of the origin of the extensor tendon.^[4]

Laser therapy

Low-level laser treatments have not been proven to be an effective method to treat patients with pain from lateral epicondylitis.^[15]

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.^{[12, 16]} 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 as well as providing necessary cellular and humoral mediators to induce a healing cascade. Edwards and Calandruccio studied 28 people in whom conservative therapy had failed to resolve symptoms from their lateral epicondylitis.^[17] They were given a cock-up wrist splint and told to avoid any other bracing or physical therapy for 3 weeks. A home exercise program was initiated at week 3. The study demonstrated 22 (79%) of 28 of the patients had a reduction in Nirschl pain scores over 9.5 months after autologous blood injection therapy.^[17] Most often, this occurred after only one injection. However, this study is limited as it lacked a control group.^[5]

A study by Connnell et al in 2005 looked at ultrasound-guided autologous blood injections as a treatment for 35 individuals with lateral epicondylitis confirmed on MRI. These patients had symptoms for a median of almost 14 months and conservative therapy had not been successful. Outcomes were measured as reduction in VAS and Nirschl pain scores at 4 weeks and 6 months. No formal physical therapy or home exercise program was recommended. Autologous blood injections demonstrated significant improvements in VAS and Nirschl pain measurements at 4 weeks and at 6 months. Autologous blood injections also demonstrated statistical improvements in tendon thickness, interstitial cleft formation, echoic foci, hyperechoic change, and neovascularity.^[6]

A small study was recently published comparing autologous blood, corticosteroid, and saline injection in the treatment of lateral epicondylitis of less than 6 months’ duration in 28 individuals. Patients were followed for 6 months after the injections, and the outcomes measured were reduction in DASH scores and pain- and disease-specific functional scores. Participants were not given any formal physical therapy regimen or orthotics. They were simply given a standard sheet of stretching exercises to which compliance was not measured. All 3 injections caused a decrease in DASH scores at 2 weeks and 2 months and a significant decrease at 6 months; however, there were no significant differences between the 3 groups. In addition, patient reported scores of pain and function also improved among all 3 groups.^[7]

An August 2010 study by Kazremi et al performed a single blinded randomized clinical trial comparing autologous blood injections to corticosteroid injection in 60 individuals with lateral elbow tendinopathy during the past year.^[8] Bracing, physical therapy, or anti-inflammatory medications were not allowed during the duration of the study.

Outcomes were measurement of VAS pain scale, DASH questionnaire, modified Nirschl pain scores, maximum grip strength, and pain pressure threshold. Short-term follow-up was ascertained at 4- and 8-week intervals. Corticosteroid injections demonstrated improvements at 4 weeks in all outcome scores except pain pressure threshold. There was no significant improvement from 4-8 weeks in the steroid group for any of the outcomes except a decrease in limb pain and a worsening of grip strength. The autologous blood group demonstrated statistically significant improvements in all outcomes measured at 4 and 8 weeks. Autologous blood injections demonstrated superiority to corticosteroid injections at 4 and 8 weeks in all parameters measured.^[8]

Platelet rich plasma (PRP)

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.^[18] 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.^[18] 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.

A study was published in August 2011 comparing PRP therapy injections to autologous blood injections in 28 patients who had symptoms of lateral epicondylitis for greater than 3 months. Patients were instructed on home physical therapy consisting of eccentric exercises. Reevaluation was done at 6 weeks, 3 months, and 6 months to asses symptoms on a VAS pain scale and a Liverpool elbow score, which measured range of motion, activity level, and ulnar nerve function. On the VAS scale, both groups demonstrated improvements at all follow-up appointments. The PRP group had better results at each visit, with statistically better results at 6 weeks. Both groups also showed improvements on the Liverpool elbow score at all visits, with no significant differences noted.^[9]

Botulinum 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.^[19] 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 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.^[20] However, another randomized controlled trial demonstrated no significant difference when comparing injections of BTX and saline in the treatment of lateral epicondylitis.^[21]

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.^[22]

Rehabilitation Program

Physical Therapy

Strength training, exercise, and stretching have been shown to decrease pain in patients with lateral epicondylitis.^[12] 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.^[12] 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,^{[12, 15]} although US- and color Doppler-guided intratendinous injections with polidocanol in the extensor origin have shown promising clinical results,^[23] and there is insufficient evidence to support the use of transverse friction, soft-tissue therapy in the treatment of lateral epicondylitis.^[24]

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.^[25]

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.