Physical Medicine and Rehabilitation for Lateral Epicondylitis 

Updated: Sep 16, 2019
Author: John W Hawkins, DO; Chief Editor: Stephen Kishner, MD, MHA 

Overview

Practice Essentials

Lateral epicondylitis, or tennis elbow, is the most common overuse injury of the elbow. It has an annual incidence of 3% in the general population[1]  and is responsible for 10 million visits to physicians every year in the United States.[2] Lateral epicondylitis is usually precipitated by repetitive contraction of the wrist extensors and is characterized by aching pain that is worsened with activity. It is most commonly attributed to pathology of the extensor carpi radialis brevis tendon.[3]

Early conservative management is the key to symptom resolution, which eventually allows return to vocational and avocational activities without restriction. Resistance exercise is a widely accepted nonoperative treatment option for lateral epicondylitis, but patients with symptoms that persist beyond 6 months may have a prolonged course that ultimately requires surgical intervention.[4, 5, 6, 7, 8, 9]

Signs and symptoms of lateral epicondylitis

The patient usually describes a gradual onset of lateral elbow pain, which is characterized as follows:

  • The aching pain generally increases with activity; the patient may describe symptoms occurring during simple activities of daily living (ADL), such as picking up a cup of coffee or a gallon of milk

  • Pain may be present at night

  • Symptoms are typically unilateral

Most commonly, a physical examination reveals localized tenderness to palpation just distal and anterior to the lateral epicondyle.

Workup of lateral epicondylitis

Imaging studies usually are not necessary in the workup of lateral epicondylitis, but tendinopathies can be visualized with magnetic resonance imaging (MRI) and with diagnostic ultrasonography.[10, 11]

Electrodiagnostic studies may help to determine whether other causes of lateral elbow pain, such as cervical radiculopathy or posterior interosseous nerve palsy, are present.

Histologic findings in lateral epicondylitis can include collagen disorientation, collagen disorganization, fiber separation by increased mucinoid substance, an increased prominence of cells and vascular spaces (with or without neovascularization), and focal necrosis or calcification. Superimposed evidence of a tear, including fibroblastic proliferation, hemorrhage, and organizing granulation tissue, may be revealed.

Management

Anti-inflammatory modalities include ice, ultrasonography, and iontophoresis. Iontophoresis with topical nonsteroidal anti-inflammatory drugs (NSAIDs) has been shown to help reduce pain.

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.[12, 13]

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.

Resistance exercise is a widely accepted nonoperative treatment option for lateral epicondylitis.

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.[10, 14, 15, 16, 17, 18, 19] However, the role of corticosteroid injection in tendinopathy remains controversial.

For cases of refractory lateral epicondylitis, surgical resection of the lateral extensor aponeurosis may be considered.[20, 21]

Related Medscape Drugs & Diseases topics:

Elbow and Forearm Overuse Injuries

Lateral Epicondylitis Surgery [Orthopedic Surgery]

Lateral Epicondylitis [Sports Medicine]

Overuse Injury

Tendonitis

Pathophysiology

The etiology of chronic tendinopathy has been debated in the literature. Tendons are hypovascular, with some suggesting that they receive one third the blood flow of muscles.[22] Thus, once tendons are injured, healing times can be prolonged.

Most clinicians agree that lateral epicondylitis is a result of inflammation, or enthesitis, at the muscular origin of the extensor carpi radialis brevis (ECRB). This inflammation leads to microtears of the tendon, with subsequent fibrosis and, ultimately, tissue failure. Less commonly, the attachments of the extensor carpi radialis longus (ECRL), extensor digitorum communis (EDC), or extensor carpi ulnaris (ECU) are involved.[23, 24, 25]

 

Epidemiology

Frequency

Lateral epicondylitis is seen in up to 50% of tennis players.[26]

Sex

The condition affects men and women with equal frequency.

Age

Lateral epicondylitis most often occurs between the third and fifth decades of life.

 

 

Presentation

History

The patient usually describes a gradual onset of lateral elbow pain, which is characterized as follows:

  • The aching pain generally increases with activity. The patient may describe symptoms occurring during simple activities of daily living (ADL), such as picking up a cup of coffee or a gallon of milk.

  • Pain may be present at night.

  • Symptoms are typically unilateral.

Physical Examination

Most commonly, the examination reveals localized tenderness to palpation just distal and anterior to the lateral epicondyle. Other symptoms include the following[27] :

  • The patient may have a weakened grip on the affected side.

  • Elbow range of motion (ROM) is typically normal.

  • In chronic, refractory cases, be sure to fully assess shoulder integrity and scapular stability. Weakness or instability of the scapular stabilizers may perpetuate lateral epicondylitis by leading to overuse of the wrist extensors.

  • Cozen test - With the practitioner's thumb over the extensor tendon origin, the patient makes a fist and takes his or her wrist into extension. A positive test means that pain is reproduced underneath the practitioner's thumb at the common extensor origin/lateral epicondyle. This test is more sensitive with the elbow in full extension.

  • Mill test - A positive test occurs when there is reproduction of pain with palpation of the lateral epicondyle while pronating the patient's forearm, with full flexion of the wrist and passive extension of the elbow.

  • Long finger test or Maudsley test - A positive test occurs when there is reproduction of pain with palpation of the lateral epicondyle with resisted extension of the third digit.

Causes

See the list below:

  • Lateral epicondylitis is an overuse syndrome generally caused by repetitive use of the wrist extensors or sustained power gripping.[28]

  • Lateral epicondylitis can be associated with an imbalance secondary to muscle weakness and soft-tissue inflexibility.

 

DDx

Diagnostic Considerations

Posterior interosseous neuropathy at the radial tunnel or arcade of Frohse

Synovitis of the radiohumeral joint

Neuralgic amyotrophy

Radial head dysfunction

Intra-articular elbow pathology

Differential Diagnoses

 

Workup

Laboratory Studies

Laboratory studies generally are not indicated for the diagnosis of lateral epicondylitis.

Imaging Studies

Imaging studies usually are not necessary, but tendinopathies can be visualized with magnetic resonance imaging (MRI) and with diagnostic ultrasonography.[10, 11]

Other Tests

Electrodiagnostic studies may help to determine whether other causes of lateral elbow pain, such as cervical radiculopathy or posterior interosseous nerve palsy, are present.

Histologic Findings

Findings can include collagen disorientation, collagen disorganization, fiber separation by increased mucinoid substance, an increased prominence of cells and vascular spaces (with or without neovascularization), and focal necrosis or calcification. Superimposed evidence of a tear, including fibroblastic proliferation, hemorrhage, and organizing granulation tissue, may be revealed.

 

Treatment

Rehabilitation Program

Physical therapy

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 randomized, double-blind clinical trial by da Luz et al indicated that iontophoresis in patients with lateral epicondylitis can effectively reduce pain and improve function. The study evaluated 24 patients divided into two groups, the first of which underwent iontophoresis via a solution of dexamethasone and gel lidocaine administered through a negative electrode, with a base gel solution applied to the positive electrode, and the second of which was treated with galvanic current, with a base gel applied to both electrodes. Although pain on exertion and rest, handgrip strength with an extended or flexed elbow, and function significantly improved in both groups, as measured on the Patient-Rated Tennis Elbow Evaluation scale, results regarding pain and function were better in the iontophoresis patients.[29]

A wrist splint used during activities can be helpful in lateral epicondylitis 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.[12, 13, 30, 31]

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.[32]

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.[33, 34]

Jafarian et al compared 3 common types of orthoses for their effect on grip strength in patients with lateral epicondylitis.[35] 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.[36]

Home exercise programs

Resistance exercise is a widely accepted nonoperative treatment option for lateral epicondylitis. A review of 12 studies demonstrated that resistance exercise programs yielded significant improvement in pain and grip strength.[37]  The duration of the exercise programs evaluated ranged from 4-52 weeks. The number of exercise sessions per day ranged from 1-6, with 1-4 sets per session and an average of 15 repetitions per set. The most studied modality in the review was eccentric exercise, but no optimal regimen was found to be clearly defined.

A systematic review suggested that the use of eccentric exercises may be helpful in improving function and decreasing pain, but the evidence is limited, and well-designed studies with more power are needed.[1]  

Occupational therapy

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.

Medical Issues/Complications

Radial tunnel syndrome, also called posterior interosseous neuropathy, should be considered for refractory cases of lateral epicondylitis. Criteria for diagnosis of radial tunnel syndrome are controversial in the literature.[38] 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 may also be attributed to radial tunnel syndrome.[27]

Electrodiagnostic studies may be helpful in demonstrating nerve injury in cases of radial tunnel syndrome, thereby differentiating this entity from a dorsal 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 cutaneous sensory symptoms. Electrodiagnostic findings in posterior interosseous nerve compression may include denervation in radial-supplied muscles distal to the supinator, and possibly slowing (conduction block) 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 nonoperative management.

Surgical Intervention

For cases of refractory lateral epicondylitis, surgical resection of the lateral extensor aponeurosis may be considered.[20, 21]

Consultations

An orthopedic hand specialist may be consulted.

Other Treatment

Topical medications

Topical NSAIDs such as diclofenac topical may provide short-term pain relief, but evidence is conflicting on the use of oral NSAIDs.

Topical nitric oxide has been used to treat tendinopathy. The mechanism of action is thought to involve increased levels of nitric oxide at the area of pathology, which is believed to stimulate fibroblasts and increase collagen synthesis and remodeling.[39] Other theories suggest that the agent works through an increase in blood flow and the elimination of inflammatory mediators. A randomized, prospective, double-blinded clinical trial by Paoloni et al evaluating the efficacy of topical nitric oxide in lateral epicondylitis found "significantly reduced elbow pain with activity at 2 weeks, reduced lateral epicondylar and tendon tenderness at 6 and at 12 weeks, and improved elbow peak force for total work at 24 weeks."[39] Ischemic heart disease is a relative contraindication for the use of nitric oxide.

Corticosteroid injections

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.[10, 14, 15, 16, 17, 18, 19] However, the role of corticosteroid injection in tendinopathy remains controversial. Most lateral epicondylitis is combination of a degenerative and inflammatory process, and injecting steroid around a tendon may 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 performing steroid injections, ultrasonographic guidance is recommend for confirmation of location and avoidance of unintended consequences, such as inadvertent injection into nearby neurovascular structures.

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.[40]

Platelet-rich plasma injections

Platelet-rich plasma (PrP) utilizes autologous, concentrated platelet-rich plasma proteins containing several different growth factors and cytokines, that can be injected to promote cellular growth and healing. PrP has been used to treat chronic lateral epicondylitis, albeit with mixed results.[41, 42] A systematic literature review by Miller et al involving the treatment of chronic tendinopathy with PrP found that PrP "may have greater efficacy in lateral epicondylar tendinopathy." The results of the review showed level 1 evidence to support the use of PrP in the treatment of chronic tendinopathy.[22]

Some studies have shown PrP to be more efficacious than corticosteroid injection, with improvement on visual analogue scale (VAS) and disabilities of the arm, shoulder, and hand (DASH) scores at 2-year follow-up.[43]  PrP preparation methods vary widely, and some studies have shown variable results in tendinopathy outcomes depending on the method of preparation; leukocyte-rich preparations have been suggested to have superior effect regarding pain outcome measures.[44]

Botox injections

Other substances used for injection include local anesthetics and botulinum toxin. A literature review by Lin et al indicated that botulinum toxin and corticosteroids have similar efficacy in the treatment of lateral epicondylitis, although corticosteroids were found to provide greater pain relief in early follow-up (2-4 wks); at the next follow-up (after 8 wks), botulinum toxin seemed to be providing comparable pain relief. However, it is important to note that weakness can be a substantial side effect of Botox injections. The Lin study found botulinum toxin to be associated with reduced grip strength at 2- to 4-week follow-up, with a high equivalent dose capable of extending this reduction to 8-12 weeks.[45]  Studies have provided conflicting evidence as to whether botulinum toxin injection has positive long-term benefits for lateral epicondylitis.[46, 47, 48]

Percutaneous ultrasonic tenotomy

Ultrasonic percutaneous tenotomy is a relatively new procedure that has shown promising results in the treatment of lateral epicondylitis. Using an ultrasonic probe, ultrasonic energy tenotomizes diseased tendon but spares normal tissue. The necrotic tissue is emulsified and aspirated through the probe. The residual void created by the ultrasonic therapy is hypothesized to allow a more normal and rapid healing response. The procedure can be performed in an office-based setting or an ambulatory surgical center[2]  and is generally completed in about 15 minutes. The patient may be placed in a splint or treated with a simple ace bandage postprocedure, with no heavy lifting for 1 week. Return to normal activity is usually achieved by 4-6 weeks.[49]

Multiple studies have shown high patient satisfaction rates and excellent improvement in VAS and DASH scores with percutaneous ultrasonic tenotomy.[49, 50, 51]  Results have been found to be sustained at 1, 3, 6, 12, and 36 months. One study showed 100% normalized tendon thickness and patient satisfaction at 3 years.[50]

Complications in percutaneous ultrasonic tenotomy are rare. One study reported that in over 2500 procedures performed using this technology, no complications requiring medical attention or further treatment occurred.[49] Another study reported that one case out of more than 1000 was complicated by posterior interosseous nerve palsy, which resolved after 3 hours.[2]  The most common complication reported has been postprocedure soreness.

Bracing and taping

Evaluating the effects of bracing is often challenging. Terminology varies, with terms such as brace, orthosis, strap, wrap, and splint being used, and there are different brand names to contend with as well.[26] Additionally, there has been inconsistency in the materials used to construct different bracing options. Some studies have shown reduction of pain in the short-term with bracing, but a Cochrane review concluded that "no definitive conclusions can be drawn concerning effectiveness of orthotic devices for lateral epicondylitis."[52] As a result, further research is required.[53]

Other

Other types of treatment have included extracorporeal shockwave therapy.[54, 55, 56, 57] However, reviews of trials using shockwave treatment have found reasons not to support this as a therapeutic option.

According to a literature review by Bisset et al, the evidence shows that there is "currently insufficient evidence for the use of manual therapy, tape, orthotics, and exercise in the management of [lateral epicondylitis], but there are preliminary studies that appear to warrant further evaluations."[53]  Manual therapy has shown some promise for short-term relief. However, there are no studies that show positive long-term effects from manual therapy on lateral epicondylitis. Some evidence exists that compared with placebo, acupuncture can be beneficial in the short-term, for around 2-8 weeks. However, there appears to be more research needed.[53]

 

Medication

Medication Summary

The goal of drug treatment in cases of lateral epicondylitis is pain control, in order to facilitate the performance of ADL.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Class Summary

These agents have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Diclofenac topical (Solaraze)

Designated chemically as 2-[(2,6-dichlorophenyl) amino] benzeneacetic acid, monosodium salt, with an empirical formula of C 14 H 10 Cl 2 NO 2 NA. Diclofenac is one of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacologic studies. It is believed to inhibit the activity of COX, which is essential in the biosynthesis of prostaglandins.

Ibuprofen (Motrin, Ibuprin, Advil, Excedrin IB)

DOC for patients with mild to moderate pain. Ibuprofen inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Naproxen (Naprosyn, Naprelan, Anaprox, Aleve)

For relief of mild to moderate pain. Naproxen inhibits inflammatory reactions and pain by decreasing the activity of COX, which is responsible for prostaglandin synthesis.

Celecoxib (Celebrex)

Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, being 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, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient.

Corticosteroids

Class Summary

The medications have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Triamcinolone (Amcort, Aristospan Intra-articular)

For inflammatory dermatosis responsive to steroids. This agent decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and by reversing capillary permeability.

Analgesics

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who experience pain.

Acetaminophen (Tylenol, Aspirin-Free Anacin, Tempra, FeverAll)

DOC for pain in patients who have documented hypersensitivity to aspirin or NSAIDs, who have upper GI disease, or who are taking PO anticoagulants.

 

Follow-up

Deterrence/Prevention

To avoid a recurrence of lateral epicondylitis, the etiology of the condition must be considered. Job modifications may be necessary and may be facilitated by a job site evaluation. Investigation into avocational activities also is necessary, because contributing factors to this condition may be identified. In addition, adherence to a home exercise program is important in preventing a recurrence of lateral epicondylitis.

Prognosis

Patients who present acutely (< 3 mo) generally respond well to treatment. Chronic cases that are refractory to treatment may take months to resolve.

Patient Education

Education regarding the proper use of tools, good body mechanics, and the importance of flexibility and strength of the involved musculature should be emphasized to the patient.

For excellent patient education resources, see eMedicineHealth's patient education articles Tennis Elbow, Repetitive Motion Injuries, and Sprains and Strains.