Synopsis Clear guidelines for the clinical management of individuals with lateral elbow tendinopathy (LET) are hampered by many proposed interventions and the condition's prognosis, ranging from ...immediate resolution of symptoms following simple advice in some patients to long-lasting problems, regardless of treatment, in others. This is compounded by our lack of understanding of the complexity of the underlying pathophysiology of LET. In this article, we collate evidence and expert opinion on the pathophysiology, clinical presentation, and differential diagnosis of LET. Factors that might provide prognostic value or direction for physical rehabilitation, such as the presence of neck pain, tendon tears, or central sensitization, are canvassed. Clinical recommendations for physical rehabilitation are provided, including the prescription of exercise and adjunctive physical therapy and pharmacotherapy. A preliminary algorithm, including targeted interventions, for the management of subgroups of patients with LET based on identified prognostic factors is proposed. Further research is needed to evaluate whether such an approach may lead to improved outcomes and more efficient resource allocation. J Orthop Sports Phys Ther 2015;45(11):938-949. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5841.
There is controversy regarding the optimal treatment for lateral elbow tendinopathy (LET), and not all available treatment options have been compared directly with placebo/control. A network ...meta-analysis was conducted to compare the effectiveness of different LET treatments directly and indirectly against control/placebo based on a validated outcome, the Patient-Rated Tennis Elbow Evaluation (PRTEE) pain score.
Randomized, controlled trials comparing different treatment methods for LET were included, provided they reported outcome data using the PRTEE pain score. A network meta-analysis with random effect was used to combine direct and indirect evidence between treatments compared with placebo in the short term (up to six weeks) and midterm (more than six weeks and up to six months) after intervention.
Thirteen studies with 12 comparators including control/placebo were eligible. The results indicated no significant improvement in PRTEE pain score in the short term across all treatments compared with control/placebo. In the midterm, physiotherapy/exercise showed benefit against placebo (mean difference: −4.32, 95% confidence interval: −7.58 and −1.07). Although steroid injections, dry needling, and autologous blood also exhibited potential treatment effects, it is crucial for the clinician to consider certain pitfalls when considering these treatments. The limited number of small studies and paucity of data call for caution in interpreting the results and need for further evidence.
Patients should be informed that there is currently no strong evidence that any treatment produces more rapid improvement in pain symptoms when compared with control/placebo in the short and medium terms.
Therapeutic I.
PURPOSEThis study aimed to investigate the effect of unsupervised isometric exercise compared with a wait-and-see approach on pain, disability, global improvement, and pain-free grip strength in ...individuals with lateral elbow tendinopathy.
METHODSForty participants with unilateral lateral elbow tendinopathy of at least 6 wk duration were randomized to either wait-and-see (n = 19) or a single supervised instruction session by a physiotherapist, followed by an 8-wk unsupervised daily program of progressive isometric exercise (n = 21). Primary outcomes were Patient-Rated Tennis Elbow Evaluation, global rating of change on a six-point scale (dichotomized to success and no success) and pain-free grip strength at 8 wk. Secondary outcomes were resting and worst pain on an 11-point numerical rating scale, and thermal and pressure pain thresholds as a measure of pain sensitivity.
RESULTSThirty-nine (98%) participants completed 8-wk measurements. The exercise group had lower Patient-Rated Tennis Elbow Evaluation scores compared with wait-and-see at 8 wk (standardized mean difference SMD, −0.92; 95% confidence interval CI, −1.58 to −0.26). No group differences were found for success on global rating of change (29% exercise vs 26% wait-and-see (risk difference, 2.3%; 95% CI, −24.5 to 29.1)), or pain-free grip strength (SMD, −0.33; 95% CI, −0.97 to 0.30). No differences were observed for all secondary outcomes except for worst pain, which was moderately lower in the exercise group (SMD, −0.80; 95% CI, −1.45 to −0.14).
CONCLUSIONSUnsupervised isometric exercise was effective in improving pain and disability, but not perceived rating of change and pain-free grip strength when compared with wait-and-see at 8 wk. With only one of the three primary outcomes being significantly different after isometric exercises, it is doubtful if this form of exercise is efficacious as a sole treatment.
Tendinopathy is a common cause of elbow pain in the active population. Ultrasound-guided tenotomy (USGT) is a minimally invasive treatment option for cases recalcitrant to conservative management. ...Several case studies have shown promising preliminary results of USGT for common extensor tendinopathy and common flexor tendinopathy, but none have included USGT for triceps tendinopathy. This larger retrospective study evaluates the effectiveness and safety of USGT for all elbow tendinopathy sites at short- and long-term follow-up.
Retrospective chart review identified 131 patients (144 procedures; mean age ± standard deviation SD, 48.1 ± 9.8 years; mean body mass index ± SD, 32.2 ± 7.7; 59% male) with elbow tendinopathy (104 common extensor tendinopathy, 19 common flexor tendinopathy, 8 triceps tendinopathy) treated with USGT over a 6-year period by a single physician. Pain and quality-of-life measures were collected at baseline. Pain, quality-of-life, satisfaction with outcome, and complications were collected at short-term (2-, 6-, and 12-week) and long-term (median 2.7 years, interquartile range = 2.0-4.0 years) follow-up.
Overall, USGT for elbow tendinopathy decreased pain from moderate/severe at baseline to mild/occasional at short- and long-term follow-up (P < .01). Quality-of-life assessments showed significant improvement in physical function at short- and long-term follow-up (P < .01). The majority (70%) of patients were satisfied with the procedure. There was a 0% complication rate.
Benefits of USGT include pain relief, improved physical function, and high patient satisfaction. USGT is a safe, minimally invasive treatment for refractory elbow tendinopathy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Study Design RCT. Introduction Lateral elbow tendinopathy is a common clinical condition. eccentric exercises. eccentric-concentric loading and, isometric exercises are indicated to reduce ...and manage tendon pain. Purpose of the Study To compare the effectiveness of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. Methods A randomized clinical trial was carried out in a rheumatology and rehabilitation center. A group of 34 patients with later elbow tendinopathy was randomly allocated to Group A ( n = 11) who underwent eccentric training, Group B had eccentric-concentric and Group C who had eccentric-concentric and isometric training. All patients received 5 treatments per week for 4 weeks. Pain was evaluated using a visual analog scale and function using a visual analog scale and pain-free grip strength at the end of the 4-week course of treatment (week 4) and 1 month (week 8) after the end of treatment. Results The eccentric-concentric training combined with isomentric contractions produced the largest effect in the reduction of pain and improvement of function at the end of the treatment ( P < .05) and at any of the follow-up time points ( P < .05). Conclusion The eccentric-concentric training combined with isomentric contractions was the most effective treatment. Future well-designed studies are needed to confirm the results of the present trial. Level of evidence III.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Lateral Epicondylalgia (LE) represents one of the most common injuries of the upper limb. It is necessary to find effective treatments that reduce pain and increase functionality.
To determine the ...effects of an integrated intervention of Pulsed Negative Pressure Myofascial Vacuum Therapy (VT), Percutaneous Electrolysis (PE) and eccentric exercise (EE) in the treatment of LE compared versus Manual Therapy soft tissue mobilization (MT) and Ultrasound therapy (US) and EE.
Single-blind randomized controlled trial.
Forty participants, with unilateral LE, were randomly divided into two groups: VT + PE + EE group (n = 20) and MT + US + EE group (n = 20). The VT + PE + EE group received one weekly session for four weeks and a regimen of EE daily at-home, and the MT + US + EE group received 10 sessions over a period of two weeks and a regimen of EE daily at-home. Numerical pain rating scale (NPRS), range of motion (ROM) pressure pain threshold (PPT) and function (PRTEE questionnaire) were measured before treatment, at the end of treatment, and at one- and three-month follow-ups.
The statistically significant improvements were found post-treatment, favoring the VT + PE group in pain intensity (p < 0.001; ES = 0.408), PRTEE-S Pain (p = 0.001; ES = 0.377), PRTEE-S Specific function (p = 0.004; ES = 0.306) and PRTEE-S Total (p = 0.001; ES = 0.355). The VT + PE + EE treatment showed greater effectiveness than the MT + US + EE treatment at immediate post-treatment, as well as at the one-month and three-months follow-up.
VT and PE added to an EE program could be an effective treatment for pain, ROM, PPT, and function in patients with LE.
•Electrolysis and Myofascial Vacuum Therapy in epicondylalgia.•Electrolysis, negative pressure & eccentric exercises: effective in epicondylalgia.•Electrolysis+negative pressure+exercise more effective than manual therapy+ultrasound.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Purpose: The main purpose of the current study was to assess whether counter force brace (CFB) offers any additional value over Kinesiotaping (KT) in the management of tennis elbow. Materials and ...Methods: Forty-five females with clinically diagnosed tennis elbow participated in the current study. They were equally assigned into three groups of equal numbers. 12 sessions over 4 weeks of treatment interventions; experimental group A received the traditional physiotherapy program in addition to KT. Group B received the physiotherapy program in addition to the CFB. Group C (Control Group) received the physiotherapy program only. The degree of tennis elbow pain and myoelectrical activities of forearm muscles were measured. Results: There was a statistically significant reduction of pain in the experimental group A (KT) in comparison with the control group (p = 0.000), while a statistically significant reduction of pain (p = 0.000) and improvement of the myoelectrical activities of the forearm muscles (p = 0.000) were detected in the experimental group B (CFB) in comparison with the control group. In addition, the statistically significant reduction of pain (p = 0.000) and improvements in wrist flexors and extensors (p = 0.001 and p = 0.000, respectively) were detected in CFB compared with KT. Conclusion: Compared to KT or a physical therapy program alone, the use of CFB in the treatment of lateral elbow tendinopathy may be beneficial, especially in reducing pain and enhancing the muscle activities of the elbow flexors and extensors.
Weakness of the shoulder girdle muscles has been reported in patients with chronic lateral elbow tendinopathy. The aim of this study was to assess the short- and long-term effects of a conventional ...treatment plus scapular exercises program in patients with chronic lateral elbow tendinopathy.
A single-group prestudy and poststudy were conducted. The primary outcome was the Patient-Rated Tennis Elbow Evaluation questionnaire score. Secondary outcomes were grip strength; Disabilities of the Arm, Shoulder, and Hand questionnaire score; Visual Analogue Scale score at rest and at grip, and presence of scapular dyskinesis.
A total of 65 patients (72.3% females), with a mean age of 41.8 years, were analyzed. At the end of 6 weeks, the results showed clinically and statistically significant differences (P < .05). At 1-year follow-up, the differences were: Patient-Rated Tennis Elbow Evaluation -31 points (P < .001); grip strength +33.6% (P < .001); Disabilities of the Arm, Shoulder, and Hand -34.2 points (P < .001); Visual Analogue Scale at rest -2.5 cm (P < .001); and Visual Analogue Scale at grip -2.3 cm (P < .001).
At the end of 6 weeks and at 1-year follow-up, conventional treatment plus scapular exercises program showed statistically and clinically significant differences in all functional outcomes assessed in patients with lateral elbow tendinopathy.
The purpose of this study was to assess the effects of adding electrical dry needling and thrust manipulation into a multimodal program of exercise, mobilization, and ultrasound in patients with ...lateral elbow tendinopathy.
Randomized, single-blinded, multicenter, parallel-group trial.
Thirteen outpatient physical therapy clinics in nine different US states.
One hundred and forty-three participants (n = 143) with lateral elbow tendinopathy were randomized.
Cervical spine manipulation, extremity manipulation, and percutaneous tendon electrical dry needling plus multimodal physical therapy (n = 73) or multimodal physical therapy (n = 70) alone.
The primary outcome was elbow pain intensity and disability as measured by the Patient-Rated Tennis Elbow Evaluation at baseline, 1 week, 4 weeks, and 3 months. Secondary outcomes included the Numeric Pain Rating Scale, Tennis Elbow Functional Scale, Global Rating of Change, and medication intake.
The 2 × 4 analysis of covariance demonstrated that individuals with lateral elbow tendinopathy receiving electrical dry needling and thrust manipulation plus multimodal physical therapy experienced significantly greater improvements in disability (Patient-Rated Tennis Elbow Evaluation: F = 19.675; P < 0.001), elbow pain intensity (Numeric Pain Rating Scale: F = 22.769; P < 0.001), and function (Tennis Elbow Function Scale: F = 13.269; P < 0.001) than those receiving multimodal physical therapy alone at 3 months. The between-group effect size was large for pain and disability (Patient-Rated Tennis Elbow Evaluation: standardized mean difference = 1.13; 95% confidence interval: 0.78, 1.48) in favor of the electrical dry needling and thrust manipulation group.
The inclusion of percutaneous tendon electrical dry needling and thrust manipulation into a multimodal program of exercise, mobilization and ultrasound was more effective than multimodal physical therapy alone in individuals with lateral elbow tendinopathy.
www.clinicaltrials.gov NCT03167710 May 30, 2017.
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