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Physical Therapy Reviews 2006; 11: 155–160
WENDY-ANN WOOD1, AIMEE STEWART1 AND TANYA BELL-JENJE2 1Department of Physiotherapy, University of the Witwatersrand, South Africa 2Private Practitioner, Gauteng, South Africa Lateral epicondylalgia is a complex condition affecting both athletes and sedentary people.
Many patients do not respond to physiotherapy and the condition has a high recurrence rate.
Lateral epicondylalgia may be more complex than a simple lesion at the common extensortendon. Clinical trials in this area have failed to find conclusive evidence to support theconservative treatment of lateral epicondylalgia. Common confounding variables in suchclinical trials include wide ranges of duration of symptoms within a sample, and subjects withdifferent modes of onset. In some trials, the co-existence of cervical spine dysfunction andaltered neurodynamics is noted, but not treated; this may represent a reason for the poorresults reported from clinical trials. It has been suggested that lateral epicondylalgia is amultistructural pathology, but this is not quantified or controlled for in any of the clinicaltrials; this also has implications for therapy. If lateral epicondylalgia is a multistructuralpathology, then it is essential to have a standard method of assessing and quantifying theextent to which other structures are involved. This would allow for better standardisation ofthe samples included in clinical trials, which would then potentially lead to a betterunderstanding of appropriate therapy.
Keywords: Elbow, lateral epicondylitis, tennis elbow The following article provides a brief overview of the epidemiology, natural history and pathogenesis of Lateral epicondylalgia (or ‘tennis elbow’ as it is more lateral epicondylalgia; these are important factors to commonly known) is a complex condition. Review of consider when reviewing clinical trials as they may the literature highlights the fact that a certain group influence outcomes of treatment. The majority of of patients do not respond to conservative treatment papers reviewed are treatment trials, but the emphasis of the common extensor origin, and that the condi- of this paper is not on specific treatment techniques.
tion has a high recurrence rate.1 A frequently cited Rather, it is a review of the subject samples and how paper by Labelle et al.2 concluded that there is a lack the sample profiles may have influenced treatment of scientific evidence for the treatment of tennis outcomes. It also considers what structures have been elbow; this group was unable to complete a quantita- treated within clinical trials, and how this may have tive meta-analysis due to the variable methodology of the few randomised controlled trials that were avail- Many of the references in this review are dated, but able for inclusion in their review. A recent extensive are used as the older treatment trials were more systematic review conducted by Bisset et al.3 also descriptive in terms of the sample profile and were report a lack of evidence to support any long-term found to be more useful. There is little recent research benefits of physiotherapy intervention.
available on most of the treatment modalities. A PubMed search for English language papers con- treatment. Subjects in studies by Vicenzino et al.19 ducted in July 2006, using the keyword ‘lateral epi- and Haker and Lundeberg20 had symptoms for up to condylalgia’, revealed only 27 references more recent 36 months. Haker and Lundeberg21 reported symp- than 2000 and only another 8 more recent than 1995.
toms from 1–60 months. A condition that may persist The review that follows highlights two issues that for up to 8 years can hardly be called self-limiting.
may be confounding the results of treatment trials.
Hamilton1 also reported a high relapse rate; this First, it is possible that the condition is more complex may imply inadequate or inappropriate treatment of than a soft tissue injury of the extensor tendons.
the primary injury or it may be part of the natural his- Second, chronic cases may not respond to conserva- tory of the condition. The available evidence cannot tive treatment in the same way as acute cases.
definitively support either proposal: rather, it appearsthat many cases become chronic. The role of chronicpain and central sensitisation has also been consid- ered as potential factors underpinning the high recur-rence and chronicity in this condition.4,22–24 Lateral epicondylalgia affects 1–3% of the popula-tion.4 It has been described as an overuse injury.5 Only5% of all patients seen are recreational tennis players.6 Hutchinson et al.7 found that the incidence and preva-lence in male championship tennis players between Terms that have been used to describe the condition the ages of 16 and 18 years was 0.3% and 1.2%, include ‘lateral epicondylitis’, ‘humeral epicondylitis’, respectively. The incidence and prevalence in older, ‘elbow tendinosis’ and lateral epicondylalgia. The recreational tennis players is reported to be 9.1% and terms epicondylitis and tendonitis imply an acute 14.1%.8 This implies that age may play a role in the inflammation of the epicondyle or the tendon; how- aetiology of lateral epicondylalgia. Lateral epicondy- ever, histological examinations often fail to identify lalgia has also been considered to be an occupational inflammatory cells. Nirschl5 reported that the tendon disease.9,10 The dominant arm is affected in more than fibres are disrupted by a characteristic invasion pat- 70% of cases.1,9,11–14 Most authors have found no dif- tern of fibroblasts and vascular, atypical granulation- ference in the incidence and prevalence between gen- like tissue and called this angiofibroblastic tendinosis.
ders.1,9 In contrast, Verhaar15 found that between the However, the cases that undergo surgery have a ages of 40 and 60 years, 10% of women and only 3% lengthy duration, and poor response to conservative of men were affected. Epidemiological studies pose a treatment and cortisone injections. This degenerative problem in that the sample sizes need to be large for picture may be different to that seen in acute cases of credible results; however, detailed and accurate lateral epicondylalgia. In view of the pathological assessments of a large sample by a small number of findings and the suggestion of a multistructural qualified people may have logistical difficulties. At the pathology,22,25 lateral epicondylalgia is considered an time of writing this report, there were no South African statistics or epidemiological studies available.
In the study by Kivi,9 61.4% of subjects reported a spontaneous occurrence; these subjects were all accustomed to repeated forearm movements. Halle etal.16 reported that 68% of subjects in their study were Treatment for lateral epicondylalgia includes thera- unable to confirm how the condition started. A rea- peutic ultrasound, phonophoresis, corticosteroid son why many patients are often unable to identify a injections, acupuncture,26,27 electromagnetic field ther- causative activity may be due to the multistructural apy,12 extracorporeal shockwave therapy, laser,28 deep transverse friction massage, cervical spine mobilisa-tion, elbow joint mobilisation, exercise, elbow ‘cuffs’20and surgery.18,29 It has been stated that lateral epicondylalgia is a self- limiting condition.17 However, this view is not sup-ported by findings from a number of studies. Subjects The lack of evidence to support the use of ultrasound in studies by Wilhelm18 and by Abbott et al.10 had a for the treatment of lateral epicondylalgia may be due range of duration of symptoms from 2 months to 8 to the scarcity of well-designed, randomised con- years, during which time they received conservative trolled trials.2 Alternatively, it may be due to the fact that lateral epicondylalgia is a multistructural pathol- This pattern, of positive outcomes at 6 weeks and ogy and treatment of only the extensor tendon is then a high recurrence rate, was also evident in a trial by Smidt et al.,13 who compared hydrocortisone injec- Binder et al.30 compared pulsed ultrasound to placebo tions to physiotherapy and a period of rest using a ultrasound; results after 8 weeks showed pulsed ultra- comprehensive set of subjective and objective out- sound to be beneficial. At a 1-year follow-up, more than comes. After 1 year, the success rate for injections was half the subjects still experienced intermittent pain. It very much lower than that for physiotherapy or rest.
should be noted, however, that the subjects who had ini- Overall, subjects who have corticosteroid injections tially responded to pulsed-ultrasound treatment experi- seem to have a high recurrence rate; this may because enced a lower incidence of recurrence of severe pain at the cause of the problem is not being addressed, or the 1-year follow-up. A possible interpretation of these the pathology extends beyond the extensor tendons.
findings is that there may be some cases of lateral epi-condylalgia that are perpetuated by causes other thansimple tendon degeneration, and thus do not respond to Shockwave therapy has been found to be effective inthe treatment of chronic tennis elbow. Rompe et al.34 showed a significant decrease in pain as well as animprovement in strength up to 24 weeks follow-up.
Stratford et al.31 evaluated phonophoresis with 10% However, results would have been more convincing if hydrocortisone ointment and friction massage as follow-up had continued for 12 months, as this seems treatments for tennis elbow; they could provide no evidence to support the use of hydrocortisone as a Another trial by Rompe et al.35 compared low- coupling medium. Of interest is their finding that energy shockwave therapy in conjunction with man- those subjects who presented with a recurring injury ual therapy of the cervical spine to a control of had a poorer prognosis: it appears that there may be a shockwave therapy alone. At 12 months’ follow-up, sub-group of patients who tend to have recurrence of there was no difference between the groups, with both symptoms and associated poor prognosis.
Extracorporeal shockwave therapy may be benefi- cial in the treatment of chronic lateral epicondylalgia.
The apparent long-term success rate of these two tri-als is interesting because the main effect of shockwave There is conflicting evidence for the use of cortisone therapy is analgesia. It is surprising that it seems more injections for the treatment of lateral epicondylalgia.
effective than, for example therapeutic ultrasound, Price et al.32 compared local injections of hydrocorti- which should theoretically have a histological effect sone, triamcinolone and lignocaine in different and modify the course of the pathology. All cases in dosages, and showed that at a 6-month follow-up these trials were chronic, and results may be due to there was no significant difference between the modification of chronic pain mechanisms.
groups. The range of duration of symptoms was4–154 weeks. This, in itself, may yield a poor resultsince the pathology that is being injected would likely be very different at 4 weeks compared to 154 weeks. Ahigh recurrence rate was reported: a finding seem- Deep transverse friction massage has been incorpo- ingly common to most treatment trials.
rated into more complex physiotherapy treatments in Verhaar et al.33 compared corticosteroid injections trials such as that undertaken by Smidt et al.13 They to deep transverse friction and Mill’s manipulations.
also included pulsed ultrasound and an exercise pro- At 6 weeks, the group that received corticosteroid gramme, and compared this with a ‘wait-and-see’ pol- injections was significantly better than the group icy (the control group), and another group which receiving physiotherapy in terms of grip strength and received cortisone injections. While the physiotherapy a patient-rated scoring system based on function, package was only slightly more effective than the pain and patient satisfaction. At 1-year follow up, ‘wait-and-see’ policy, it is difficult to conclude there was no difference between the groups and, once whether the improvement in the physiotherapy group again, the injection group had a high recurrence rate.
was from the massage or the exercise programme or It was observed that subjects with prior cervical spine both. Smidt et al.13 reported that 29% of the subjects in complaints were more likely to have a poor outcome.
the cortisone group and 14% of patients in the exercise group had concomitant neck disorders. The authors Vicenzino and Wright40 has shown improvement at 6- did not see this as a confounding variable, but the role week follow-up, but it is clear that recurrence occurs of cervical spine dysfunction in lateral epicondylalgia beyond this stage. The literature on this kind of treat- has not been sufficiently explored in any of the litera- ment for lateral epicondylalgia is recent and further ture to conclude that it would not have an effect on studies to evaluate the effectiveness of these treatment prognosis. Stratford et al.31 found no advantage to strategies over 24 months are needed.
using deep friction massage in addition to ultrasound.
They did not use Mill’s manipulation after the frictionmassage so no conclusions can be drawn from this study regarding the use of deep transverse friction.
It is impossible from the literature to draw any There are numerous arguments for the use of exercise definitive conclusions regarding the use of deep trans- for the treatment of soft-tissue injuries. Graded and verse frictions for lateral epicondylalgia.
controlled motion improves the functional result ofhealing of soft tissue.41,42 The fact that lateral epi-condylalgia is thought to be a multistructural pathol- ogy25 may lend itself to the use of active exercise as atreatment because during active exercise the muscular Vicenzino et al.36 evaluated the initial effects of cervi- as well as neural, articular, and circulatory systems cal spine mobilisation on the pain and dysfunction of are affected,43 A progressive strengthening and lateral epicondylalgia; outcome measures included a stretching exercise programme was investigated by neurodynamic test, pain-free grip strength, pressure Pienimäki et al.;44 this progressed over four steps, and pain threshold, resting pain score as well as pain and consisted of slow, repetitive, resisted active movement function over a 24-h period. This trial found that the followed by stretching. The value of this programme mobilisation technique elicited an immediate hypo- was compared to pulsed ultrasound. After 8 weeks of algesic effect, with significant improvement in all out- treatment, pain was significantly lower in the exercise comes which lasted for up to 24 h. Mobilisation of the group. A 36-month follow-up study45 showed that the cervical spine may alter upper limb neurodynamics.37 exercise group had better long-term results than the A retrospective analysis by Cleland et al.38 showed ultrasound group in terms of pain relief and ability to that patients with lateral epicondylalgia, who received work. However, the exercise programme was only cervical manual therapy in addition to local manage- compared to pulsed ultrasound, for which there is no ment, had a successful outcome in significantly less conclusive evidence to support its use for the treat- treatment sessions than those who received local ment of lateral epicondylalgia; thus any treatment, management only. Further trials are needed to deter- when compared with pulsed ultrasound, may prove to mine whether there is long-term value of cervical be more effective. From the review of these trials, no spine mobilisation for the treatment of lateral epi- conclusion can be made regarding the use of exercise, condylalgia; however, these preliminary findings are except that it is more effective than pulsed ultrasound in the short term and cortisone injections in the longterm.
The elbow joint mobilisation technique that appearsmost frequently in the literature is the mobilisation- Many of the studies reviewed included subjects with with-movement described by Mulligan.39 Clinical tri- variable ranges of duration of symptoms. The pathol- als10,19 have shown that this form of treatment can ogy may be so variable between such subjects that it is significantly improve pain-free grip strength during difficult to recognise any trends as subjects may have and directly after treatment. Paungmali et al.14 found different responses to treatment. Some authors claim that this technique produced similar hypo-algesic to have found no association between duration of effects to Vicenzino et al.19 as well as mild sympatho- symptoms and outcome in their studies, but a subject excitatory effects. From these studies, it is difficult to with 2 months of symptoms can hardly be compared conclude whether the relief experienced by the sub- jects was mainly due to mechanical effects or changes It is clear that lateral epicondylalgia is a complex in sympathetic nervous system function. None of condition, which is more than a simple soft-tissue these trials was aimed at showing any long-term ben- injury of the extensor tendons. Beyond this, there efit of the technique; an isolated case study by seems to be a certain subgroup of patients that does not respond to conservative treatment of the extensor well as on the mechanisms of pain relief of various tendon, and there is also a high recurrence rate.
physical interventions.49,50 This type of research will There is limited literature in which structures other also allow for better standardisation of samples as than the common extensor tendon are fully investi- well as more appropriate treatment selection.
gated. Yaxley and Jull46 investigated adverse tensionin the neural system in subjects with tennis elbow andtheir results suggest that it may contribute to the pain.
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WENDY-ANN WOOD MSc (for correspondence)
Lecturer, Department of Physiotherapy, University of the Witwatersrand Medical School, 7 York Road, Parktown 2192, South Africa Tel: +2711 717 3702; Fax: +2711 717 3719; E-mail: Wendy-Ann.Wood@wits.ac.za AIMEE STEWART PhD
Associate Professor, Department of Physiotherapy, University of the Witwatersrand Medical School, TANYA BELL-JENJE BSc MSc
Private Practitioner, Gauteng, South Africa

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