ArticlePDF Available

Tennis Elbow (Lateral Epicondylitis)

  • Penn Highlands Healthcare System


Lateral epicondylitis, also commonly referred to as tennis elbow, describes an overuse injury secondary to eccentric overload of the common extensor tendon at the origin of the extensor carpi radialis brevis (ECRB) tendon.[1][2]
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.
Tennis Elbow (Lateral Epicondylitis)
Benjamin K. Buchanan ; Matthew Varacallo .
William Beaumont Army Medical Center
Department of Orthopaedic Surgery, University of Kentucky School of Medicine
Last Update: January 20, 2019.
Lateral epicondylitis, also commonly referred to as tennis elbow, describes an overuse injury secondary to eccentric
overload of the common extensor tendon at the origin of the extensor carpi radialis brevis (ECRB) tendon.[1][2]
Tennis elbow is often an overuse injury primarily due to repetitive strain from tasks and activities that involve loaded
and repeated gripping and/or wrist extension. It historically occurs in tennis players but can result from any sports that
require repetitive wrist extension, radial deviation, and/or forearm supination. It is also seen in athletes who play
squash and badminton and other sports or activities that require similar movements. As it relates to athletes, this
condition is often precipitated by poor mechanics and technique or improper equipment.[3]
Tennis elbow is the most common cause of elbow symptoms in patients presenting with elbow pain in general. The
condition tends to affect men and women equally. The annual incidence is one to three percent in the United States.
Despite the condition being commonly referred to as tennis elbow, tennis players make up only 10% of the patient
population. Half of tennis players develop pain around the elbow, of which 75% represent true tennis elbow. It is more
common in individuals older than 40 years of age. Smoking, obesity, a repetitive movement for at least two hours
daily, and vigorous activity (managing physical loads over 20 kg) are risk factors in the general population for the
development of this condition. The natural course of the condition is favorable with spontaneous recovery within one
to two years in 80% to 90% percent of the patients.[4][5][4]
This condition is primarily a degenerative overuse process of the extensor carpi radialis brevis and common extensor
tendon. Aside from degenerative changes, the histological findings include granulation tissue, micro-rupture, an
abundance of fibroblasts, vascular hyperplasia, unstructured collagen, and notably a lack of traditional inflammatory
cells (macrophages, lymphocytes, neutrophils) within the tissue. The term has been previously described as
angiofibroblastic dysplasia based on multiple histologic studies describing its microscopic appearance and
characteristics [6][7]. Ultrasound evaluation often reveals calcifications, intrasubstance tears, marked irregularity of
the lateral epicondyle, and thickening and heterogeneity of the common extensor tendon.[8]
Multiple studies reporting the histologic appearance of pathologic ECRB specimens characterize any combination of
1 2
the following characteristics: [7]
hypertrophic or abundant fibroblasts
collagen disorganization
vascular hyperplasia
lack of inflammatory cells
History and Physical
Patients will typically report pain with an insidious onset but upon further questioning will often relate an overuse
history without a specific inciting traumatic event. The pain commonly occurs one to three days after unaccustomed
activity that involves repeated wrist extension.
In an athlete, the history may reveal new equipment use or an atypical workout circumstance such as an abnormally
intense or prolonged workout. This condition can also be precipitated by an acute injury or strain such as lifting a
heavy object or performing a hard backhand swing in tennis. This acute injury can lead to a more chronic process (i.e.
acute-on-chronic overuse injury). The pain is usually over the lateral elbow that worsens with activity and improves
with rest. The pain can vary from being mild, for example, with aggravating activities like tennis or the repeated use
of a hand tool, or it can be such severe pain that simple activities like picking up and holding a coffee cup or a coffee
cup sign will act as a trigger for the pain.
On examination, the point of maximal tenderness is usually over the lateral epicondyle, occasionally in a focal, distal
location about 1 cm to 2 cm from the lateral epicondyle itself. Palpation of the entire tendon may have some degree
and discomfort, and the connecting muscle may exhibit significant tightness. The patient’s pain will increase or be
reproduced with resisted wrist extension, especially when the elbow is extended and the forearm is pronated. Resisted
extension of the middle finger, while the elbow is extended, is particularly painful secondary to increased stress
placed on the tendon, further supporting the diagnosis. Notably, there should be an absence of radicular symptoms or
numbness/tingling. These symptoms suggest an alternative process such as a radial nerve entrapment although these
conditions can coexist[9].
Lateral epicondylitis is a clinical diagnosis and imaging is often not necessary. A provider may consider obtaining
elbow radiographic series (anteroposterior and lateral) if other injuries or conditions are suspected by history and/or
physical exam. Other conditions warranting potential imaging workup include evaluating for concomitant
degenerative joint changes, fractures, tumors, or bursitis. If the patient is not responding to nonoperative
management modalities, then the provider may consider ordering an MRI or ultrasound to evaluate for tears, stress
fractures, or osteochondral defects.[10]
Treatment / Management
Nonoperative management
First line management for the management of lateral epicondylitis includes rest from offending activity as guided by
the level of pain. Ice after activity and oral/topic NSAIDs can be used to help with pain control. Forearm
counterforce straps ("Cho-Pat" straps) are prescribed to relieve tension at the lateral epicondyle. These should be worn
during activity. The role of cho-pat straps is relatively controversial as some patients may report pain over the area of
maximal tenderness secondary to direct mechanical compression on the area itself. Brace use in the form of a cock-
up wrist splint should be prescribed to take stress off of the wrist extensors [9].
Occupational therapy with a focus on forearm stretching and strengthening and progression to eccentric muscle
strengthening of the common extensor tendon has also shown to be helpful. If pain does not respond to conservative
measures, then consider more advanced or invasive techniques such as topical nitrates, botulinum toxin, autologous
platelet-rich plasma, and dextrose prolotherapy.
Surgical management
Surgery should be considered as a last resort in the management of lateral epicondylitis. Prolonged
nonoperative management (i.e. 6- to 12-months) should be attempted prior to considering surgical management.
Specific surgical techniques utilized vary throughout the literature. Most surgeons prefer varying degrees of ECRB
debridement and/or release of the tendinous origin at the lateral epicondyle. In the setting of the surgeon electing
to forego an actual ECRB detachment, a generous debridement should be performed at the ECRB origin
with confirmation of debridement of the pathologic tissue and stimulation of a healthy, bleeding, bony bed of tissue at
the lateral epicondyle to help stimulate healing potential.[11][12]
Differential Diagnosis
The differential diagnosis for lateral epicondylitis includes, but is not limited to, any of the following conditions: [13]
Elbow bursitis
Cervical radiculopathy
Posterolateral elbow plica
Posterolateral rotatory instability (PLRI)
Radial nerve entrapment
Radial tunnel syndrome
palpation 3-4 cm distal and anterior to the lateral epicondyle
pain with resisted third-finger extension
pain with resisted forearm supination
Occult fracture(s)
Capitellar osteochondritis dissecans
Triceps tendinitis
Radiocapitellar osteoarthritis
Failing to address concomitant pathology
patients report inferior outcomes and lack of improvement if the primary cause of symptoms is not
addressed; patients should be educated regarding the risks and benefits of surgery -- the former include
but are not limited to infection, blood loss, neurovascular injury, continued pain, stiffness, or continued or
worsening overall dysfunction
radial nerve entrapment can be missed or not addressed clinically in up to 5% of patients being managed
for lateral epicondylitis
Iatrogenic LUCL injury
occurs iatrogenically with increased risk if the surgical dissection extends beyond the radial head equator
postoperative iatrogenic posterolateral rotatory instability (PLRI) can develop if the extension or LUCL
compromise is significant
Iatrogenic neurovascular injury
radial nerve injury
Heterotopic ossification
decrease risk with via copious saline irrigation following decortication and debridement
Pearls and Other Issues
After diagnosis, patient education, and a prescription for conservative treatment, patients can typically follow-up, as
needed. Sometimes more chronic cases will need additional follow-up to consider more advanced therapies. Posterior
interosseous nerve entrapment (radial tunnel syndrome) may coexist in up to 15% of cases. Keep this diagnosis in
mind as a coexisting condition or alternative diagnosis if radicular symptoms are present. Corticosteroid injections
have been shown to be beneficial in the short-term (less than six weeks) but ineffective in the long term. Topical
nitrates are thought to increase blood flow to the area and as a result, promote healing to the tendon. There has been
some suggestion that extracorporeal shockwave therapy can be used to treat this condition chronically. Although,
there have been no significant improvements using this therapy thus far. Although evidence has been mixed, platelet-
rich plasma and dextrose prolotherapy are pro-inflammatory agents that are designed to cause inflammation or
irritation to the tendon and trigger a healing response. Platelet rich plasma seems to have better evidence to date as
compared to dextrose prolotherapy. Most notably patients with chronic pain due to this condition report decreased
levels of pain and increased levels of functionality compared to corticosteroid injections.[14][15]
Enhancing Healthcare Team Outcomes
Tennis elbow is very common in society and can occur from many types of racquet sports including golf. Most
patients present to the primary care provider with pain around the elbow and the key is patient education. One has to
adopt good habits like stretching before taking part in the intense physical activity. In addition, when the pain comes
on, it is important to rest the hand. Nurses and physicians in a sports clinic should emphasize the importance of
improving muscle strength and conditioning. In addition, one has to use proper equipment.
With rest, the majority of patients with tennis elbow improve within 3-18 months. Surgery is rarely required. [16]
To access free multiple choice questions on this topic, click here.
Welsh P. Tendon neuroplastic training for lateral elbow tendinopathy: 2 case reports. J Can Chiropr Assoc. 2018
Aug;62(2):98-104. [PMC free article: PMC6173218] [PubMed: 30305765]
Kwapisz A, Prabhakar S, Compagnoni R, Sibilska A, Randelli P. Platelet-Rich Plasma for Elbow Pathologies: a
Descriptive Review of Current Literature. Curr Rev Musculoskelet Med. 2018 Dec;11(4):598-606. [PMC free
article: PMC6220004] [PubMed: 30255288]
Patiño JM, Corna AR, Michelini A, Abdon I, Ramos Vertiz AJ. Elbow Posterolateral Rotatory Instability due to
Cubitus Varus and Overuse. Case Rep Orthop. 2018;2018:1491540. [PMC free article: PMC6098894] [PubMed:
Degen RM, Conti MS, Camp CL, Altchek DW, Dines JS, Werner BC. Epidemiology and Disease Burden of
Lateral Epicondylitis in the USA: Analysis of 85,318 Patients. HSS J. 2018 Feb;14(1):9-14. [PMC free article:
PMC5786580] [PubMed: 29398988]
Chevinsky JD, Newman JM, Shah NV, Pancholi N, Holliman J, Sodhi N, Eldib A, Naziri Q, Zikria BA, Reilly JP,
Barbash SE, Urban WP. Trends and Epidemiology of Tennis-Related Sprains/Strains in the United States, 2010 to
2016. Surg Technol Int. 2017 Dec 22;31:333-338. [PubMed: 29315449]
Jeon JY, Lee MH, Jeon IH, Chung HW, Lee SH, Shin MJ. Lateral epicondylitis: Associations of MR imaging and
clinical assessments with treatment options in patients receiving conservative and arthroscopic managements. Eur
Radiol. 2018 Mar;28(3):972-981. [PubMed: 29027008]
Nowotny J, El-Zayat B, Goronzy J, Biewener A, Bausenhart F, Greiner S, Kasten P. Prospective randomized
controlled trial in the treatment of lateral epicondylitis with a new dynamic wrist orthosis. Eur. J. Med. Res. 2018
Sep 15;23(1):43. [PMC free article: PMC6138897] [PubMed: 30219102]
Sirico F, Ricca F, DI Meglio F, Nurzynska D, Castaldo C, Spera R, Montagnani S. Local corticosteroid versus
autologous blood injections in lateral epicondylitis: meta-analysis of randomized controlled trials. Eur J Phys
Rehabil Med. 2017 Jun;53(3):483-491. [PubMed: 27585054]
Coombes BK, Bisset L, Vicenzino B. Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. J
Orthop Sports Phys Ther. 2015 Nov;45(11):938-49. [PubMed: 26381484]
Chiavaras MM, Jacobson JA, Carlos R, Maida E, Bentley T, Simunovic N, Swinton M, Bhandari M. IMpact of
Platelet Rich plasma OVer alternative therapies in patients with lateral Epicondylitis (IMPROVE): protocol for a
multicenter randomized controlled study: a multicenter, randomized trial comparing autologous platelet-rich
plasma, autologous whole blood, dry needle tendon fenestration, and physical therapy exercises alone on pain
and quality of life in patients with lateral epicondylitis. Acad Radiol. 2014 Sep;21(9):1144-55. [PubMed:
Hegmann KT, Hoffman HE, Belcourt RM, Byrne K, Glass L, Melhorn JM, Richman J, Zinni P, Thiese MS, Ott
U, Tokita K, Passey DG, Effiong AC, Robbins RB, Ording JA., American College of Occupational and
Environmental Medicine. ACOEM practice guidelines: elbow disorders. J. Occup. Environ. Med. 2013
Nov;55(11):1365-74. [PubMed: 23963225]
Nishizuka T, Iwatsuki K, Kurimoto S, Yamamoto M, Onishi T, Hirata H. Favorable Responsiveness of the
Hand10 Questionnaire to Assess Treatment Outcomes for Lateral Epicondylitis. J Hand Surg Asian Pac Vol.
2018 Jun;23(2):205-209. [PubMed: 29734897]
Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological,
immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999 Feb;81(2):259-78.
[PubMed: 10073590]
Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am.
1979 Sep;61(6A):832-9. [PubMed: 479229]
Ramage JL, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Dec 3, 2018.
Anatomy, Shoulder and Upper Limb, Wrist Extensor Muscles. [PubMed: 30521226]
Buchanan BK, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Oct 27, 2018.
Radial Nerve Entrapment. [PubMed: 28613749]
Copyright © 2018, StatPearls Publishing LLC.
This book is distributed under the terms of the Creative Commons Attribution 4.0 International License (,
which permits use, duplication, adaptation, distribution, and reproduction in any medium or format, as long as you give appropriate credit to the original
author(s) and the source, a link is provided to the Creative Commons license, and any changes made are indicated.
Bookshelf ID: NBK431092 PMID: 28613744
... Risk factors for this condition are smoking, obesity, and repetitive activity for more than 2 hours daily. (4) It has been discovered that pathology is a degenerative tendinosis, which differs from tendinitis in that it has dense populations of fibroblasts, vascular hyperplasia, and unorganized collagen. On radiographs, the lateral epicondyle may appear to have some mild calcification. ...
... Although it mostly affects tennis players, it can happen in any sport or line of employment when there is excessive wrist extension, radial deviation, or forearm supination. (4) In a previous study data was taken from 179 participants including students, faculty members and research assistants of fine arts department and it showed 64% prevalence of performance related musculoskeletal pain among studied population, 96% expressed musculoskeletal discomfort in at least one location and 42% reported musculoskeletal pain in at least two locations. (13) This corelates with present study results indicating 48.59% prevalence of tennis elbow among fine arts students. ...
Full-text available
Objective: To determine the prevalence of tennis elbow in fine arts students and to check its association with duration and type of art activity. Methodology: In this descriptive cross-sectional study, 354 participants were selected from fine arts department of various universities of Sargodha, Pakistan, through non-probability convenient sampling technique from May to August 2022. A self-designed questionnaire, PRTEE scale, and cozen test was used to estimate the prevalence and association of risk factors for tennis elbow. Data was analyzed by using SPSS version 21. Results: Findings revealed that prevalence of tennis elbow among fine art students was 48.59%. About 62.43% students were doing painting and almost 50% perform art activity more than 5 hours daily. Total PRTEE score's mean value was found to be 30.97 ± 21.609. Cozen test was positive in 48.87% individuals. Significant association of tennis elbow was found with type and duration of art activity having p-values 0.033 and 0.040 respectively. Conclusion: Tennis elbow is a common musculoskeletal condition among fine art students. Duration and type of art activity significantly affects the occurrence of tennis elbow. Painting was reported as a major type of art activity associated with prevalence of tennis elbow. Moreover, engaging in artwork for more than 5hours daily also increase the risk of developing tennis elbow. The policy makers in fine arts faculties who are responsible for students' health should prioritize strategies to prevent and manage this condition.
... [1][2][3][4] The microtears are usually observed due to loaded and repeated gripping, wrist and finger extension, or supinator muscle contraction. [3,5,6] Patients experience pain in the lateral part of the elbow and weakness of their wrist extension and grip strength. [1,[3][4][5] Pain can range from intermittent and low grade to constant and severe. ...
... [3,5,6] Patients experience pain in the lateral part of the elbow and weakness of their wrist extension and grip strength. [1,[3][4][5] Pain can range from intermittent and low grade to constant and severe. [3,6] A study of Finnish adults (aged 30-64 years) reported 1.3% overall prevalence of lateral epicondylitis, with the highest prevalence in individuals between the ages 45 to 54 years, and no statistically significant difference between males and females. ...
Full-text available
Background: Lateral epicondylitis is one of the most common causes of elbow pain. Most patients recover with conservative treatments; however, some patients require surgical intervention. There are 3 common procedures offered: open tenotomy, arthroscopic tenotomy, and percutaneous microtenotomy. In comparison, percutaneous microtenotomy has been proven as a less invasive procedure to treat lateral epicondylitis. We reviewed the literature on the safety and efficacy of using a microdebrider coblation wand to treat lateral epicondylitis, and we compared its outcomes to open and arthroscopic tenotomy. Methods: A search was completed through PubMed Central, Google Scholar, EBSCO host, and Embase for studies that performed percutaneous microtenotomy with a microdebrider coblation wand to treat lateral epicondylitis. Studies were then screened to determine if they met inclusion and exclusion criteria and were reviewed for data analysis and potential risks of bias. Results: A total of 27 articles were identified and 9 articles (eight studies) met the inclusion criteria. Small sample sizes in the studies and heterogeneity of the methodology limited the capacity to carry out a meta-analysis. Percutaneous microtenotomy outcomes seem to be favorable for reduced pain, increased grip strength, and improved functional outcomes, which were similar to outcomes reported with the other surgical techniques. There were no major adverse events reported in the studies secondary to the use of the microdebrider coblation wand. Procedure time and return to daily activities were shorter for the microtenotomy group. Conclusion: Percutaneous microtenotomy performed with a microdebrider coblation seems to be an effective treatment for lateral epicondylitis that provides similar outcomes to the surgical techniques with a lower rate of complications.
... Furthermore, there should be no numbness or tingling. [16] There is no universal classification of vitamin D deficiency or insufficiency. In our study, vitamin D levels >30 ng/mL were considered normal, 20-30 ng/mL levels were accepted as vitamin D insufficiency, and <20 ng/mL as vitamin D deficiency. ...
... When the LE and control group were compared in vitamin D, patients with LE had significantly lower levels than the control group (p<0.001). The mean vitamin D level was 16 (Table II). ...
Full-text available
Objectives: This study aims to examine the relationship between low vitamin D levels and lateral epicondylitis (LE). Patients and methods: Between January 2016 and January 2018, a total of 40 patients (17 males, 23 females; mean age: 38.6±10.7 years; range, 18 to 59 years) diagnosed with LE were included as the study group, while 66 patients (33 males, 33 females; mean age: 33.6±12.5 years; range, 18 to 58 years) who did not have any elbow complaints and met the study criteria were included as the control group. Both groups were compared in terms of vitamin D levels, of which levels of >30 ng/mL were considered normal, levels between 20-30 ng/mL were accepted as vitamin D insufficiency, and levels <20 ng/mL were categorized as vitamin D deficiency. Results: Vitamin D levels of the LE group were significantly lower than the control group (p<0.001). The mean vitamin D level was 16.47±8.22 (range, 8.32 to 39.55) ng/mL in the LE group, and 23.64±8.4 (range, 11.6 to 49) ng/mL in the control group. While 31 of the patients (77.5%) diagnosed with LE had vitamin D deficiency, four (10%) had vitamin D insufficiency, and five (12.5%) had normal vitamin D levels. In the control group, 29 (43.9%) patients had vitamin D deficiency, 20 (30.3%) had vitamin D insufficiency, and 17 (25.8%) had normal vitamin D levels. Conclusion: Although the etiology of LE has not been fully understood yet, vitamin D levels were significantly lower in LE patients in our study. This finding supports that low vitamin D may be one of the factors in the etiology of LE.
... It is characterized by pain in the region of the lateral epicondyle of the humerus which is aggravated during resisted dorsiflexion of the wrist, supination and power grip. 1 With an annual incidence of 1-3% in the general population, it could lead to a substantial loss of labour due to the pain experienced by the patients. 2 It typically occurs during the 4th and 5th decades of life without gender disposition. 2 It is caused by inflammation of the common extensor origin on the lateral epicondyle of the humerus, with resultant microtears and histologic changes of angio-fibroblastic hyperplasia. ...
... 2 It typically occurs during the 4th and 5th decades of life without gender disposition. 2 It is caused by inflammation of the common extensor origin on the lateral epicondyle of the humerus, with resultant microtears and histologic changes of angio-fibroblastic hyperplasia. 3 The extensor carpi radialis brevis (ECRB) and the extensor digitorum communis (EDC) have been implicated as the most commonly affected tendons. ...
Full-text available
p class="abstract"> Background: The purpose of our study was to compare the efficacy of a wrist splint with a forearm counterforce strap brace in the management of tennis elbow. Methods: This prospective study was conducted between January and December 2018 comprising of 75 patients suffering from lateral epicondylitis managed conservatively with splints. Patients were randomized into three treatment groups, group 1 received tennis elbow forearm brace, group 2 received wrist extension splint, group 3 received both tennis elbow forearm brace and wrist extension splint. The patient-rated tennis elbow evaluation (PRTEE) score and visual analogue scale (VAS) scores were calculated at 0, 3 and 6 weeks of the treatment. Results: Mean difference of pre-treatment and post-treatment PRTEE score was significant in all three groups and was maximum for group 3 patients (32.42) followed by group 2 patients (27.04) followed by group 1 patients (20.06). Pre-treatment and post-treatment VAS score difference was maximum for group 3 patients. Conclusions: Significant symptomatic relief can be achieved in patients with tennis elbow by using either tennis elbow forearm brace or wrist extension splint or both. Provided proper patient selection and compliance, wrist extension splint achieves better symptomatic relief and functional outcome as compared to tennis elbow brace.</p
... Manual therapy and traditional modalities encompassing direct (therapeutic ultrasound, instrumented soft tissue mobilization) and indirect techniques (Positional Release Therapy) are commonly utilized to treat lateral elbow pain [14][15][16][17][18]. However, it is not known how these therapies affect blood flow or tissue fiber alignment at the elbow, which are often primary therapeutic targets to promote expedient healing [5,19,20]. Therefore, using diagnostic ultrasound, the purpose of the study was to examine how the application of Positional Release Therapy (PRT), instrumented assisted soft tissue mobilization (IASTM), therapeutic ultrasound (US) and a combination of all three, affect lateral elbow immediate blood flow and tissue fiber alignment. ...
Full-text available
Background: Manual therapy is commonly used by clinicians to improve blood flow and tissue fiber orientation. Hypothesis/Purpose: Using diagnostic ultrasound, the purpose of the study was to examine how the application of Positional Release Therapy (PRT), instrumented assisted soft tissue mobilization (IASTM), therapeutic ultrasound (US) and a combination of all three, affect lateral elbow immediate blood flow and tissue fiber alignment. Study Design: Controlled laboratory study. Methods: Twenty-five participants (26.0 ± 4.5 years; 69.3 ± 4.3 cm; 81.8 ± 16.9 kg) received PRT =13, US =12, IASTM =13, and a combination treatment = 12. Results: Blood flow was significantly higher following PRT (691.54 ± 1237.16 mm2) compared to IASTM (18.73 ± 227.10 mm2) (p=0.050; ES=0.073 (0.16-1.5) and US (-10.09 ± 479.26 mm2) (p=0.042; ES=0.72 (-0.03-1.29), but no different from the combination intervention (627.64 ± 820.22 mm2) (p=0.849). Seventy-five percent of elbows in the PRT intervention showed improvement in blood flow, 54% in the IASTM group, 45% in US, and 73% in the combination group. Tissue fiber alignment was significantly better following IASTM (-5756.00 ± 8156.19 mm2) compared to PRT (-1552.54 ± 3896.58 mm2) (p=0.042; ES=0.66 (-0.01 – 1.31), but no difference was demonstrated among the other interventions (p>0.066). All elbows (100%) that received IASTM showed improved tissue orientation, 77% in the PRT group, 64% in US and 64% in the combination group. Conclusion: Manual therapy, particularly PRT and IASTM, seem to be better at increasing blood flow and muscle fiber orientation, respectively. Level of Evidence: II.
... Lateral epicondylitis or tennis elbow is a common condition, occurring in 50% of tennis players as well as those who do repetitive grip and lifting tasks [1]. ...
... LE is more common in individuals 40-45 years of age or people with manual labor occupations, with men and women being affected equally (27,28). Despite tennis players making up less than 10% of the patient population, half of the tennis players do develop pain around the elbow, 75% of which is characteristic of true "tennis elbow" (29,30). The diagnosis is usually clinical, but some LE patients may benefit from additional imaging for a specific differential diagnosis. ...
Background: To investigate the role of shear wave elastography (SWE) in patients with lateral epicondylitis (LE) by assessing the common extensor tendon (CET) elasticity. Methods: A total of 62 unilateral LE patients were enrolled. Shear wave speed (SWS) and the thickness of CET in both elbows, along with the involved elbows with pre- and post-treatment, were obtained by SWE. The differences between groups, inter- and intra-observer agreements, and diagnostic accuracy were analyzed with a paired t-test, intraclass correlation coefficients (ICCs), and receiver operator characteristic (ROC) curve, respectively. Results: LE patients had significantly lower SWS on lesion sides compared to healthy elbows (P<0.05). The SWS of involved elbows were significantly higher after non-operation treatment than before treatment. The inter- and intra-observer agreements were excellent (ICCs: 0.900-0.993) for SWE measurements. Moreover, a 12.2 m/s cutoff value of mean SWS (Cmean) for discriminating LE patients from healthy subjects revealed a sensitivity and specificity of 93% and 93%, respectively. Conclusions: SWE is a valid imaging technique for the diagnosis of LE and monitoring of the treatment effect. Future studies are essential for investigating the correlations among clinical examinations, conventional ultrasound, and SWE.
Full-text available
Introduction There is ongoing controversy regarding the non-operative treatment of lateral epicondylitis. Given that the evidence surrounding the use of various treatment options for lateral epicondylitis has expanded, an overall assessment of non-operative treatment options is required. The purpose of this systematic review and meta-analysis was to compare physiotherapy [strengthening], corticosteroids (CSI), platelet-rich plasma (PRP), and autologous blood (AB) with no active treatment or placebo control in patients with lateral epicondylitis. Methods Medline, Embase, and Cochrane were searched through to March 8, 2021. Additional studies were identified from reviews. All English-language randomized trials comparing non-operative treatment of patient > 18 years of age with lateral epicondylitis were included. Results A total of 5 randomized studies compared physiotherapy (strengthening) with no active treatment. There were no significant differences in pain (mean difference (MD) -0.07, 95%CI -0.56 – 0.41) or function (standardized mean difference (SMD) -0.08 95%CI -0.46 – 0.30). Seven studies compared CSI with a control. The control group had statistically superior pain (MD 0.70, 95%CI 0.22 – 1.18) and functional scores (SMD -0.35, 95%CI -0.54 – -0.16). Two studies compared PRP with controls and no differences were found in pain (SD -0.15, 95%CI -1.89 – 1.35) or function (SMD 0.14, 95%CI -0.45 – 0.73). Three studies compared AB with controls, and no differences were observed in pain (0.49 95%CI -2.35 – 3.33) or function (-0.07 (95%CI -0.64 – 0.50). Discussion The available evidence does not support the use of non-operative treatment options including physiotherapy (strengthening), corticosteroids, PRP, or AB in the treatment of lateral epicondylitis.
Tennis elbow or lateral postoperative treatment is named after tennis players for they are prone to this disease. Golfers, plumbers, painters, gardeners, bricklayers, civil carpentry and housewives are also prone to tennis elbow.
The main function of the palmar aponeurosis is to increase grip of the hand. The central portion of palmar aponeurosis occupies the middle of the palm, triangular in shape (Fig. 5.1). Dupuytren’s contracture or Dupuytren’s disease (DD) is a progressive condition that causes the fibrous tissue of the palmar fascia to shorten and thicken. The ring finger and little finger are the fingers most commonly affected. The middle finger may be affected in advanced cases, but the index finger and the thumb are nearly always spared [1]. The disease is common in men older than 40 years; in persons of Northern European descent; and in persons who smoke, use alcohol, or have diabetes [2]. A review and meta-analysis results support the hypothesis of an association between high levels of work exposure (manual work and vibration exposure) and Dupuytren’s contracture in certain cases [3].
Full-text available
The wrist extensor muscles make up a significant component of the posterior forearm musculature. In general, these muscles originate on or near the lateral epicondyle and insert on the distal forearm or in the hand. Clinical pathology affecting one or multiple muscles in this group is not uncommon. For example, lateral epicondylitis affects 1­5% of the general population.
Full-text available
Objective: To report 2 cases of lateral elbow tendinopathy treated with a novel adaptation of tendon neuroplastic training (TNT). Clinical features: Patient 1: A 61-year-old male machine operator presented with one year of bilateral lateral elbow pain related to his occupation of using torque wrenches.Patient 2: A 37-year-old male electrician presented with two months of recurrent left lateral elbow pain related to repetitive motions of gripping and pulling at work. Intervention and outcome: Both patients underwent 8 weeks of a novel rehabilitation program, including TNT, which involved pacing their resistance exercises to a metronome. Both patients experienced clinically meaningful improvements in pain and functional outcome scores that were sustained at the 3-month follow-up. Summary: Recent evidence suggests that the central nervous system may play a role in chronic tendinopathies. It is possible that TNT may address the central nervous system component of chronic/recurrent tendinopathy that is not addressed by traditional passive therapies. However, further research is needed.
Full-text available
Purpose of Review Platelet-rich plasma is used in many orthopedic pathologies such as tendinopathies and ligament injuries. The clinical results reported in the scientific literature are, however, confusing. The aim of this manuscript is to provide a narrative literature review regarding the role of PRP in the most common elbow soft tissue pathologies. Recent Findings The response to PRP seems to be favorable when compared to steroid injection for pain management and for patient-reported outcomes in lateral epicondylitis. PRP injection does not seem to have the potential complications associated with a steroid injection such as skin atrophy, discoloration, and secondary tendon tears. Only a few manuscripts comparing the results of PRP treatment with either extracorporeal shockwave (ESW), dry needling, or even surgical treatments in lateral epicondylitis exist. The use of PRP in other elbow pathologies such as golfer’s elbow, ulnar collateral ligament injury, and distal biceps and triceps pathology is examined in few studies, with unclear recommendations. Summary Regarding elbow pathologies, PRP injections in tennis elbow seems to be the best-studied intervention. A major limitation in these studies is the significant heterogeneity in the methods used for preparing PRP, for example employing leukocyte-rich, leukocyte-poor preparations, PRP with or without activation, which makes the results of the studies difficult to compare. Results of this review show that more studies on larger cohorts, with comparable formulations, and with longer follow-up are required to give optimal suggestions concerning the use of PRP in elbow pathologies.
Full-text available
Background: In the treatment of lateral epicondylitis (LE), the role of a new dynamic wrist orthosis is unclear. Patients and methods: Patients suffering from a LE longer than 3 months were multicentrically and prospectively randomized into a physiotherapeutic group (PT group) and in a physiotherapy group plus wrist orthosis (PT + O group). Physiotherapy consisted of daily eccentric strengthening exercises under initial professional supervision. Inclusion criteria were a Placzek score greater than 4. Exclusion criteria were previous surgery, rheumatic arthritis, elbow instability, radicular symptoms, higher-grade extensor tendon rupture, or cervical osteoarthritis. The clinical evaluation was performed after 12 weeks and 12 months. The Patient-Rated Tennis Elbow Evaluation (PRTEE) scale, Placzek Score, the pain rating (VAS), range of motion and the Subjective Elbow Score were evaluated. Results: Of the initially 61 patients, 31 were followed up after 12 weeks and 22 after 12 months. Twenty-nine patients (43%) were male, the mean age was 46, and 44 patients (66%) had the right elbow involved. At 12 weeks, there was a pain reduction on the VAS in both groups (PT + O: 6.5-3.7 [p = .001]; PT: 4.7-4.1 [p = .468]), albeit it was only significant for the PT + O group. At 12 months, reduction was significant in both groups (PT + O: 1.1 [p = .000]; PT: 1.3 [p = .000]). The painless maximum hand strength in kg improved in both groups significant after 3 and 12 months. The Placzek score was reduced from 8.25 to 3.5 [p = .001] after 12 weeks for the PT + O group and from 8.1 to 3.8 [p = .000] in the PT group, as well as after 12 months in the PT + O group to 0 [p = .000] and in the PT group to 2.0 [p = .000]. The PRTEE improved in both groups after 12 weeks (PT + O: 52.8--31.3 [p = .002]; PT: 48.6-37.6 [p = .185]) and 12 months (PT + O: 16.15 [p = .000]; PT: 16.6 [p = .000]), although the reduction at 12 weeks was not significant for the PT group. Conclusion: The elbow orthosis appears to accelerate the healing process with respect to the PRTEE and pain on the VAS (12 weeks follow-up), although there is an adjustment after 12 months in both groups and a significant improvement of symptoms is achieved in all endpoints.
Full-text available
A malunion as a complication of distal humerus fractures has been frequently linked with aesthetic problems but less frequently with posterolateral rotatory instability. We report 2 cases of childhood posttraumatic cubitus varus with subsequent posterolateral rotatory instability and their treatment with a minimum of 2 years of follow-up. The etiology of the so-called posterolateral rotatory instability of the elbow is mostly traumatic, but iatrogenic causes have also been described such as the treatment of tennis elbow and less frequently and chronically due to overuse and overload because of distal humerus malunion.
Full-text available
Synopsis Clear guidelines for the clinical management of individuals with lateral elbow tendinopathy (LET) are hampered by the proposal of many potential 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. In this paper, 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 and pharmacotherapies. 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 leads to improved outcomes and more efficient resource allocation. J Orthop Sports Phys Ther, Epub 17 Sep 2015. doi:10.2519/jospt.2015.5841.
Background: The aim of our study was to compare the responsiveness of the Hand10 questionnaire and the Pain visual analogue scale (VAS) for the assessment of lateral epicondylitis. Methods: The standardized response mean and effect size were used as indicators of responsiveness, measured at baseline and after 6 months of treatment. Among the 54 patients enrolled, 28 were treated using a forearm band, compress and stretching, with the other 26 patients treated using compress and stretching. Results: The standardized response mean and the effect size were 1.18 and 1.38, respectively, of the Hand10 and 1.39 and 1.75, respectively, for the Pain VAS. Conclusions: The responsiveness of both tests was considered to be large, based on Cohen's classification of effect size, supporting the use of the Hand10 questionnaire to assess treatment outcomes for lateral epicondylitis.
Objectives: We assessed the implications of MR imaging with clinical history in lateral epicondylitis management by evaluating imaging and clinical features in patients with lateral epicondylitis treated conservatively or operatively. Methods: Sixty patients with lateral epicondylitis treated conservatively (n = 38) or operatively (n = 22) from 2011-2015 were included. MR imaging findings of common extensor tendon (CET), lateral collateral ligament (LCL) complex, muscle oedema, ulnar nerve and elbow joint were reviewed. Clinical data recorded were frequency, duration and intensity of pain, history of trauma and injection therapy, range of motion. Results: MRI-assessed CET and LCL complex abnormalities, muscle oedema, radiocapitellar joint widening, joint effusion/synovitis, pain frequency and intensity differed significantly between the two groups (p < .05) with increased severity in operative group. Persistent pain (OR 12.2, p < .01), CET abnormality on longitudinal plane (OR 7.5, p = .03 for grade 2; OR 22.4, p < .01 for grade 3) and muscle oedema (OR 6.7, p = .03) were major factors associated with operative treatment. Area under the ROC curve of predicted probabilities for combination of these factors was 0.83. Conclusion: MR imaging, combined with clinical assessment, could facilitate appropriate management planning for patients with lateral epicondylitis. Key points: • MRI can reflect different disease severity between patients treated conservatively/operatively. • CET abnormality, muscle oedema were major MRI findings with operative treatment. • Patients in operative group were more likely to experience persistent pain. • MRI plus clinical symptoms could facilitate appropriate management for lateral epicondylitis.
Background: National rates of lateral epicondylitis and surgical treatment are poorly defined. Disease burden of lateral epicondylitis (LE) continues to increase annually. Further study is necessary to optimize treatment algorithms to reduce associated health-care expenditures. Questions/purposes: The purpose of this study is to review the annual incidence of LE, surgical rates, and associated health-care costs in a population setting. Methods: A national database was queried for LE from 2007 to 2014. Surgical cases were identified and annual rates were recorded. Demographic and epidemiologic data were reported with descriptive statistics, while trends over time were analyzed using linear regression. Results: Eighty-five thousand three hundred eighteen cases of LE were identified. The annual incidence per 10,000 patients remained constant (p = 0.304). The proportion of diagnoses in patients <65 years decreased (p ≤ 0.002) and ≥65 years increased (p < 0.001) over the study period. One thousand six hundred ninety-four patients (2%) required operative treatment. The annual rate of surgical intervention remained constant (p = 0.623). The proportion of patients <40 years requiring surgery decreased (p < 0.001) as the proportion of patients ≥65 years needing surgery increased (p = 0.003). Total reimbursement for LE procedures during the study period was $7,220,912. Average per-patient reimbursement was $4263. Both annual total reimbursement (p = 0.006) and per-patient reimbursement rates (p = 0.002) significantly increased. Conclusion: The annual incidence of LE and rate of surgical intervention have remained constant from 2007 to 2014. The proportion of patients over >65 years diagnosed with, and receiving surgical treatment for, LE has significantly increased in recent years. Total reimbursement and average per-patient reimbursement have steadily risen, demonstrating the increasing burden of cost on the health-care system.
Background: Lateral epicondylitis is a common painful elbow disorder. Several approaches to treatment have been proposed, with a local injection of corticosteroids being the most frequently used. Recent insights into the pathophysiology encouraged the introduction of autologous blood injections as an alternative treatment method. Aim: The aim of this meta-analysis is to summarize quantitatively the evidence regarding the efficacy of corticosteroids and autologous blood injections for treatment of pain in lateral epicondylitis. Design: Meta-analysis. Setting: Outpatient treatment. Population: Studies were considered eligible based on the following inclusion criteria: adult human, diagnosis of lateral epicondylitis, randomized controlled trials comparing corticosteroids versus autologous blood injections, pain assessment. Exclusion criteria were previous surgery for lateral epicondylitis or for other elbow disorders, concurrent treatment with drugs or physiotherapy, diagnosis of musculoskeletal systemic disorder. Methods: A systematic search of literature was performed according to PRISMA statement. Effect size of each included study was calculated and analyzed in a random-effects model. Results: Four studies, enrolling total of 218 patients (139 females and 79 males), were included in quantitative analysis. At 2 weeks there was a trend towards a reduction of VAS score in the corticosteroid group (WMD = 2.12 [95% CI: 4.38 to 0.14], P=0.07). No significant differences were recorded in the medium-term (4-12 weeks; WMD = 0.85 [95% CI: -0.44 to 2.15], P= 0.19) and long-term (24 weeks; WMD = 0.63 [95% CI: -2.40 to 3.66], P= 0.68) follow-up. Conclusions: Few high-quality trials compare the efficacy of corticosteroid and autologous blood injections in the control of pain related to lateral epicondylitis. Available data indicate that corticosteroids tend to reduce VAS score in short-term follow-up, although these data are not statistically significant. No differences were recorded in the medium and long term. Clinical rehabilitation impact: Contrary to popular opinion among medical professionals, and despite pathophysiological cues, the currently available data offer no support for the effectiveness of autologous blood injections in medium- and long- term follow-up. Further studies are necessary to establish which treatment has more impact on pain in lateral epicondylitis. These data could be then used as a basis for practical guidelines and new protocols of treatment.