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Galley Proof 19/08/2021; 9:36 File: bmr–1-bmr210053.tex; BOKCTP/ljl p. 1
Journal of Back and Musculoskeletal Rehabilitation -1 (2021) 1–15 1
DOI 10.3233/BMR-210053
IOS Press
Review Article
Physiotherapy treatment of lateral
epicondylitis: A systematic review
Laura Landesa-Martínezaand Raquel Leirós-Rodríguezb,∗
aFaculty of Physical Therapy, University of Vigo, Pontevedra, Spain
bSALBIS Research Group, Universidad de León, Nursing and Physical Therapy Department, Spain
Received 19 February 2021
Accepted 12 July 2021
Abstract.
BACKGROUND:
Lateral epicondylitis is a tendinopathy with a prevalence of between 1–3% of the population aged 35–54 years.
It is a pathology with a favorable evolution, but with frequent recurrences (which imply an economic extra cost).
OBJECTIVE:
The objective of this review was to determine the efficacy of physiotherapy treatment for the treatment of
epicondylitis and, if any, to identify the most appropriate techniques.
METHODS:
A systematic search was carried out in October 2020 in the databases of PubMed, Cinahl, Scopus, Medline and Web
of Science using the search terms: Physical therapy modalities, Physical and rehabilitation medicine, Rehabilitation, Tennis elbow
and Elbow tendinopathy.
RESULTS:
Nineteen articles were found, of which seven applied shock waves, three applied orthoses, three applied different
manual therapy techniques, two applied some kind of bandage, one applied therapeutic exercise, one applied diacutaneous
fibrolysis, one applied high intensity laser, and one applied vibration.
CONCLUSIONS:
Manual therapy and eccentric strength training are the two physiotherapeutic treatment methods that have the
greatest beneficial effects, and, furthermore, their cost-benefit ratio is very favorable. Its complementation with other techniques,
such as shock waves, bandages or Kinesio
R
taping, among others, facilitates the achievement of therapeutic objectives, but entails
an added cost.
Keywords: Tennis elbow, physical therapy modalities, rehabilitation, tendinopathy, lateral epicondylitis
1. Introduction1
Lateral epicondylitis (LE) is a tendinopathy of the
2
forearm extensor muscles, often caused by overuse or
3
repetitive use (mostly of the extensor carpi radialis
4
brevis), forced extension or direct trauma in the epi-
5
condyle [1]. Histologically, it presents signs of tendon
6
degeneration, such as the presence of fibroblasts, vas-
7
cular hyperalgesia and disorganised collagen [2]. The
8
pain is usually localised in the epicondyle, although in
9
more severe cases it can expand to the shoulder and
10
∗
Corresponding author: Raquel Leirós-Rodríguez, Faculty of
Health Sciences s/n Ponferrada 24401, Spain. E-mail: rleir@unileon.
es.
wrist, and it is usually triggered by exerting pressure
11
on the epicondyle, resisting wrist and/or third finger
12
extension and stretching of the epicondylar muscles [3].
13
LE has an approximate rate of 40% and a prevalence of
14
1–3% of the general population, being most common in
15
the age range of 35–54 years [4,5]. Regarding duration,
16
its natural evolution is considered to be favourable at
17
two years, since it usually relapses after asymptomatic 18
periods. Due to the latter phenomenon, this disorder
19
implies a great economic investment [4]. 20
Different treatment approaches have been proposed,
21
such as the recommendation of rest, drugs, surgery,
22
etc. [6]. The first therapeutic step usually involves rest
23
and the administration of drugs that provide short-term
24
pain relief, but also bad results for the resolution of the
25
problem and for the prevention of relapses [7]. With the
26
ISSN 1053-8127/$35.00 c
2021 – IOS Press. All rights reserved.
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2L. Landesa-Martínez and R. Leirós-Rodríguez / Physical therapy & epicondylitis
Table 1
Search strategy according to the focused question (PICO)
Database Search equation
PubMed (“Physical Therapy Modalities”[Mesh]) AND “Tennis Elbow”[Mesh]
(“Physical Therapy Modalities”[Mesh]) AND “Elbow Tendinopathy”[Mesh]
(“Rehabilitation”[Mesh] AND “Tennis Elbow”[Mesh])
(“Rehabilitation”[Mesh] AND “Elbow Tendinopathy”[Mesh])
Medline (MH “Physical Therapy Modalities”) AND (MH “Tennis Elbow”)
(MH “Physical Therapy Modalities”) AND (MH “Elbow Tendinopathy”)
(MH “Rehabilitation”) AND (MH “Tennis Elbow”)
(MH “Rehabilitation”) AND (MH “Elbow tendinopathy”)
Cinahl (MH “Physical Therapy”) AND (MH “Tennis Elbow”)
(MH “Physical Therapy”) AND (MH “Elbow tendinopathy”)
(MH “Rehabilitation”) AND (MH “Tennis Elbow”)
(MH “Rehabilitation”) AND (MH “Elbow tendinopathy”)
Web of science TOPIC: (‘physical therapy modalities’) AND TOPIC: (‘tennis elbow’)
TOPIC: (‘physical therapy modalities’) AND TOPIC: (‘elbow tendinopathy’)
TOPIC: (‘rehabilitation’) AND TOPIC: (‘elbow tendinopathy’)
TOPIC: (‘rehabilitation’) AND TOPIC: (‘tennis elbow’)
Scopus
( TITLE-ABS-KEY (“Physical Therapy Modalities”) AND TITLE-ABS-KEY (“Tennis Elbow”)) AND PUBYEAR
>
2014
(TITLE-ABS-KEY (“Physical Therapy Modalities”) AND TITLE-ABS-KEY (“Elbow tendinophaty”)) AND PUBYEAR
>2014
(TITLE-ABS-KEY (“rehabilitation”) AND TITLE-ABS-KEY (“Tennis Elbow”)) AND PUBYEAR >2014
(TITLE-ABS-KEY (“rehabilitation”) AND TITLE-ABS-KEY (“Elbow tendinophaty”)) AND PUBYEAR >2014
surgical approach, immediate pain relief is achieved in
27
80–97% of cases, although 1.5% of intervened patients
28
underwent a second surgical procedure in the following
29
18–24 months [8]. Lastly, the physiotherapeutic treat-
30
ment has been shown to be effective [2] and, in general,
31
it must include manual therapy to relieve the pain and
32
improve the joint’s range of motion (ROM) [6], tak-
33
ing into account that it must be performed under the
34
pain threshold [9]. It is worth highlighting that, in this
35
pathology, as in the rest of tendinopathies, good results
36
are obtained from strengthening the affected area [10];
37
for example, eccentric training has been reported to
38
decrease pain and improve functionality, since, during
39
exercise: (a) the blood flow in the neovessels of the
40
tendon is temporarily interrupted; (b) a constant me-
41
chanical stimulus is generated, which would lead to the
42
remodeling of the tendon, and (c) collagen synthesis
43
increases in damaged tendons [11,12].44
The aim of this review was to determine the efficacy
45
of the new physical therapy (PT) techniques for the
46
treatment of LE that have been studied in the last years
47
and identify the most adequate techniques.48
2. Materials and methods49
2.1. Search strategy and information sources50
This study was registered on PROSPERO (ID:
51
CRD42021230014) and followed the Preferred Report-
52
ing Items for Systematic Reviews and Meta-analyses
53
(PRISMA) reporting guidelines and the recommenda-
54
tions from the Cochrane Collaboration [13,14]. The
55
PICO question was then chosen as follows: P – pop-
56
ulation: men and women diagnosed with LE; I – in-
57
tervention: physical therapy techniques; C – control:
58
different physiotherapy and/or pharmacological treat-
59
ment interventions (platelet-rich plasma, corticosteroids
60
and naproxen); O – outcome: intensity and frequency
61
of pain, range of movement and degrees of functional-
62
ity and perceived disability, mainly; S – study designs:
63
experimental studies. 64
A systematic search of publications was conducted
65
in Ocotber 2020 in the following databases: PubMed,
66
SpringerLink, SportsDiscus, Medline, Scopus, and Web
67
of Science. The search strategy included different com-
68
binations with the following Medical Subject Headings
69
(MeSH) terms: Physical therapy modalities, Physical
70
and rehabilitation medicine, Rehabilitation, Tennis el-
71
bow and Elbow tendinopathy. The search strategy ac-
72
cording to the focused PICOS question is presented in
73
Table 1. 74
2.2. Eligibility criteria 75
After removing duplicates, two reviewers (L.L.-P.
76
and R.L.-R.) independently screened articles for eligi-
77
bility. In case of disagreement, both reviewers debated
78
until an agreement was reached. For the selection of
79
results, the inclusion criteria established that the articles
80
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L. Landesa-Martínez and R. Leirós-Rodríguez / Physical therapy & epicondylitis 3
Fig. 1. PRISMA flow diagram.
must have been published in the last five years (from
81
2015 to the present), that the sample of studies con-
82
sisted exclusively of patients with LE (regardless of its
83
duration) and that the authors applied a treatment inter-
84
vention that included at least one physical therapy tech-
85
nique. On the other hand, studies were excluded from
86
this review if they had a non-experimental methodology
87
and their full text was not available.88
2.3. Study selection, data collection process, data89
items and summary measures90
After screening the data, extracting, obtaining and
91
screening the titles and abstracts for inclusión criteria,
92
the selected abstracts were obtained in full texts. Ti-
93
tles and abstracts lacking suficient information regard-
94
ing inclusion criteria were also obtained as full texts.
95
Full text articles were selected in case of compliance
96
with inclusion criteria by the two reviewers using a data
97
extraction form. The two reviewers mentioned inde-
98
pendently extracted data from included studies using a
99
customized data extraction table in Microsoft Excel. In
100
case of disagreement, both reviewers debated until an
101
agreement was reached. 102
The following data from the included articles for fur-
103
ther analysis: demographic information (title, authors,
104
journal and year), characteristics of the sample (age,
105
inclusion and exclusion criteria, and number of partici-
106
pants), study-specific parameter (study type, duration
107
of intervention, number of sessions, techniques of phys-
108
ical therapy included in the intervention, follow-up and
109
drop-out) and results obtained. Tables were used to de-
110
scribe both the studies’ characteristics and the extracted
111
data. When possible, the results were gathered based on
112
type of intervention applied. The Oxford 2011 Levels
113
of Evidence and the Jadad scale were used to assess the
114
quality of studies. 115
3. Results 116
3.1. Study selection 117
Out of 1955 search results, 458 studies were consid-
118
ered eligible for inclusion after removing duplicates.
119
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4L. Landesa-Martínez and R. Leirós-Rodríguez / Physical therapy & epicondylitis
Among the 458 papers screened, 439 were excluded
120
after abstract and title screening. Kappa score of re-
121
viewer 1 and 2 was 0.187, indicating slight agreement.
122
Of the 19 full-text articles assessed for eligibility, all
123
were finally included in the synthesis, as depicted by
124
the PRISMA flowchart in Fig. 1.125
3.2. Study characteristics and risk of bias126
All the studies have been published in the last 5 years
127
(from 2015 to 2020). Of the 19 articles, seven applied
128
extracorporeal shock waves (SW) [15
–
21], five applied
129
ultrasounds (US) [15,16,19,22,23], five applied conven-
130
tional physiotherapy techniques (thermotherapy [19],
131
electrotherapy [19,21,23], cryotherapy [21], educa-
132
tion [24,25]), six manual therapy [22
–
24,26
–
28], seven
133
applied orthoses or taping techniques [21,22,25,28
–
31],
134
nine applied therapeutic exercises [17,21,22,24,25,28,
135
30
–
32], and one applied a laser [33]. The methodolog-
136
ical characteristics of the analysed studies are shown
137
in Table 2 and the characteristics of the interventions
138
applied in them are presented in Table 3.3.139
Regarding the experimental designs, 14 studies were
140
randomized and controlled trials [15
–
17,21
–
26,28,
141
30
–
33] and the remaining five studies were quasi-
142
experimental [18–20,27,29].143
The methodological quality of the studies was three
144
points or more on the JADAD scale in 52.6% of the
145
studies [17,21
–
23,25,30,31,33] but was zero in 26.3%
146
of the results [18
–
20,27,29]. At the same time, as can
147
be seen in Table 2, the level of evidence provided
148
was between I (73.7%) [15
–
17,21
–
26,28,30
–
33] and II
149
(26.3%) [18–20,27,29].150
3.3. Results of individual studies151
One of the revised studies evaluated the effect of
152
SW [17] in combination and comparison with a pro-
153
gramme of strength and mobility exercises. The ap-
154
plication of SW was conducted in two stages: in the
155
first stage, the energy density was 0.348 mJ/cm
2
, at
156
5 Hz and 300 pulses; in the second stage, the energy
157
density was 0.372 mJ/cm
2
, at 3.5 Hz and 1200 pulses.
158
Although the authors observed that the pain intensity
159
and degree of disability decreased significantly in both
160
groups, such decrease was greater in the SW group.
161
Moreover, the duration of the sick leave was shorter
162
with SW. However, the grip strength did not improve
163
significantly in any case. In this line, Altun et al. [19]
164
compared the efficacy of SW with a conventional PT
165
treatment (thermotherapy, ultrasound [US] and transcu-
166
taneous electrical nerve stimulation [TENS]). SW were
167
applied to the lateral epicondyle (at 15 Hz, 1.4–1.6 bar
168
and 1500 pulses) and to the extensor muscles (at 21 Hz,
169
1.8 bar and 2000 pulses). This study showed significant
170
improvements in maximum grip strength and function-
171
ality in both groups (with no differences between them).
172
However, the pain intensity and the number of patients
173
with a positive result in the Thomsen and Maudsley
174
tests at one month after the intervention was signifi-
175
cantly lower in the conventional PT group with respect
176
to the SW group. Another study compared the effects
177
of SW on acute and chronic LE (of less than 3 months
178
and over 6 months of evolution, respectively) [18]. Both
179
groups received SW with pulses of 2000 Kg*m/s, at
180
5 Hz and 2.5 bar. The authors reported that both the
181
acute and chronic groups showed significant improve-
182
ments in pain intensity. In the intergroup comparison,
183
initially, the improvement was statistically greater in the
184
chronic patients; then, at 6 months after the interven-
185
tion, the improvement was greater in the acute patients.
186
Two studies were aimed at comparing the effects
187
of US and SW [15,16]. One of them applied the SW
188
sessions divided into two phases: a first phase of 2000
189
pulses, at 8 Hz and 1.5–2.5 bar in the epicondylar re-
190
gion, and a second phase of 2000 pulses, at 8 Hz and
191
2.5–3.5 bar in the extensor carpi radialis brevis [16].
192
The other study applied a total of 2000 pulses at a fre-
193
quency of 10–15 Hz and 1.5–2.5 bar, using ultrasound
194
gel as the means of transmission [15]. The parameters
195
of US application were also different. In one of the
196
studies, the authors applied a first phase with a head of
197
5 cm
2
around the epicondyle, at 0.5 W/cm
2
and 1 MHz
198
for 3 minutes through a pulsed application at 50%;
199
in the second phase, the same parameters were used
200
with an application time of 2 minutes [16]. The other
201
study used a transducer continuously in the painful area,
202
with an application area of 1 cm
2
, at 1.5 W/cm
2
and
203
1 MHz [15]. Both studies obtained significant improve-
204
ments in grip strength [15], elbow functionality [15,16],
205
pain frequency [16], use of analgesics [16] and pain
206
intensity [15,16] with the two therapeutic modes; how-
207
ever, such improvements were statistically greater with
208
SW [15,16], although at 8 weeks the results of both
209
groups were similar [16] or even greater in the US
210
group [15,16]. 211
Alessio-Mazzola el al. [20] compared the efficacy of
212
the platelet-rich plasma (PRP) treatment with that of
213
SW. Their intervention with echo-guided SW had a fre-
214
quency of 4 Hz, an intensity compatible with pain toler-
215
ance (initially 0.03–0.07 mJ/mm
2
, which was increased
216
to 0.08–0.13 mJ/mm
2
) and a dose of 1000 pulses per
217
218
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L. Landesa-Martínez and R. Leirós-Rodríguez / Physical therapy & epicondylitis 5
Table 2
Methodological characteristics of the studies analyzed
Authors Design Sample size Inclusion criteria Exclusion criteria Jadad scale LE
RD∗BD∗∗ WD∗∗∗ FS
Alessio-
Mazzola
et al.
(2018)
QES 63 Pain of more than six months of evolution,
persistence of pain and functional deterioration
refractory to rest, ice and pharmacological
therapy. Persistence of symptoms after previous
treatments (laser, radiofrequency, ultrasound and
electrotherapy). Previous treatments completed
more than six months before.
Consumption of simultaneous drug treatment. Carry
a pacemaker. History of surgery or trauma to the
affected elbow, neurological or musculoskeletal
disorders. Diagnosis of systemic diseases, blood
disorder, epilepsy or infections. Presence of
malformations or open wounds on the affected arm.
Pregnant or lactating women.
0 0 0 0 II
Altun
et al.
(2018)
QES 73 Pain of more than six weeks of evolution, age
over 18 years, tenderness to palpation anterior
and distal to the epicondyle, positive test in
resisted wrist extension with the elbow in
extension and the forearm in pronation.
Diagnosis of nerve compression syndrome or
cervical radiculopathy. History of surgery or trauma
to the region. No consent to participate in the study.
0 0 0 0 II
Dones
III et al.
(2018)
QES 23 Positive result in the Cozen, Mill or Maudsley
tests.
Physiotherapy treatment of the elbow in the last six
months. Presence of orthopedic alterations or
paresthesias in the elbow. History of fracture,
arthritis, or nerve compression of the elbow.
Multiple sclerosis diagnosis.
0 0 0 0 II
Dundar
et al.
(2015)
RCT 93 Pain in the epicondyle of less than three months
of evolution. Tenderness to palpation of the
epicondyle. Pain on wrist movement and/or third
finger extension against resistance. Positive result
to Mill’s test.
Diagnosis of fibromyalgia, rheumatoid arthritis,
osteoarthritis, inflammatory arthropathy, carpal
and/or ulnar tunnel syndrome, cervical
radiculopathy, neurological deficit, systemic
metabolic diseases, cervical and/or shoulder
disorders. Previous treatment of epicondylitis.
History of surgery, fracture in the elbow. Bilateral
elbow pain.
1 1 1 3 I
Eraslan
et al.
(2017)
RCT 45 Diagnosis of lateral epicondylitis of more than
three months of evolution, pain in the epicondyle
and during the grip strength test, to the wrist
extension against resistance or to the passive
stretching of the wrist extensors.
Receipt of any other treatment during the study
period. Diagnosis of inflammatory, autoimmune,
endocrine or kidney diseases, cubital or carpal
tunnel syndrome, cervical radiculopathy, arthritis,
allergy to bandages or other pathologies in the
affected upper limb. History of surgery or trauma to
the affected upper limb or corticosteroid treatment
in the previous three months.
2 0 1 3 I
Furnes
et al.
(2018)
RCT 45 Diagnosis of lateral epicondylitis. Older than 18
years. Pain at wrist extension and third finger
against resistance.
Diagnosis of inflammatory arthritis, deformity in the
affected elbow. History of surgery, shock wave
treatments or injections in the affected elbow.
1 0 1 2 I
Giray
et al.
(2019)
RCT 30 Pain of less than three months of evolution,
presence of pain in the lateral epicondyle, positive
result in the Maudley and/or Mill test. Diagnosis
of lateral epicondylitis confirmed by ultrasound.
Diagnosis of cervical spondylosis or radiculopathy,
diabetes mellitus, concomitant neuropathy,
polyneuropathy, systemic arthritics. History of
surgery or trauma to the elbow, injections and/or
physical therapy treatment to the elbow. Bandage
allergy. Pregnancy.
2 2 1 5 I
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6L. Landesa-Martínez and R. Leirós-Rodríguez / Physical therapy & epicondylitis
Table 2, continued
Authors Design Sample size Inclusion criteria Exclusion criteria Jadad scale LE
RD∗BD∗∗ WD∗∗∗ FS
Gönen et
al. (2017)
RCT 46
Result on the Visual Analogue Scale greater than
6, pain of less than three months of evolution, no
previous treatment in the affected area, complete
follow-up after receiving the intervention.
Other diagnoses in the cervical spine, upper limbs,
vasculitis, infections, malignant diseases,
connective tissue, rheumatic, dermatological or
neurological. Pregnancy, Anticoagulant treatment.
Age under 18 years. Invasive treatments in the
previous three months.
2 0 1 3 I
Kachanat
et al.
(2019)
RCT 40 Pain of more than three months of evolution,
limited range of motion of flexion and extension
of the wrist and weakness in grip strength.
History of surgery, dislocation, fracture,
osteoarthritis, or corticosteroid injection in the
elbow.
2 2 1 5 I
Köksal et
al. (2015)
QES 54 Diagnosis of lateral epicondylitis. Diagnosis of local infection, arthritis, or bleeding
disorder. Age under 18 years. Pregnancy.
0 0 0 0 II
Kubot et
al. (2017)
RCT 60 Result on the Visual Analogue Scale higher than
6, pain of less than three months of evolution, no
previous treatment in the affected area in the
previous three months, complete follow-up after
receiving the intervention.
Other diagnoses in the cervical spine, upper limbs,
vasculitis, infections, malignant diseases,
connective tissue, rheumatic, dermatological or
neurological. Pregnancy, Anticoagulant treatment.
Age under 18 years. Invasive treatments in the
previous three months.
2 0 0 2 I
López-
Celis et al.
(2018)
RCT 54 Diagnosis of lateral epicondylitis. Presence of
pain of more than three months of evolution.
Positive result in the Cozen and/or Mill test. Age
over 18 years. Delivery of informed consent for
participation in the study.
Diagnosis of other concomitant pathologies in the
affected upper limb, of inflammatory processes,
contraindications for diacutaneous fibrolysis.
History of previous surgery in the affected elbow
or of injections in the previous three months in the
affected elbow.
2 2 1 5 I
Nishizuka
et al.
(2016)
RCT 110 Pain of more than a week of evolution and on
anterior and distal palpation of the epicondyle.
Positive result to the Thomsen test.
Diagnosis of bilateral lateral epicondylitis or
osteoarthritis History of elbow surgery. Previous
treatments in the elbow or use of corticosteroids in
the previous six months.
2 0 1 3 I
Nowotny
et al.
(2018)
RCT 31 Result in the Placzek score higher than 4.
Delivery of informed consent for participation in
the study.
History of surgery or elbow fracture. Diagnosis of
rheumatic arthritis, elbow instability, extensor
radius tendon rupture, or cervical radiculopathy.
2 0 1 3 I
Olaussen
et al.
(2015)
RCT 177
Presence of pain at the resisted dorsiflexion of the
wrist with the elbow extended, at the resisted
extension of the third finger and/or at the radial
deviation of the wrist of less than three months of
evolution.
Bilateral pain and/or of less than two months of
evolution, treatment with corticosteroids and/or
physiotherapy during the previous year. History of
previous surgery on the elbow. Presence of
deformities in the elbow, referred pain in the neck
and/or shoulder, fractures or ruptures of tendons of
the forearm. Diagnosis of cervical radiculopathy,
systemic musculoskeletal diseases,
contraindications to corticosteroids, lidocaine or
anti-inflammatory drugs. Pregnant or lactating
women.
1 0 1 2 I
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L. Landesa-Martínez and R. Leirós-Rodríguez / Physical therapy & epicondylitis 7
Table 2, continued
Authors Design Sample size Inclusion criteria Exclusion criteria Jadad scale LE
RD∗BD∗∗ WD∗∗∗ FS
Seo et al.
(2018)
QES 20 Diagnosis of lateral epicondylitis. Diagnosis of orthopedic or nervous system
abnormalities affecting the arm or upper limb
neuropathy.
0 0 0 0 II
Stasino-
poulos et
al. (2016)
RCT 34
Diagnosis of lateral epincondylitis of more than a
month of evolution. Pain on palpation of the
epicondyle. Positive result in at least two of the
following tests: Thomsen test, third finger against
resistance, mill, force with grip dynamometer.
Diagnosis of some dysfunction of the shoulder,
neck and/or chest, arthritis, neurological deficit,
radial nerve entrapment. History of surgery on the
elbow or of previous treatments for lateral
epicondylitis during the month before the study.
1 2 1 4 I
Yalvaç et
al. (2018)
RCT 50
Medical diagnosis of lateral epicondylitis, pain of
more than three months of evolution, positive
tests in wrist extension, third finger extension and
passive wrist flexion.
History of elbow surgery and/or elbow or arm
fracture. Corticosteroid treatment in the previous
month. Diagnosis of cervical radiculopathy,
neuropathic entrapment, acute infection or
vascular disorder, Carrier of pacemaker or
interstitial implant.
2 1 1 4 I
Yi et al.
(2018)
RCT 34 Pain of less than six months of evolution, age
older than 18 years, sensitivity to palpation
anterior and distal to the epicondyle, positive
result in the resistance wrist extension tests with
the elbow in extension and the forearm in
pronation. Delivery of informed consent for
participation in the study.
Diagnosis of nerve compression syndrome,
cervical radiculopathy, pain of less than six weeks
of evolution. History of previous surgery or
trauma to the elbow.
1 0 1 2 I
GD: Gestational diabetes; LE: Level of evidence; LOS: Longitudinal observational study; QES: Quasi-Experimental study; RCT: Randimized controlled trial.
∗
RD: Randomization (1 point if
randomization is mentioned; 2 points if the method of randomization is appropriate).
∗∗
BD: Blinding (1 point if blinding is mentioned; 2 points if the method of blinding is appropriate).
∗∗∗
WD:
Whithdrawals (1 point if the number and reasons in each group are stated).
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8L. Landesa-Martínez and R. Leirós-Rodríguez / Physical therapy & epicondylitis
Table 3
Characteristics of the interventions of the studies analyzed
Authors Intervention Time of intervention Number of sessions
(frequency)
Experimental group Control group
Alessio-
Mazzola
et al. (2018)
Group 1: Extracorporeal shock waves.
Group 2: Platelet Rich Plasma injection.
Not applicable. 1 month Group 1: 4 (weekly).
Group 2: 1.
Altun et al.
(2018)
Extracorporeal shock waves and CP. CP (ultrasound and TENS). 3 weeks 3 (weekly).
Dones III et
al. (2018)
Group 1: Biomechanical Taping (Standard Biomechanical Tap-
ing and two Vector Correction Dysfunction Techniques).
Group 2: Biomechanical Taping (Vector Correction
Dysfunction Technique, Standard Biomechanical Taping and
other Vector Correction Dysfunction Technique).
Not applicable. 5 days 3 (alternating days).
Dundar et al.
(2015)
Group 1: High Intensity Laser Therapy.
Group 2: High Intensity Laser Therapy placebo.
Group 3: ferule.
Not applicable. Groups 1 and 2: 3 weeks.
Group 3: 1 month.
Groups 1 and 2: 15 (5
each week).
Group 3: 30 (daily).
Eraslan et al.
(2017)
Group 1: extracorporeal shock waves and CP.
Group 2: Kinesio R
taping and CP.
CP (cryotherapy, TENS, and eccentric
exercises).
3 weeks Group 1: 1.
Group 2 and control: 15
(5 each week).
Furnes et al.
(2018)
Vibration and CP. CP (educational tips). 6 weeks 45 (daily).
Giray et al.
(2019)
Group 1: Kinesio R
taping and CP.
Group 2: Kinesio R
taping placebo and CP.
CP (educational tips, stretching and eccentric
strengthening).
2 weeks 5 (one every five days).
Gönen et al.
(2017)
Extracorporeal shock waves and CP. CP (exercise routine). 1 month 4 (weekly).
Kachanat et
al. (2019)
Orthotics and CP. CP (ultrasound, friction massage and
stretching).
3 weeks 3 (weekly).
Köksal et al.
(2015)
Extracorporeal shock waves. Not applicable. 10 days 3 (one every the first
three days).
Kubot et al.
(2017)
Group 1: Extracorporeal shock waves.
Group 2: ultrasound.
Not applicable. Group 1: 3 weeks.
Group 2: 10 days.
Group 1: 3 (weekly).
Group 2: 10 (daily).
López-Celis
et al. (2018)
Group 1: diacutaneous fibrolysis and CP.
Group 2: diacutaneous fibrolysis placebo and CP.
CP (ultrasound, TENS and stretching). 3 weeks
Group 1: 15 (5 each
week).
Group 2: 6 (2 each
week).
Nishizuka et
al. (2016)
Orthotics and CP. CP (stretching). 6 months 180 (daily).
Nowotny et
al. (2018)
Orthotics and CP. CP (eccentric strengthening). 3 months 90 (daily).
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L. Landesa-Martínez and R. Leirós-Rodríguez / Physical therapy & epicondylitis 9
Table 3, continued
Authors Intervention Time of intervention Number of sessions
(frequency)
Experimental group Control group
Olaussen
et al.
(2015)
Group 1: corticosteroid injection, drug treatment with naproxen
and CP.
Group 2: injection placebo, drug treatment with naproxen and
CP.
Drug treatment with naproxen and CP
(friction massage, Mills manipulation and
stretching).
6 weeks
Groups 1 and 2: 2 (one session
the first and the third weeks).
Control group: 12 (two
sessions each week).
Seo et al.
(2018)
Eight variants of extensor carpi radialis brevis stretch. Not applicable. Not applicable. Not applicable.
Stasino-
poulos et
al. (2016)
Group 1: eccentric-concentric and isometric strengthening.
Group 2: eccentric-concentric strengthening.
Group 3: eccentric strengthening.
Not applicable. 1 month 30 (daily).
Yalvaç et
al. (2018)
Group 1: extracorporeal shock waves.
Group 2: ultrasounds.
Not applicable. Group 1: 3 weeks.
Group 2: 2 weeks.
Group 1: 3 (weekly).
Group 2: 10 (5 each week).
Yi et al.
(2018)
Group 1: orthosis and deep friction massage.
Group 2: orthosis.
Group 3: orthosis and cortisone injections.
Not applicable.
Groups 1 and 3: 1 week.
Group 2: 6 weeks.
Groups 1 and 3: 7 (daily).
Group 2: 42 (daily).
CP: conventional physiotherapy techniques.
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10 L. Landesa-Martínez and R. Leirós-Rodríguez / Physical therapy & epicondylitis
session. The obtained results showed significant im-
219
provements in functionality and pain intensity in both
220
groups (with no differences between them). However,
221
the reincorporation of the participants to their usual
222
activities was significantly faster with PRP. Lastly,
223
Eraslan et al. [21] compared the effects of Kinesio
R
224
taping (KT) [34], SW and conventional PT (cryother-
225
apy, TENS and a programme of eccentric exercises).
226
SW were applied at a dose of 2000 pulses and low-
227
energy density (0.06–0.12 mJ/mm
2
), which resulted
228
in significant improvements in pain intensity, muscle
229
state, maximum grip strength and functionality with the
230
application of both KT and SW in combination with
231
conventional PT and with the latter alone.232
In addition to the above study, Nishizuka et al. [30]
233
analysed the effects of Tennis Elbow Support
234
(ALCARE), applied for over six hours per day in com-
235
bination and comparison with the execution of stretch-
236
ing exercises for the wrist extensor muscles. After the
237
treatment, pain intensity and the number of positive
238
Thomsen tests decreased significantly in both cases
239
(with no differences between them). They also evalu-
240
ated the efficacy of a dynamic extension orthosis called
241
CARP-X (Sporlastic) in combination and comparison
242
with the execution of eccentric strength exercises [31].
243
In this case, the maximum grip strength, pain inten-
244
sity and functionality improved in both groups progres-
245
sively after the treatment and nine months after the end
246
of the intervention, although strength did not improve
247
significantly in any case. Lastly, Kachanathu et al. [22]
248
evaluated the efficacy of the Futuro
R
splint (3M) for
249
6–8 hours per day in combination and comparison with
250
a programme of conventional PT (stretching, US and
251
deep friction massage). The splint was used to pre-
252
vent the complete flexion, and it was fixed to the ex-
253
tension range of 50–100
◦
. After the intervention with
254
the orthosis, there were significant improvements in
255
pain intensity, wrist movement range and maximum
256
grip strength. Although the conventional PT group also
257
showed improvements, these were only significant in
258
the movement range.259
Regarding the evaluation of bandages, Dones III et
260
al. [29] analysed the effectiveness of different appli-
261
cations of Biomechanical Taping (BMT): one group
262
received, firstly, the biomechanical bandage technique
263
with muscular energy (Standard Biomechanical Taping,
264
SBMT) and, subsequently, two vector correction dys-
265
function techniques (VCDT1 and VCDT2); the other
266
group received the same techniques, with a different
267
application sequence (first VCDT1, then SBMT and,
268
lastly, VCDT2). The authors identified that pain inten-
269
sity, maximum grip strength and functionality showed
270
significant improvements in all patients. However, both
271
immediately and one week after the intervention, the
272
group that received SBMT as the first technique ob-
273
tained better scores in pain intensity. 274
Finally, Giray et al. [25] evaluated the efficacy of
275
KT [35,36] in comparison with the application of a
276
placebo bandage and a programme of conventional PT.
277
All participants received the conventional PT interven-
278
tion with instructions on activity modification and a
279
home exercise programme of stretching and eccentric
280
strengthening. The obtained results showed that func-
281
tionality and pain intensity improved in all groups, al-
282
though the KT group obtained significantly better re-
283
sults. On the other hand, grip strength also improved in
284
the three groups, although with no statistical differences
285
between them. 286
Two studies determined the efficacy of deep fric-
287
tion massage in comparison with a corticosteriod injec-
288
tion [26,28]. In one of the cases, all participants received
289
a wrist splint and a daily protocol of conventional PT,
290
which included stretching and elbow and wrist mobility
291
exercises [28]. The results showed that pain intensity,
292
grip strength and functionality improved significantly
293
and similarly both with the massage and with the in-
294
jection, but not with the splint and the conventional
295
PT protocol. However, at 6 months after the treatment,
296
all groups showed improvements in all variables, al-
297
though such improvements were only significant in the
298
massage group. The other study applied corticosteroids
299
invasively in combination and comparison with a PT
300
intervention that included deep transverse friction mas-
301
sage at the origin of the tendon, Mill’s manipulation
302
and wrist stretching exercises [26]. The results showed
303
that, in the PT group, there was a progressive improve-
304
ment in all variables, which was significant at 3, 6 and
305
12 months after the treatment. In the group the received
306
corticosteroids, the improvement percentage was better
307
at week 6 than in the subsequent evaluations. Between
308
groups, the perception of improvement in the corticos-
309
teriod group showed better results in the first evaluation
310
and worse results in the subsequent evaluations. Lastly,
311
there were no statistical differences between groups one
312
year after the evaluation. 313
On their part, the study of Seo et al. [27] was aimed
314
at determining the most effective stretching position for
315
the common extensor carpi radialis. They concluded
316
that the shear modulus was always significantly higher
317
when the wrist was flexed, especially with the elbow
318
extended and the forearm in the prone position. 319
Regarding methods of assisted manual therapy with
320
other instruments, studies have been conducted on di-
321
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L. Landesa-Martínez and R. Leirós-Rodríguez / Physical therapy & epicondylitis 11
acutaneous fibrolysis (DF) [23] and vibration [24].
322
López-de-Celis et al. [23] evaluated the efficacy of DF323
in combination and comparison with US, TENS and
324
stretching exercises with respect to a placebo group.
325
Their results showed that, immediately after the treat-
326
ment, the group that received DF presented significant
327
improvements in all variables (pain intensity, maxi-
328
mum strength and functionality), whereas the conven-
329
tional PT and placebo groups only presented significant
330
changes in pain intensity, although with significantly
331
lower changes compared to the DF group. However, at
332
three months after the treatment, all variables improved
333
in the three groups, with grip strength showing a signif-
334
icantly greater improvement in the DF group. Vibration
335
assisted through a Tenease
R
device was evaluated in
336
combination and comparison with a conventional treat-
337
ment (information leaflet and education about LE, activ-
338
ities to be avoided and exercises to be performed) [24].
339
After the intervention, functionality improved in all
340
participants, although such improvement was only sig-
341
nificant with the conventional treatment. However, six
342
months after the treatment, neither the quality of life
343
nor pain intensity improved in any of the groups.344
One study was aimed at comparing the efficacy of dif-
345
ferent modes of strength training for the wrist extensor
346
muscles: eccentric, eccentric-concentric and eccentric-
347
concentric combined with isometric training [32]. All
348
participants showed significant improvements in pain
349
intensity, functionality and maximum grip strength. In
350
the intergroup comparison, the group that performed
351
the eccentric-concentric training combined with iso-
352
metric training obtained significantly better results with
353
respect to the other two groups, both immediately after
354
and one month after the intervention.355
Lastly, Dundar et al. [33] explored the effects of high-
356
intensity laser therapy (HILT) with pulse emissions
357
(1064 nm), very high peak power (3 kW), high fluidity
358
level (360–1780 mJ/cm
2
), short duration (120–150
µ
s),
359
mean power of 10.5 W, a frequency of 10–40 Hz, a
360
work cycle of 0.1%, a beam diameter of 0.5 cm and a
361
dot size of 0.2 cm
2
. This treatment was compared with
362
a group who received placebo laser (with the device
363
disconnected) and another group who only used an or-
364
thosis for the entire day. The groups that received laser
365
and orthosis showed significant improvements in grip
366
strength, pain intensity, disability degree and quality of
367
life (with no significant differences between them). On
368
the other hand, the placebo group showed no significant
369
improvements in any case. However, the thickness of
370
the common extensor tendon did not change with any
371
of the interventions.372
4. Discussion 373
The aim of this review was to determine the efficacy
374
of PT for the treatment of LE and identify the most ade-
375
quate techniques. After presenting the analysed studies,
376
we can assert that, in general, PT techniques have a
377
positive effect on the symptoms and resolution of the
378
clinical characteristics of LE. 379
Pain intensity improved with all the applied treat-
380
ments [15
–
24,30
–
33], although the interventions that
381
included SW [15
–
20], PRP [20], US, friction and
382
stretching exercises [22] and bandages [29] achieved
383
positive results in less time (between 3 and 9 sessions).
384
This finding is in line with previous investigations
385
about the SW treatment of other tendinopathies [37,38].
386
For long-term pain relief, among the three studies
387
that conducted more than one post-treatment evalua-
388
tion [18,26,31], one of them applied SW and the other
389
two carried out manual therapy [26], eccentric strength-
390
ening [26,31] and corticosteroid infiltration [26]. The
391
latter [26] carried out the latest evaluation, obtaining
392
positive results one year after the intervention. 393
Regarding pain, other studies evaluated the pressure
394
pain threshold (PPT) [15,23,33], which is a specially
395
relevant variable in tendinopathies [39] and in the eval-
396
uation of chronic pain [40,41]. This variable showed
397
improvements with the interventions based on SW [15],
398
orthosis [33], HILT [33], DF [23] and US, TENS and
399
stretching exercises [23], since they can all affect hy-
400
percellularity, the collagen matrix, the proteoglycan
401
content and neovascularisation, which is generated by
402
the accumulation of microinjuries, due to the repetitive
403
overload that exceeds the healing capacity of the ten-
404
don [42]. However, it is important to highlight that: (a)
405
the combined application of US, TENS and stretching
406
exercises obtained better results than DF [23]; and (b)
407
the SW showed positive changes after only three ses-
408
sions [15]. This could be due to the fact that the appli-
409
cation of SW implies the administration of a series of
410
short energy fluctuations that are rapidly transmitted,
411
which is a method that has been revealed to be effective
412
in the treatment of musculoskeletal disorders due to
413
its angiogenic, analgesic and anti-inflammatory effects
414
when applied on the painful area [43,44]. 415
Functionality improved in all the studies in which it
416
was evaluated [15,16,19
–
21,23
–
25,28,31,32], although
417
SW obtained better effects than US [16], probably due 418
to the fact that the latter showed lower reliability in the
419
application of the selected frequency and presented an
420
unpredictable behavior of their acoustic diffraction [45].
421
On the other hand, SW are more reliable [39] and their
422
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12 L. Landesa-Martínez and R. Leirós-Rodríguez / Physical therapy & epicondylitis
efficacy increases when combined with strength exer-
423
cises [46], as was also reported by Aydin et al. [17].
424
However, the use of orthoses did not show positive ef-
425
fects on functionality [28,31], which could be explained
426
by the fact that, by restricting movement, they may
427
lead to muscle disuse; therefore, if orthoses are com-
428
bined with strength exercises, they may show better re-
429
sults [32,47]. The interventions based on conventional
430
techniques (ortheses [28], stretching and mobility exer-
431
cises [28] and education [24]) showed good results on
432
functionality. Stretching exercises are commonly used
433
in PT programmes, and it has been reported that the re-
434
covery time of a tendinopathy depends, to a great extent,
435
on the frequency of their execution [48,49]. Moreover,436
the article by Yi et al. [28] also obtained good results in
437
the friction massage group, probably due to the capacity
438
of this technique to soften the extracellular matrix and
439
cause a slight inflammation that activates the restoration
440
of the conjunctive tissue; in fact, it has been demon-
441
strated to reduce pain and improve functionality in mus-
442
cle and ligamentous pathologies [50]. DF was also ca-
443
pable of improving functionality after six sessions [23].
444
This could be explained by the fact that its mechanism
445
of action consists in ripping the conjunctive tissue fibres
446
that form adhesions, in order to recover the normal glide
447
between the different tissue layers [51]; thus, it can im-
448
prove the ROM and reduce myotendinous reflexes [52].
449
Lastly, with all the interventions, the improvement of
450
this variable was achieved in the short term, especially
451
with the application of SW [15,16,20,21] and PRP [20]
452
compared to US [15,16]. The positive effects obtained
453
with SW in several of the analysed variables can be due
454
to the fact that their optimal effect is attained at a maxi-
455
mum depth of 3.5 cm, where epicondylar tendons can
456
be fully treated regardless of the size of the patient [53].
457
Similarly, with a high concentration of growth factors,
458
PRP favours the resolution of tendinopathies and mus-
459
cle and cartilage injuries [54].460
Another aspect closely related to functionality and
461
objectively quantifiable is grip strength, which was also
462
analysed [15,17,19,22,23,25,26,28
–
32]. Regarding the
463
improvement of this variable, the interventions based
464
on therapeutic exercise [17,31] and manual therapy [26]
465
obtained good results in the long-term, and even signifi-
466
cantly higher results compared to those based on orthe-
467
ses [31], SW [15,17,19] and corticosteroids [26]. This
468
could be due to the fact that corticosteroids regulate the
469
immune function of inflammatory cells and chemical
470
mediators, thus decreasing pain; however, injections
471
increase protein catabolism and reduce type I collagen
472
and the synthesis of glycosaminoglycans, thereby de-
473
laying the healing process in the long term [55]. DF im-
474
proved grip strength after one session [18], thanks to its
475
capacity to improve the mechanical and inflammatory
476
pain of the musculoskeletal system by removing the tis-
477
sue adhesions and allowing the optimal glide of the my-
478
ofibrils [52]. In the short term, SW also obtained good
479
results in this variable [15,20,30], although they proved
480
to be less effective when compared to KT [21]. KT
481
reduces pain and edema and facilitates motor activity
482
by activating the circulatory and nervous systems with
483
movement, improves the ROM by relieving abnormal
484
muscle tension and stimulates the mechanoreceptors by
485
applying pressure on the skin, which are effects that
486
have a direct impact on the generation of strength [56].
487
On the other hand, the improvements obtained with KT
488
reach a limit in time after the intervention [22,25,29],
489
unless this technique is combined with conventional
490
PT methods, such as ergonomic measures, stretching
491
exercises and strength training [25]. 492
The ROM was only evaluated in the studies that used
493
orthoses [22,31]; this variable was improved in both
494
cases. However, also in both cases, the orthosis was
495
applied in combination with strength exercises [31] or
496
with US, friction and stretching exercises [22], which
497
are techniques known for their improvement effect on
498
joint mobility [11,48,50,57]. In fact, the improvement
499
was greater with the intervention that only included
500
eccentric exercises [31], since this training modality
501
is currently among the most effective techniques in
502
the treatment of tendinopathies [58
–
60]. This type of
503
training leads to the production of collagen, reduces
504
the prevalence of inflammation and neovascularisation 505
and decreases pain by increasing tendinous resistance
506
and desensitising the central nervous pathways of pain 507
transmission [11,61]. 508
Therefore, the treatment of LE should include ec-
509
centric strengthening, due to its benefits on pain reduc-
510
tion and the increase of tendinous resistance [11,58],
511
with techniques such as friction massage and DF (de-
512
pending on the patient’s preferences), which are non-
513
invasive and follow the same neurophysiological prin-
514
ciples to reduce pain and inflammation, with the differ-
515
ence that DF can reach deeper layers [23,50,52], or KT,
516
which stimulates circulation by displacing the skin, fas-
517
cia and subcutaneous tissues, achieving the correction
518
of the fascia, reducing pain and attaining neuromuscu- 519
lar reeducation with the stimulation of mechanorecep-
520
tors [55,56]. If the patient presents a lot of pain, orthoses
521
are a non-invasive method with short-term efficacy for
522
the immediate relief of pain and the improvement of
523
hand functionality [3], although, in these cases, com-
524
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L. Landesa-Martínez and R. Leirós-Rodríguez / Physical therapy & epicondylitis 13
plying with the guideline of exercises becomes more
525
important for the prevention of their harmful effects.
526
Lastly, it must be considered that, for the treatment of
527
acute LE (processes of less than three months of evo-
528
lution) [16,17,19,25,26,28,30,33,58], US and PRP are
529
less effective. On the other hand, for the treatment of
530
chronic LE [15,18,20
–
23], no particularities were found
531
in terms of suitability for any techniques.532
With respect to the methodological limitations of this
533
study, it must be pointed out that the inclusion of non-
534
controlled and non-randomised experimental studies
535
reduces the validity of the conclusions drawn in this
536
review. Moreover, the small sample size of some of
537
the analysed articles limits the generalisation of their
538
results. Regarding the operationalisation of the study
539
variables, many of them were evaluated through meth-
540
ods that depend on the patient’s subjectivity. Finally,
541
in the results selection process, a considerable num-
542
ber of studies were eliminated because their full text
543
was not available. On the other hand, this review has
544
some strengths that must be highlighted, such as the
545
comparison of different treatment techniques (including
546
conventional low-cost techniques and other more re-
547
cent methods that require greater economic investment
548
and/or multidisciplinary intervention) and the fact that
549
it is an update on the different PT techniques for the
550
treatment of LE.551
Future studies should conduct further RCT with
552
larger sample sizes and compare the different combina-
553
tions of the most effective techniques: manual therapy,
554
strength training, SW and bandages. Furthermore, fu-
555
ture research must compare and adequately define the
556
particularities of the different approaches in acute and
557
chronic LE.558
5. Conclusions559
Taken together, findings from papers included in the
560
present systematic review suggested that manual ther-
561
apy (e.g., stretching exercises and friction massages)
562
and eccentric strength training are the two physiother-
563
apy treatments with the most beneficial effects on LE,
564
and their cost-benefit ratio is very favourable. Other
565
techniques have positive effects, although they require
566
greater economic investment, such as SW and the ad-
567
ministration of PRP.568
In any case, before deciding to perform surgical in-
569
tervention, it is crucial to deplete all the conservative
570
therapeutic options (drugs and PT), regardless of their
571
economic cost. In addition, there are many PT tools
572
that can complement the mentioned techniques, such as
573
cryotherapy, electrotherapy, ultrasound therapy, and the
574
application of tapes or orthoses. 575
Conflict of interest 576
The authors report no conflict of interest. 577
Data availability 578
The data that support the findings of this study are
579
available upon reasonable request from the correspond-
580
ing author. 581
Funding 582
No financial support was received from any commer-
583
cial company. 584
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