A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia

The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: a prospective, randomized, controlled trial

The aims of this study were to evaluate the effects of low-level laser therapy (LLLT) and to compare these with the effects of brace or ultrasound (US) treatment in tennis elbow. The study design used was a prospective and randomized, controlled, single-blind trial. Fifty-eight outpatients with lateral epicondylitis (9 men, 49 women) were included in the trial. The patients were divided into three groups: 1) brace group-brace plus exercise, 2) ultrasound group-US plus exercise, and 3) laser group-LLLT plus exercise. Patients in the brace group used a lateral counterforce brace for three weeks, US plus hot pack in the ultrasound group, and laser plus hot pack in the LLLT group. In addition, all patients were given progressive stretching and strengthening exercise programs. Grip strength and pain severity were evaluated with visual analog scale (VAS) at baseline, at the second week of treatment, and at the sixth week of treatment. VAS improved significantly in all groups after the treatment and in the ultrasound and laser groups at the sixth week (p<0.05). Grip strength of the affected hand increased only in the laser group after treatment, but was not changed at the sixth week. There were no significant differences between the groups on VAS and grip strength at baseline and at follow-up assessments. The results show that, in patients with lateral epicondylitis, a brace has a shorter beneficial effect than US and laser therapy in reducing pain, and that laser therapy is more effective than the brace and US treatment in improving grip strength.

Poorer elbow proprioception in patients with lateral epicondylitis than in healthy controls: a cross-sectional study

Two groups of women, 15 patients with lateral epicondylitis and 21 healthy controls, were studied to compare proprioception in the elbows and knees between the groups. Outcome measures were absolute error and variable error for joint position sense and for threshold to detection of a passive movement. Both absolute error and variable error of threshold to detection of a passive movement were greater in the lateral epicondylitis-diagnosed elbows than in the controls' elbows (lateral epicondylitis, 1.8 degrees vs controls 1.1 degrees, P = .026; lateral epicondylitis, 0.8 degrees vs controls 0.3 degrees, P = .015), and there was a tendency toward a greater absolute error of joint position sense compared with the control elbows (lateral epicondylitis, 8.2 degrees vs controls, 5.6 degrees; P = .078). Absolute error of joint position sense was greater in the elbows than in the knees of the lateral epicondylitis patients, but no group differences were found for knees. Proprioception seems, therefore, to be poorer in elbows with lateral epicondylitis elbows than in the controls' elbows. This needs to be taken into consideration in the management of lateral epicondylitis.

Effects of 904-nm low-level laser therapy in the management of lateral epicondylitis: a randomized controlled trial

OBJECTIVE

The aim of this study was to evaluate the effectiveness of 904-nm low-level laser therapy (LLLT) in the management of lateral epicondylitis.

BACKGROUND DATA

Lateral epicondylitis is characterized by pain and tenderness over the lateral elbow, which may also result in reduction in grip strength and impairment in physical function. LLLT has been shown effective in its therapeutic effects in tissue healing and pain control.

METHODS

Thirty-nine patients with lateral epicondylitis were randomly assigned to receive either active laser with an energy dose of 0.275 J per tender point (laser group) or sham irradiation (placebo group) for a total of nine sessions. The outcome measures were mechanical pain threshold, maximum grip strength, level of pain at maximum grip strength as measured by the Visual Analogue Scale (VAS) and the subjective rating of physical function with Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

Significantly greater improvements were shown in all outcome measures with the laser group than with the placebo group (p < 0.0125), except in the two subsections of DASH.

CONCLUSION

This study revealed that LLLT in addition to exercise is effective in relieving pain, and in improving the grip strength and subjective rating of physical function of patients with lateral epicondylitis.

Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment

Lateral epicondylitis (tennis elbow) is the most frequent type of myotendinosis and can be responsible for substantial pain and loss of function of the affected limb. Tennis biomechanics, player characteristics and equipment are important in preventing the condition. This article presents an overview of the current knowledge on lateral epicondylitis, and focuses on treatment strategies. Conservative and surgical treatment options are discussed, and recent techniques are outlined.

Chronic elbow dislocation: a rare complication of tennis elbow surgery. Successful treatment by open reduction and external articular distrator

A case is presented of chronic dislocation of the elbow after tennis elbow surgery combined with posterior interosseous nerve (PIN) release. An open reduction with repair of the collateral ligaments was performed. Postoperative rehabilitation involved the use of an articulated external fixator and there was a successful outcome. Possible causes of the dislocation are discussed.

A unified approach to radial tunnel syndrome and lateral tendinosis

Two of the most common diagnoses assigned to patients presenting with lateral elbow and proximal forearm pain are lateral tendinosis and radial tunnel syndrome. Traditionally, these 2 conditions have been treated as distinct and separate entities with most patients being diagnosed with either one or the other, but not both. The extensor carpi radialis brevis (ECRB) and, to a lesser the degree, a portion of the extensor digitorum communis that form the conjoined lateral extensor tendon are thought to be primarily responsible for the excessive traction that induces lateral tendinosis (a degenerative process of microtears in the tendon with impaired healing), but the supinator blends with these same fibers and shares a role in the pathology. The supinator, primarily the arcade of Frohse, has been thought to play the majority role in compressing the posterior interosseous nerve in radial tunnel syndrome, but the undersurface thick tendon of the ECRB may also cause substantial nerve compression. Reduction of the linear tension transmitted by the ECRB is the common element in the various surgical treatments for lateral tendinosis, performed anywhere from directly at the lateral epicondyle to the distal myotendinous junction. Nerve decompression by division of fascial bands is the goal in surgery for radial tunnel syndrome. These 2 surgical approaches need not be mutually exclusive. In fact, this separation of the 2 clinical entities may play a role in the unpredictable results reported in the literature. This article presents a unified approach to treating both pathologies simultaneously including short-term clinical results.

Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial

OBJECTIVE

To investigate the efficacy of physiotherapy compared with a wait and see approach or corticosteroid injections over 52 weeks in tennis elbow.

DESIGN

Single blind randomised controlled trial.

SETTING

Community setting, Brisbane, Australia.

PARTICIPANTS

198 participants aged 18 to 65 years with a clinical diagnosis of tennis elbow of a minimum six weeks' duration, who had not received any other active treatment by a health practitioner in the previous six months.

INTERVENTIONS

Eight sessions of physiotherapy; corticosteroid injections; or wait and see.

MAIN OUTCOME MEASURES

Global improvement, grip force, and assessor's rating of severity measured at baseline, six weeks, and 52 weeks.

RESULTS

Corticosteroid injection showed significantly better effects at six weeks but with high recurrence rates thereafter (47/65 of successes subsequently regressed) and significantly poorer outcomes in the long term compared with physiotherapy. Physiotherapy was superior to wait and see in the short term; no difference was seen at 52 weeks, when most participants in both groups reported a successful outcome. Participants who had physiotherapy sought less additional treatment, such as non-steroidal anti-inflammatory drugs, than did participants who had wait and see or injections.

CONCLUSION

Physiotherapy combining elbow manipulation and exercise has a superior benefit to wait and see in the first six weeks and to corticosteroid injections after six weeks, providing a reasonable alternative to injections in the mid to long term. The significant short term benefits of corticosteroid injection are paradoxically reversed after six weeks, with high recurrence rates, implying that this treatment should be used with caution in the management of tennis elbow.

Sclerosing polidocanol injections in chronic painful tennis elbow-promising results in a pilot study

Sclerosing polidocanol injections targeting the area with neovessels (vascularity) have been demonstrated to give promising clinical results in patients with chronic painful Achilles and patellar tendinosis. Recently, we demonstrated vascularity in the extensor origin in patients with chronic painful tennis elbow, but not in controls with pain-free elbows. In this pilot study, 11 patients (four men and seven women, mean age 46 years) with the diagnosis of tennis elbow in altogether 13 elbows, were included. All patients had a long duration of pain symptoms (mean 23 months), and ultrasonography (US) + colour Doppler (CD) examination showed structural tendon changes with hypo-echoic areas, and a vascularity, corresponding to the painful area in the extensor origin. All patients were treated with US- and CD-guided injections of the sclerosing substance polidocanol, targeting the area with vascularity. At 8-month follow-up after treatment, there was a good clinical result in 11/13 elbows. Extensor origin pain during wrist loading activities (recorded on a VAS-scale) was significantly reduced (mean VAS from 75 to 34; P < 0.003), and maximal grip strength was significantly increased (from 29 to 40 kg; P < 0.025). Our findings indicate that one treatment with sclerosing polidocanol injections, targeting the area with vascularity in the extensor origin, has a potential to reduce the tendon pain and increase grip strength, in patients with chronic painful tennis elbow.

Chronic tendinopathy: effectiveness of eccentric exercise

OBJECTIVES

To determine the effectiveness of eccentric exercise (EE) programmes in the treatment of common tendinopathies.

DATA SOURCES

Relevant randomised controlled trials (RCTs) were sourced using the OVID website databases: MEDLINE (1966-Jan 2006), CINAHL (1982-Jan 2006), AMED (1985-Jan 2006), EMBASE (1988-Jan 2006), and all EBM reviews--Cochrane DSR, ACP Journal Club, DARE, and CCTR (Jan 2006). The Physiotherapy Evidence Database (PEDro) was also searched using the keyword: eccentric.

REVIEW METHODS

The PEDro and van Tulder scales were employed to assess methodological quality. Levels of evidence were then obtained according to predefined thresholds: Strong--consistent findings among multiple high-quality RCTs. Moderate--consistent findings among multiple low-quality RCTs and/or clinically controlled trials (CCTs) and/or one high-quality RCT. Limited--one low-quality RCT and/or CCT. Conflicting--inconsistent findings among multiple trials (RCTs and/or CCTs). No evidence-no RCTs or CCTs.

RESULTS

Twenty relevant studies were sourced, 11 of which met the inclusion criteria. These included studies of Achilles tendinopathy (AT), patella tendinopathy (PT) and tendinopathy of the common wrist extensor tendon of the lateral elbow (LET). Limited levels of evidence exist to suggest that EE has a positive effect on clinical outcomes such as pain, function and patient satisfaction/return to work when compared to various control interventions such as concentric exercise (CE), stretching, splinting, frictions and ultrasound. Levels of evidence were found to be variable across the tendinopathies investigated.

CONCLUSIONS

This review demonstrates the dearth of high-quality research in support of the clinical effectiveness of EE over other treatments in the management of tendinopathies. Further adequately powered studies that include appropriate randomisation procedures, standardised outcome measures and long-term follow-up are required.

Common tendinopathies in the upper and lower extremities

Overuse tendon injuries (tendinopathies) present a challenge to sports medicine patients and clinicians. Despite the high prevalence of tendinopathy in recreational and competitive athletes, treatment is often hampered by contradictory definitions and descriptions of the underlying pathology, with a limited repertoire of evidence-based treatments. This review provides the clinician with a basic overview of tendon structure and pathophysiology, and highlights the most common tendinopathies affecting the upper and lower extremities, including an update on recent advances in conservative management.

Lateral epicondylosis: a case study of conservative care utilizing ART and rehabilitation

OBJECTIVE

To present the diagnostic features of lateral epicondylosis and response to treatment by Active Release Technique (ART), a promising treatment for lateral epicondylosis.

CLINICAL FEATURES

The most important feature is pain at the lateral epicondyle of the humerus, most notably in actively extending or passively flexing the wrist.

INTERVENTION AND OUTCOME

Treatment involves eliminating any inflammation, reducing muscular pain and hypertonicity, correcting biomechanical dysfunction, and restricting/modifying the offending activity. ART was successfully utilized in an attempt to remove adhesions and promote restoration of normal tissue texture. A sports specific rehabilitation protocol was employed to re-establish wrist extensor strength and interferential current and ice were used to control pain and residual inflammation.

CONCLUSION

A combination of soft tissue therapy, rehabilitation, and therapeutic modalities is a protocol that may be used by both allopathic and chiropractic practitioners alike, and allow for the athletic patient to return to play as quickly as possible.

Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial

OBJECTIVES

Pulsed low-intensity ultrasound therapy (LIUS) has been found to be beneficial in accelerating fracture healing and has produced positive results in animal tendon repair. In the light of this we undertook a randomized, double-blind, placebo controlled trial to assess the effectiveness of LIUS vs placebo therapy daily for 12 weeks in patients with chronic lateral epicondylitis (LE).

METHODS

Patients with LE of at least 6 weeks' duration were recruited from general practice, physiotherapy and rheumatology clinics, and had to have failed at least one first-line treatment including non steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injection. Participants were assigned either active LIUS or placebo. Treatment was self-administered daily for 20 min over a 12-week period. The primary end-point was a 50% improvement from baseline in elbow pain measured at 12 weeks using a patient-completed visual analogue scale.

RESULTS

Fifty-five subjects aged 18-80 were recruited over a 9-month period. In the active group 64% (16/25) achieved at least 50% improvement from baseline in elbow pain at 12 weeks compared with 57% (13/23) in the placebo group (difference of 7%; 95% confidence interval -20 to 35%). However, this was not statistically significant (chi(2) = 0.28, P = 0.60).

CONCLUSION

In this study LIUS was no more effective for a large treatment effect than placebo for recalcitrant LE. This is in keeping with other interventional studies for the condition.