Lateral Epicondyle Tendinopathy Toolkit: Section D - Summary of the Evidence

Original Editor - Rishika Babburu for BC Physical Therapy Tendinopathy Task Force:

Dr. Joseph Anthony, Paul Blazey, Dr. Allison Ezzat, Dr. Angela Fearon, Diana Hughes, Carol Kennedy, Dr. Alex Scott, Michael Yates and Alison Hoens

Top Contributors - Rishika Babburu, Evan Thomas, Kim Jackson, Vidya Acharya, Lucy Aird and Wanda van Niekerk  


PURPOSE, SCOPE & DISCLAIMER: The purpose of this document is to provide physical therapists with a summary of the evidence for interventions commonly used to manage tendinopathy of the lateral epicondyle. This decision-making tool is evidence-informed and where there is insufficient evidence, expert-informed. It is not intended to replace the clinician’s clinical reasoning skills and inter-professional collaboration.‘Acute’ refers primarily to symptoms of less than 3 months duration and ‘chronic’ to greater than 3 months. For studies which (1) included participants with symptoms that encompassed both acute and chronic stages or (2) did not clarify the duration of symptoms, the results have been reported within the ‘chronic’ stage.

Introduction[edit | edit source]

Clinicians want to provide evidence-informed management of tendinopathy but many struggle with accessing, appraising and synthesizing the vast array of literature available on this topic. This section forms part of the Lateral Epicondyle Tendinopathy toolkit project created by the BC (British Columbia) Physical Therapy Knowledge-Broker facilitated project team. The evidence below has been modified for Physiopedia and produced in collaboration with the authorship team to support the information found in the toolkit.

Abbreviations[edit | edit source]

CAT = Critically Appraised Topic CS = Case Study LET = Lateral Epicondyle Tendinopathy
LLLT = Low Level Laser Therapy MA = Meta-Analysis MWM = Mobilization with Movement
NR = Narrative Review NSAID = Non-Steroidal Anti-Inflammatory Drug OS = Observational Study
RCT = Randomized Controlled Trial SR = Systematic Review SWT = Shock Wave Therapy
US = Ultrasound WALT = World Association of Laser Therapy DN= DryNeedling
EO= Expert Opinion AP= Acupuncture HILT=High Intensity Laser Therapy


*Numbers in parentheses in the "Clinical Research Evidence" rows represent the number of individual studies included in each review article.

Explanation of Clinical Implications[edit | edit source]

When researching treatment options it is important to consider the clinical implications. The following interventions have been reviewed and graded according to the supporting evidence. See the table below for an explanation.

Strongly consider Credible evidence from well conducted systematic review(s) or multiple (>2) randomized controlled trials to suggest that intervention should be included in treatment
Consider Evidence from one well conducted clinical trial, or multiple (>2) trials/cohort studies that intervention should be included in treatment
May consider 1-2 trials or observational studies that support use of the intervention, AND/OR supported by expert opinion AND/OR sound physiological rationale of potential treatment effects. Option that this could be included in treatment.
Consider NOT Evidence of harm, or credible evidence of no effect outweighs evidence for benefits associated with intervention.
No Recommendation No evidence to support or reject the use of treatment in this clinical population

Manual Therapy[edit | edit source]

Manual Therapy is defined as an advanced specialty area of physical therapy practice that is based on manual examination and treatment techniques integrated with exercise, patient education, and other physical therapy modalities to address pain, loss of function, and wellness.

Elbow Joint Mobilizations - SRs[1][2][3][4][5][6][7][8][9] RCTs[10][11]EOs[12][13]

Stage of pathology Acute Chronic
Clinical research evidence

1 SR

9 SR

2 RCT

Peer-Reviewed Published Expert Opinion

Yes

Yes
Take home message

There is minimal clinical evidence to support or refute the use of elbow mobilization in the acute stage.

There is a large amount of clinical evidence supporting the use of elbow mobilizations, (MWM and Mill’s Manipulation). Moderate effect sizes are demonstrated across all timeframes (immediate, short and long term). MWM shows favorable outcomes for pain, grip strength and function. Mill’s manipulation demonstrated effectiveness for pain but not pain free grip strength. The use of Mill’s manipulation for improved function is unclear. Some clinical evidence supports the use of radial head mobilization and neural tension techniques. There is weak support for the use of wrist-specific MWM to treat LET.

Clinical implication

May consider using MWM or Mill’s Manipulation in the management of acute LET.

Strongly consider using mobilization/manipulation of the elbow, particularly MWM in the treatment of chronic LET. The effects should be apparent within the first few treatments. Effects appear to be enhanced by the addition of exercise. (See Section F for details)
May consider using radial head mobilization and neural tension techniques.

May consider using MWM of the wrist .

Spinal ManipulationTechniques - SRs[14] RCTs [15][16][17][18][19][20]EO [13]

Stage of pathology Acute Chronic
Clinical research evidence

1 SR

1 SR

6 RCT

Peer-Reviewed Published Expert Opinion

Yes

Yes

Take home message

There is minimal clinical evidence or expert opinion on the use of spinal mobilization/manipulation for patients with acute LET.

Credible clinical evidence supports the use of cervical and thoracic mobilization/manipulation into the treatment of LET for improved pain, increased PPT, grip strength and function in the short-term. In one study a stronger effect was produced when delivered with a supportive and empathetic approach. Neuromobilization techniques (radial nerve) have been shown to have a positive effect on pain

Clinical implication

May consider using spinal mobilization (cervical and/or thoracic) for patients with acute LET.

Consider using cervical/thoracic mobilization/manipulation/ neuromobilization techniques in those with cervical and/or thoracic signs even if they do not report spinal symptoms in addition to local treatment to the elbow including exercise. (See Section F for details)

Soft Tissue Techniques- SRs [21][22]RCTs[23][24][25]

Stage of pathology Acute Chronic
Clinical research evidence

1 SR

2 SR

3 RCT

Peer-Reviewed Published Expert Opinion

Yes

Yes

Take home message

Limited clinical evidence supports the use of soft tissue techniques as a stand alone treatment.

There is weak clinical evidence to support the use of soft tissue techniques such as frictions, in combination with other treatment modalities.

Note: most of the studies which examined the effect of frictions included the use of Mill’s manipulation +/- exercise.

Clinical implication

May consider using deep and superficial massage for immediate pain relieving effect in acute LET.

May consider using soft tissue techniques (such as deep transverse friction massage) as part of a multimodal treatment regime for chronic LET. (See Section F for details)


Exercise[edit | edit source]

Exercise is a physical activity that is planned and is performed with the goal of attaining or maintaining physical fitness. A proper rehabilitation program involves exercise prescription which must be both relevant and effective. The currently available evidence is mentioned in the table below.

Exercise- SRs [26][27][28][29]RCTs[30][31][32][33]Non-RCTs[34]EO[13][35]
Stage of pathology Acute Chronic
Clinical research evidence

1 N-RCT

4 SR

4 RCT

Peer-Reviewed Published Expert Opinion

Yes

Yes

Take home message

There is a small amount of clinical evidence to support the use of exercise (strength, stretching, general fitness) in the acute stage

There is a large amount of clinical evidence to support the use of exercise (strengthening and stretching) in the chronic stage. Almost all exercise studies showed improvement whether it was concentric, eccentric or isometric strengthening. While there is some evidence that commencing with eccentric exercises may provide superior pain relief, providing an exercise that the patient can tolerate (isometric, concentric or eccentric) is likely more important than the type of exercise.

There is some evidence that stretching may provide pain relief.

There is mixed evidence that in-person sessions or supervised home exercise programs are superior to unsupervised programs in providing positive outcomes.

Clinical implication

May consider using exercise in the management of acute LET

Strongly consider using local and upper limb kinetic chain exercise in the chronic stage as per clinical assessment findings.

No single type of exercise appears to be superior to another for LET rehab

May consider the use of pain-free as opposed to painful exercise interventions in more irritable or severe cases.


Acupuncture[edit | edit source]

Acupuncture may include Traditional Chinese Medicine approach, or Western medical-anatomical approach for acupoint selection. Acupuncture is differentiated from Dry Needling, although the same fine filament needle is employed, and there may be areas of crossover in point selection and technique.

Acupuncture- SRs[36][37][38][39]RCTs[40]
Stage of pathology Acute Chronic
Clinical research evidence

1 SR

3 SRs

1 RCT

Peer-Reviewed Published Expert Opinion

No

Yes

Take home message

There are a lack of studies to support Acupuncture specifically with acute lateral epicondyle tendinopathy. What does exist is weak and inconclusive. What evidence does exist suggests benefits offered are for pain specifically.

Available evidence focuses on a Western Acupuncture approach for the diagnosis and treatment of LET. Study designs are heterogeneous with no consistency on acu-point selection or technique. Acupuncture is suggested as efficacious at reducing pain. All follow-ups were in the short term, with no description of benefit for lasting effect.

Clinical implication

May consider acupuncture in acute LET for short term pain improvement

May consider acupuncture for short-term pain management in patients with chronic LET

Dry Needling[edit | edit source]

Dry Needling is the intervention using thin filament needles to penetrate the skin that stimulates myofascial trigger points (MTrP), muscular, neural and connective tissue for the management of neuromusculoskeletal disorders.

Dry Needling- SRs[41]Others[42]
State

of Pathology

Acute Chronic
Clinical

research

evidence

1 other 1 SR
Peer-

Reviewed

Published

Expert

Opinion

Yes Yes
Take home

message

Lack of studies identified

that are explicit to acute

LET. There is physiological

rationale for delaying DN

in the inflammatory phase

of injury if the tissue

irritability is high.

Clinical evidence provides low-moderate support for the use of

DN for short-term benefits for pain, function and grip strength.

Clinical

implication

May consider DN in acute LET

for short term benefit of

pain and function.

May consider DN in chronic LET for short term benefit

of pain, function and grip strength.

Low Level Laser Therapy (LLLT)[edit | edit source]

Light Amplification by Stimulated Emission of Radiation is abbreviated as LASER. Low Level Laser Therapy (LLLT) is a non-invasive light source treatment that generates a single wavelength of light. It is believed to affect the function of connective tissue cells by accelerating repair and reducing inflammation.

Low Level Laser Therapy (LLLT)- SRs[2][3][43][44][45][7][46][47]RCTs [48][49][50][51][52][53][54][55]EO[13]
Stage of pathology Acute Chronic
Clinical research evidence

3 RCT

8 SR

3 RCT

Peer-Reviewed Published Expert Opinion

Yes

Yes

Take home message

Laser at 905 nm may be effective when used in accordance with the WALT guidelines, with some studies showing benefit when used in combination with exercise.

Laser at 904 nm and possibly 832 nm or 830 nm may be effective when used in accordance with the WALT guidelines. Many of the studies demonstrate efficacy when used in combination with other treatments. Dosage is essential to effective treatment.

Clinical implication

Consider using laser (LLLT) at 905 nm with dosage as recommended by WALT guidelines. (See Section G for details for details)

Consider using laser (LLLT) at 904 nm with dosage as recommended by WALT guidelines. (See Section G for details)

High Intensity Laser Therapy (class IV)[edit | edit source]

High Intensity Laser Therapy(class IV)
State

of Pathology

Acute Chronic
Clinical

research

evidence

3 RCT
Peer-

Reviewed

Published

Expert

Opinion

No
Take home

message

Lack of studies identified

that are explicit

to acute lateral

epicondyle tendinopathy

Class IV Laser (12W, 1,064 nm) at 100 - 150J per treatment

may be effectivein reducing pain, increasing

hand grip strength and improving QDASH score.

Clinical

implication

No Recommendation Consider using HILT with dosage as

recommended. 9 or 10 treatments over 3 weeks.

Ultrasound (US)[edit | edit source]

Ultrasound is a form of mechanical energy . The normal human sound range is from 16 Hz to something approaching 15-20,000 Hz (in children and young adults). The frequencies used in Ultrasound therapy are typically between 1.0 and 3.0 MHz (1 MHz = 1 million cycles per second).US therapy helps in tissue healing, speed the rate of healing & enhance the quality of the repair.

In thermal mode, US will be most effective in heating the dense collagenous tissues and will require high intensity, preferably in continuous mode. The non‑thermal effects of US are attributed primarily to a combination of and acoustic streaming.

Ultrasound- SRs [1][56][57][58][3][59]RCTs[11][60][50][61][62][63][64]EO[13]
Stage of pathology Acute Chronic
Clinical research evidence

2 RCT

6 SR

8 RCT

Peer-Reviewed Published Expert Opinion

---

---

Take home message

Weak evidence exists to support the effectiveness of US in the management of acute LET. 1 MHz or 3 MHz, 0.5 – 1.0 W/cm2 5-10 minutes (pulsed 1:2-1:4 suggested).

Weak evidence for effectiveness of US in the management of chronic LET. 1 MHz or 3 MHz, 1.0 – 2.0 W/cm2 5-12 minutes.


The total number of treatments used in many of the studies is greater than might be economically viable in real world therapeutic settings (many studies used more than 10 sessions).

Clinical implication

May consider using US in the management of acute LET.

May consider using US in the management of chronic LET.


Extracorporeal Shock Wave Therapy : Focused and Radial[edit | edit source]

Shockwaves are sound waves that have specific physical characteristics, including nonlinearity, high peak pressure followed by low tensile amplitude, short rise time, and short duration (10 ms). They have a single pulse, a wide frequency range (0-20 MHz), and a high pressure amplitude (0-120 MPa).These characteristics produce a positive and negative phase of shockwave. The positive phase produces direct mechanical forces, whereas the negative phase generates cavitation and gas bubbles that subsequently implode at high speeds, generating a second wave of shockwaves. Therapeutic ultrasound utilises high frequency sound waves, while SWT utilises lower frequency waves.

Electric generation of Shock Wave Therapy is measured as Energy Flux Density (EFD) in mJ/mm²; Pneumatic (pulsed-pressure) SWT is measured in Bars.

Extracorporeal Shock Wave Therapy (SWT)- SRs [65][66][67][68][69]RCTs[70][71][72][73]EO[74]
Stage of pathology Acute Chronic
Clinical research evidence

2 RCT

5 SR

2 RCT

1 other

Peer-Reviewed Published Expert Opinion

---

---

Take home message

There is a small amount of support for the use of SWT in the acute phase. In the acute phase, physiological rationale suggests SWT may be effective for short term pain modulation

SWT is a treatment option for chronic LET that has failed to respond to other physical interventions. Dosage may be arbitrarily categorized as low energy <0.2 mJ/mm2 (approx. 4 Bars max); high energy >0.2 mJ/mm2. Low energy protocols apply to both radial and focused SWT devices and may be better tolerated with outcomes similar to high energy focused devices. Systematic reviews with meta-analyses of SWT have pooled heterogeneous study designs. As a result, the evidence remains conflicting regarding the effectiveness of SWT for LET.

Clinical implication

May Consider using SWT for acute LET for short term pain modulation.

Consider using radial or focused, low energy SWT for chronic LET for subjects that have failed to respond to other conservative treatment. Dosage intensity should be based on patient tolerance.


Recommended dosage:

  • 0.06-0.2 mJ/mm2 (approx. 1-4 Bars)
  • 4-20 Hz
  • 1500-2500 shocks
  • 3-5 weekly sessions


SWT should be used in conjunction with exercise interventions.


Follow-up should be delayed until 3-6 months after completing treatment to allow for a tissue- based treatment response.

Iontophoresis[edit | edit source]

Iontophoresis is a procedure in which involves passing of electric current through the skin which is immersed in tap water allowing ionized or charged particles to cross the normal skin barrier. This method is considered as a non-invasive transdermal drug delivery technique based on transfer of charged molecules using low-intensity electric current.

Iontophoresis SRs [75]RCTs[76][77][78]
Stage of pathology Acute Chronic
Clinical research evidence

1 RCT

1 SR

Peer-Reviewed Published Expert Opinion

---

---

Take home message

Single study supports the delivery of corticosteroid (Dexamethasone) by iontophoresis to treat acute lateral elbow pain for short term pain reduction, allowing the subject to participate in an earlier increase in exercise activity or return to work. Iontophoresis may have advantages over injection (less pain, decreased trophic changes in tissue), but may not be as cost effective.

Evidence regarding the potential efficacy for chronic LE of iontophoresis (with dexamethasone, prednisolone, diclofenac, lidocaine or salicylate) is insufficient to base a clinical recommendation.

Clinical implication

Consider a trial of iontophoresis with

Dexamethasone for short-term pain

control for acute LET.

Recommended dosage:

  • 0.4% Dexamethasone Sodium
  • Phosphate (aqueous)
  • 40-80 mA-min
  • 4-6 sessions, alternate days

Physician prescription required.

No Recommendation


Orthotic Devices[edit | edit source]

An orthotic device is externally applied device used to compensate for impairments of the structure and function of the neuro-muscular and skeletal systems. Elbow orthosis encompasses the elbow joint.[79] Orthotic devices such as braces, sleeves or splints are used in rehabilitation of lateral epicondyle tendinopathy.

Orthotic Devices SRs [80][81]RCTs [82]
Stage of pathology Acute Chronic
Clinical research evidence

2 SR

2 SR

Peer-Reviewed Published Expert Opinion

---

---

Take home message

There is weak evidence (1SR) that orthotic devices (brace, sleeve or splint) may reduce immediate pain compared to placebo.

There is weak evidence (1SR) that a counterforce brace may reduce pain in the short term (<6 weeks).

A placebo-controlled RCT showed that addition of a counterforce brace to exercise-based rehabilitation may result in improved pain and function in the short and long terms.

Clinical implication

May consider the use of an orthotic for patients with LET. Counterforce braces appear to offer some benefit, especially in the early phase of rehabilitation.

May consider the use of an orthotic for patients with LET. Counterforce braces appear to offer some benefit, especially in the early phase of rehabilitation.


Taping[edit | edit source]

Taping is used as one of the means of rehabilitation or prophylaxis in instances where support and stability are needed, as a first-aid tool, for the prevention of injury and protection of an injured anatomical structure while healing is taking place.

Taping RCTs [83][84] N-RCTs [85]EO[86]
Stage of pathology Acute Chronic
Clinical research evidence

---

2 RCT

1 N-RCT

Peer-Reviewed Published Expert Opinion

Yes

Yes

Take home message

---

Two placebo controlled trials, and two experimental studies have demonstrated efficacy of taping for providing immediate pain relief.

Taping has not been consistently shown to benefit strength.

Studies have often been conducted alongside an exercise intervention.

Clinical implication

May consider taping as an adjunct to other treatments in the acute management of LE.

Consider a trial of taping for patients with chronic LET to reduce pain.

Resources[edit | edit source]

References[edit | edit source]

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