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

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.

Lateral Epicondyle Tendinopathy:
Summary of the Evidence for Physical Therapy Interventions

• Click to go back to the contents page
• Click to continue to Treatment Algorithm
• Click to continue to Appendix A: Exercise Programs
• Click to continue to Appendix B: Low Level Laser Therapy Dosage Calculation
• Click to continue to: Appendix C: Details of Articles on Interventions
• Click to continue to: Appendix D: Medical and Surgical Interventions

Manual Therapy

Elbow Joint Mobilizations
Stage of pathology	Acute	Chronic
Clinical research evidence*	No	• 4 RCT • 5 SR (21) • 1 CAT (5) • 1 wrist RCT
Published expert opinion	No	2 expert opinion narrative reviews
Take home message	There is no clinical evidence to support or refute the use of elbow mobilization in the acute stage.	There is a large amount of clinical evidence to support the use of elbow mobilizations for short term effects. There is a small amount of evidence that supports long-term effects. There is a small amount of clinical evidence to support the use of radial head mobilization and neural tension techniques. There is weak support for the use of wrist MWM.
Clinical implication	There is no direction provided by the literature on the use of elbow mobilization in the management of acute LET.	Strongly consider using MWM of the elbow as part of a multimodal treatment regime (manual therapy and exercise) in the treatment of chronic LET. The effects should be apparent within the first few treatments. (See Appendix B for details) Consider using radial head mobilization and neural tension techniques. Consider using MWM of the wrist as part of multimodal treatment regime.
Spinal Mobilization Techniques
Stage of pathology	Acute	Chronic
Clinical research evidence*	No	• 3 RCT • 1 RCT pilot • 1 chart review • 1 case series
Published expert opinion	No	---
Take home message	There is no clinical evidence or expert opinion on the use of spinal mobilization for patients with acute LET.	There is clinical evidence to support the use of incorporating cervical and thoracic mobilizations into the treatment of LET. However, only 1 paper had follow up of ≥ 6/12 - the others report immediate or very short term responses.
Clinical implication	There is no direction provided by the literature on the use of spinal mobilization in the management of acute LET.	Consider using cervical mobilizations as part of a multimodal approach to treatment of chronic LET. Consider using cervical and thoracic mobilization 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. (See Appendix B for details)
Soft Tissue Techniques
Stage of pathology	Acute	Chronic
Clinical research evidence*	• 1 RCT	• 2 SR (7) • 3 RCT
Published expert opinion	---	---
Take home message	There is weak clinical evidence tosupport the use of deep and superficial massage to achieve immediate pain relief.	Early SR found insufficient evidence to make recommendations. More recent SR found there is weak clinical evidence to support the use of soft tissue techniques, such as frictions. There is a small amount of weak clinical evidence to support the use of soft tissue techniques in combination with other treatment modalities. Note: some of the studies which examined the effect of frictions included the use of Mill’s manipulation.
Clinical implication	Consider using deep and superficial massage for immediate pain relieving effect in acute LET.	Consider using soft tissue techniques (deep transverse friction massage) as part of a multimodal treatment regime for chronic LET. (See Appendix B for details)

LET = Lateral Epidocndyle Tendinopathy; RCT = Randomized Control Trial; SR ‐ Systematic Review; CAT = Critically Appraised Topic; MWM = Mobilization With Movement

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

References by Topic

Manual Therapy

Elbow Joint Mobilizations

1. Vicenzino, B. et al. Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia. Manual Therapy. Nov 2001; 6(4): 205-212.
2. Kochar M and Dogra A. Effectiveness of a specific physiotherapy regimen on patients with tennis elbow: Clinical study. Physiotherapy, 2002;88(6): 333-341.
3. Paungmali, A et al. Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Physical Therapy. Apr 2003; 83(4): 374-383.
4. Bisset L, Paungmali A, Vicenzino B, Beller, E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine. 2005; 39: 411-422.
5. Bisset L. et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomized trial. British Medical Journal. Nov 4, 2006; 333(7575): 939-941.
6. Vicenzino B, Teys PA. Mulligan's mobilization-with-movement, positional faults and pain relief: Current concepts from a critical review of literature. Manual Therapy. 2007; (12): 98-108.
7. Barr S, Cerisola F, Blanchard V. Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: A systematic review. Physiotherapy. Dec 2009; 95(4): 251-265.
8. Pagorek S. Effect of manual mobilization with movement on pain and strength in adults with chronic lateral epicondylitis. Journal of Sport Rehabilitation. 2009; 18(3): 448-457.
9. Bisset L, Coombes B, Vicenzino B. Tennis elbow. Clinical Evidence. June 27: 2011. Doi.pii:1117
10. Trudel D, et al. Rehabilitation for patients with lateral epicondylitis: a systematic review. Journal of Hand Therapy. 2004; 17(2): 243-266.

Spinal Mobilization Techniques

1. Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain. Nov 1996; 68(1): 69-74.
2. Cleland JA, Whitman JM, Fritz, JM. Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis (including commentary by Vicenzino B.) Journal of Orthopaedic & Sports Physical Therapy. 2004; 34(11): 713-724.
3. Cleland JA, Flynn TW, Palmer JA. Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: a pilot clinical trial. Journal of Manual & Manipulative Therapy. 2005; 13(3): 143-151.
4. Fernandez-Carnero J, Fernandez-De-Las-Penas C, et al. Immediate hypoalgesic and motor effects after a single cervical manipulation in subjects with lateral epicondylalgia. Journal of Manual & Manipulative Therapy. 2008; 31(9): 675-681.
5. Fernandez-Carnero J, Cleland A. Examination of motor and hypoalgesic effects of cervical vs. thoracic spine manipulation in patients with lateral epicondylalgia: A clinical trial. Journal of Manual & Manipulative Therapy. 2011; 34(7): 432-440.

Soft Tissue Techniques

1. Verhaar JAN, et al. Local corticosteroid injection versus cyriax-type physiotherapy for tennis elbow. Journal of Bone and Joint Surgery. Jan 1996; British 78B(1): 128-132.
2. Brosseau L, Casimiro L, Milne S, et al. Deep transverse friction Tendinitis massage for treating tendinitis. Cochrane Database Syst 2002; Rev. 4.
3. Law LAF, et al. Massage reduces pain perception and hyperalgesia in experimental muscle pain: A randomized, controlled trial. Journal of Pain. Aug 2008; 9(8): 714-721.
4. Nagrale, A. et al. Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia [sic]. Journal of Manual and Manipulative Therapy. 2009; 17(3): 171-178.
5. Joseph M, Taft J, et al. Deep friction massage for the treatment of tendinopathy: A systematic review of a classic treatment in the face of a new paradigm of understanding. Journal of Sports Rehabilitation. 2012; 21: 343-353.
6. Viswas R, Ramachandran R, Korde Anantkumar P. Comparison of effectiveness of supervised exercise program and cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial. The Scientific World Journal. 2012. Volume 2012, Article ID 939645, 8 pagesdoi:10.1100/2012/939645
7. Ajimsha, MS, Chithra, S, Thulasyammal, RP. Effectiveness of Myofascial Release in the Management of Lateral Epicondylitis in Computer Professionals. Archives of Physical Medicine & Rehabilitation. 2012; 93(4): 604-609.

Wrist MWM

1. Struijs, PAA, et al. Manipulation of the wrist for management of lateral epicondylitis: A randomized pilot study. Physical Therapy. July 2003; 83(7): 608-616.

Systematic Reviews/Meta-Analyses Evaluating Various Interventions and Regions

1. Smidt N. et al. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Annals of Medicine. 2003; 35(1): 51-62.
2. Bisset L. et al. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine. July 1, 2005; 39(7): 411-422.
3. Herd CR, Meserve BB. A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia. Journal of Manual & Manipulative Therapy. 2008; 16(4): 225-237.
4. Gonzalez-Iglesisa J, et al. Multimodal management of lateral epicondylalgia in rock climbers: A prospective case series. Journal of Manipulative & Physiological Therapeutics. 2011; 34(9): 635-642.