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  

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (27/10/2022)

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

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

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 , AP= Dry Needling , Acupuncture

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

Explanation of Clinical Implications

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:	High level/high quality evidence that this should be included in treatment.
Consider:	Consistent lower level/lower quality or inconsistent evidence that this should be included in treatment.
May consider:	No clinical evidence but expert opinion and/or plausible physiological rationale that this should be included in treatment.
Consider NOT:	High level/high quality evidence that this should not be included in treatment.

Manual Therapy

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 - SR RCTs
Stage of pathology	Acute	Chronic
Clinical research evidence*	1 SR	9 SR 2 RCT
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
Stage of pathology	Acute	Chronic
Clinical research evidence*	1 SR	1 SR 6 RCT
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
Stage of pathology	Acute	Chronic
Clinical research evidence*	1 SR	2 SR 3 RCT
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

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.

Stage of pathology	Acute	Chronic
Clinical research evidence*	1 N-RCT	4 SR 4 RCT
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

*Definition of acupuncture: May include Traditional Chinese Medicine approach, or Western medical-anatomical approach for acupoint selection. AP 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 aims to restore the homeostatic balance by the insertion of fine acupuncture needles that influences the flow of Qi (pronouced as chee).Conventional acupuncture involves the use of single-use, pre-sterilised disposable needles of varying widths, lengths and materials that pierce the skin at the acupuncture points. Trigger point acupuncture may also be used to facilitate relaxation in specific muscles following traumas, for longer-term unresolved muscle pain, or as a means of increasing muscle length in order to aid stretch and rehabilitation.

Stage of pathology	Acute	Chronic
Clinical research evidence*	1 SR	3 SRs 1 RCT
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

Low Level Laser Therapy (LLLT)

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.

Stage of pathology	Acute	Chronic
Clinical research evidence*	3 RCT	8 SR 3 RCT
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)

Ultrasound (US)

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.

Stage of pathology	Acute	Chronic
Clinical research evidence*	2 RCT	6 SR 8 RCT
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 (SWT)*: Focused and Radial

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.

Stage of pathology	Acute	Chronic
Clinical research evidence*	2 RCT	5 SR 2 RCT 1 other
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.

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

Iontophoresis Using Dexamethasone

Stage of pathology	Acute	Chronic
Clinical research evidence*	1 RCT	1 SR
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

Iontophoresis Using NSAID or Lidocaine

Stage of pathology	Acute	Chronic
Clinical research evidence*	• 2 comparative studies • 1 experimental study	---
Published expert opinion	---	Yes
Take home message	There is a small amount of weak evidence to support the delivery of NSAID (Diclofenac, Salicylate, Naproxen) or local analgesic (Lidocaine) by means of iontophoresis for LET. Studies demonstrate short term benefit in pain management, which may be beneficial in early stages of treatment. No long term benefit is proven. Studies generally are designed with other concurrent treatment, so that the effects of iontophoresis of these drugs are inconclusive. In addition, studies of iontophoresis using NSAID involved a high number of treatments.	The studies using iontophoresis to deliver NSAID or Lidocaine do not adequately differentiate acute versus chronic conditions of LET. The physiological rationale for using NSAID may be applicable in the acute phase, but inflammatory cells are not considered part of the pathology in chronic LET.
Clinical implication	May consider a trial of iontophoresis with NSAIDs or Lidocaine for short term pain control for acute LET. Physician prescription required. Gel forms of NSAIDS should not be used for iontophoresis.	May consider a trial of iontophoresis with NSAID’s or Lidocaine for the treatment of chronic LET for short term pain control. Physician prescription required. Gel forms of NSAIDS should not be used for iontophoresis.

Orthotic Devices

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. Orthotic Devices such as Braces, sleeves or splints are used in rehabilitation of lateral epicondyle tendinopathy.

Stage of pathology	Acute	Chronic
Clinical research evidence*	2 SR	2 SR
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

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.

Stage of pathology	Acute	Chronic
Clinical research evidence*	---	2 RCT 1 N-RCT
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.

Relevant Outcome Measures

See Appendix F for details.

Note: The following outcome measures have been selected as they are commonly reported in the literature, supported by expert clinical opinion and used extensively clinically.

Performance based impairment measures such as:

• Pain-free grip strength
• Pain with isometric wrist extension (Thomsen test)
• Pain with isometric middle finger extension (Maudsley's test)

Pain rating outcome measures such as:

• Numeric Pain Rating Scale (NPRS)
• Visual Analogue Scale (VAS)

Self-report questionnaires such as:

• The Upper Limb Functional Index (ULFI):
  • http://www.users.muohio.edu/smithdl2/images/articles/UpperLimbFunctionalIndex.pdf
• Patient Rated Tennis Elbow Evaluation (PRTEE):
  • http://www.srs-mcmaster.ca/Portals/20/pdf/research_resources/PRTEE.pdf
• QuickDASH (Disabilities of the Arm Shoulder and Hand):
  • http://www.dash.iwh.on.ca/conditions-use
• Patient Specific Functional Scale (PSFS):
  • http://www.tac.vic.gov.au/upload/Patient-specific.pdf
  • Although the PSFS has not yet been validated for lateral epicondylalgia, it has been shown to be valid, reliable and responsive to change in other conditions such as knee dysfunction, cervical radiculopathy, acute low back pain, mechanical low back pain, and neck dysfunction.

Resources

• Click to go back to the Lateral Epicondyle Tendinopathy (Tennis Elbow) Toolkit
• Click to go back to Section A: Treatment Algorithm
• Click to go back to Section B - Clinical Assessment
• Click to continue toSection C: Outcome Measures
• Click to continue to Section D: Summary of Evidence
• Click to continue to Section E: Details of Exercise Prescription
• Click to continue to Section F: Manual Therapy
• Click to continue to Section G: LASER Dosage Calculation
• Click to continue to Section H: Braces, Splints, and Taping
• UBC Lateral Epicondyle Tendinopathy
• Appendix G: Medical and Surgical Interventions
• Appendix A: Details of the Articles

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 pages doi: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.
   

Exercise

1. Croisier JL, Foidart-Dessalle M, Tinant F, Crielaard JM, Forthomme B. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. British Journal of Sports Medicine. 2007; 41(4): 269-75.
2. Luginbuhl R, Brunner F, Schneeberger AG. No effect of forearm band and extensor strengthening exercises for the treatment of tennis elbow: a prospective randomised study. La Chirurgia degli Organi di Movimento. 2008; 91(1): 35-40.
3. Martinez-Silvestrini JA, Newcomer K L, Gay RE, Schaefer MP, Kortebein P, Arendt KW. Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening. Journal of Hand Therapy. 2005. Oct-Dec; 18(4): 411-419.
4. Nilsson P, Thom E, Baigi A, Marklund B, Mansson J. A prospective pilot study of a multidisciplinary home training program for lateral epicondylosis. Musculoskeletal Care. 2007; 5(1):36-50.
5. Park JY, Park HK, Choi JH, Moon ES, Kim BS, Kim WS, Oh KS. Prospective evaluation of the effectiveness of a home-based program of isometric strengthening exercises: 12-month follow-up. (eng) Clinics in Orthopedic Surgery. ISSN: 2005-4408, Sep 2010; 2(3): 173-8.
6. Peterson M, Butler S, Eriksson M, Svardsudd K. A randomized controlled trial of exercise versus wait-list in chronic tennis elbow (lateral epicondylosis). Uppsala Journal of Medical Science. 2011; 116: 269-279.
7. Pienimaki TT, Tarvainen TK, Siira PT, Vanharanta H. Progressive strengthening and stretching exercises and ultrasound for chronic lateral epicondylosis. Physiotherapy. 1996; 82(9): 522-30.
8. Pienimaki T, Karinen P, Kemila T, Koivukangas P, Vanharanta H. Long-term follow-up of conservatively treated chronic tennis elbow patients. A prospective and retrospective analysis. Scandinavian Journal of Rehabilitation Medicine. 1998; 30: 159-166.
9. Raman J, MacDermid J, Grewal R. Effectiveness of Different Methods of Resistance Exercises in Lateral Epicondylosis—A Systematic Review. Journal of Hand Therapy. Jan-Mar 2012; 25(1): 5-26.
10. Stasinopoulos D, Stasinopoulos I. (2006) Comparison of effects of cyriax physiotherapy, a supervised exercise programme and polarized polychromatic non-coherent light (bioptron light) for the treatment of lateral epicondylosis. Clinical Rehabilitation. 20(1): 12-23.
11. Tyler T, Thomas G, Nicholas S, McHugh M. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. Journal of Shoulder and Elbow Surgery. Sep 2010; 19(6): 917-922.
12. 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 pages doi:10.1100/2012/939645

Acupuncture

1. Trinh KV, Phillips SD, Ho E, Damsma K. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology. 2004; 43: 1085-90.
2. NIH Consensus Conference. November 4. 1998. Acupuncture. NIH Consensus Development Panel on Acupuncture. Journal of the American Medical Association. 1998; 280(17): 1518-1524.
   

Low Level Laser Therapy (LLLT)

1. Bisset L, Coombes B, & Vicenzino B. Tennis elbow. Clinical Evidence. 2011; 1-35.
2. Chang W-D, Wu J-H, Yang W-J, & Jiang J-A. Therapeutic effects of low-level laser on lateral epicondylitis from differential interventions of Chinese-Western medicine: systematic review. Photomedicine and Laser Surgery. 2010; 28(3): 327-336. doi: 10.1089/pho.2009.2558
3. Tumilty S, Munn J, McDonough S, Hurley D A, Basford J R, & Baxter G D. Low level laser treatment of tendinopathy: a systematic review with meta-analysis. Photomedicine and Laser Surgery. 2010; 28(1): 3-16. doi:10.1089/pho.2008.2470
4. Bjordal J M, Lopes-Martins R A B, Joense J, Couppe C, Ljunggren A E, Stergioulas A, & Johnson M I. A systematic review with procedural assessments and meta-analysis of Low
5. Level Laser Therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskeletal Disorders. 2008; 9(75). doi:10.1186/1471-2474-9-75.
6. 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(7): 411-22.
7. Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC. Rehabilitation for Patients with Lateral Epicondylitis. Journal of Hand Therapy. 2004; 17: 243-266. doi:10.1197/j.jht.2004.02.011
8. Skorupska E, Lisinski P, & Samborski W. The effectiveness of the conservative versus myofascial pain physiotherapy in tennis elbow patients: Double-blind randomized trial of 80 patients. Journal of Musculoskeletal Pain. 2012; 20(1): 41-50. doi: 10.3109/10582452.2011.635846
9. Emanet S K, Altan L I, & Yurtkuran M. Investigation of the effect of GaAs laser therapy on lateral epicondylitis. Photomedicine and Laser Surgery. 2010; 28(3): 397-403. doi:10.1089/pho.2009.2555
10. Stasinopoulos D, Stasinopoulos I, Pantelis M, & Stasinopoulou K. Comparing the effects of exercise program and low-level laser therapy with exercise program and polarized polychromatic non-coherent light (bioptron light) on the treatment of lateral elbow tendinopathy. Photomedicine and Laser Surgery. 2009; 27(3): 513-520. doi: 10.1089/pho.2008.2281
11. Oken O, Kahraman Y, Ayhan F, Canpolat S, Yorgancioglu Z R, & Oken O F. The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: A prospective, randomized, controlled trial. Journal of Hand Therapy. 2008; 21(1): 63-68. doi:10.1197/j.jht.2007.09.003
12. Lam L K Y, & Cheing G L. Effects of 904-nm low-level laser therapy in the management of lateral epicondylitis: a randomized controlled trial. Photomedicine and Laser Surgery. 2007; 25(2): 65-71. doi:10.1089/pho.2006.2047
13. Stergioulas A. Effects of low-level laser and plyometric exercises in the treatment of lateral epicondylitis. Photomedicine and Laser Surgery. 2007; 25(3): 205-213. doi:10.1089/pho.2007.2041
14. Basford J R, Sheffield C G, & Cieslak K R. Laser therapy: a randomized, controlled trial of the effects of low intensity Nd:YAG laser irradiation on lateral epicondylitis. Archives of Physical Medicine & Rehabilitation. 2000; 81(11): 1504-1510. doi:10.1053/apmr.2000.17812

Ultrasound (US)

1. Gunduz R, Malas F U, Borman P, Kocaoglu S, & Ozcakar L. Physical therapy, corticosteroid injection, and extracorporeal shock wave treatment in lateral epicondylitis. Clinical and ultrasonographical comparison. Clinical Rheumatology. 2012; 31(5): 807-812. doi:10.1007/s10067-012-1939-y
2. Skorupska E, Lisinski P, & Samborski W. The effectiveness of the conservative versus myofascial pain physiotherapy in tennis elbow patients: Double-blind randomized trial of 80 patients. Journal of Musculoskeletal Pain. 2012; 20(1): 41-50. doi: 10.3109/10582452.2011.635846
3. Akin C, Oken O, & Fusun Koseoglu B. Short-term effectiveness of ultrasound treatment in patients with lateral epicondylitis: Randomized, single-blind, placebo-controlled, prospective study. [Turkish]
4. Lateral epikondilitli hastalarda ultrason tedavisinin ki{dotless}sa donem etkinligi: Randomize, tek kor plasebo kontrollu, prospektif callsma. Turkish Journal of Rheumatology. 2010; 25(2): 50-55.doi:10.5152/tjr.2010.01
5. Oken O, Kahraman Y, Ayhan F, Canpolat S, Yorgancioglu Z R, & Oken O F. The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: A prospective, randomized, controlled trial. Journal of Hand Therapy. 2008; 21(1): 63-68. doi:10.1197/j.jht.2007.09.003
6. Struijs P A, Damen P J, Bakker E W, Blankevoort L, Assendelft W J, & van Dijk C N. Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study. Physical Therapy. 2003; 83(7): 608-616.
7. Kochar M, & Dogra A. Effectiveness of a specific physiotherapy regimen on patients with tennis elbow: Clinical study. Physiotherapy. 2002; 88(6): 333-341.
8. Stratford PW, Levy DR, Gauldie S, Miseferi D, Levy K. The evaluation of phonophoresis and friction massage as treatments for extensor carpi radialis tendinitis: a randomized controlled trial. Physiotherapy Canada. 1989; (41): 93-9.
9. Lundeberg T, Abrahamsson P, & Haker E. A comparative study of continuous ultrasound, placebo ultrasound and rest in epicondylalgia. Scandinavian Journal of Rehabilitation Medicine. 1988.
10. Binder A, Hodge G, Greenwood A M, Hazleman B L, & Thomas D P Page. Is therapeutic ultrasound effective in treating soft tissue lesions? British Medical Journal. 1985.
11. Ruane H, Hay L, & Callaghan M. Best Evidence Topic report. BET 2. Is electrotherapy useful for tennis elbow? Emergency Medicine Journal. 2010; 27(2): 142-144.
12. Nimgade A, Sullivan M, & Goldman R. Physiotherapy, steroid injections, or rest for lateral epicondylosis? What the evidence suggests. Pain Practice. 2005; 5(3): 203-215.
13. 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(7): 411-22. doi: 10.1136/bjsm.2004.016170
14. Boisaubert B, Brousse C, Zaoui A, & Montigny J P. Nonsurgical treatment of tennis elbow. [French]
15. Les traitements non chirurgicaux de la tendinopathie des epicondyliens. Annales de Readaptation et de Medecine Physique. 2004; 47(6): 346-355. doi:10.1016/j.annrmp.2004.05.002
16. Trudel D, Duley J, Zastrow I, Kerr E W, Davidson R, & MacDermid J C. Rehabilitation for patients with lateral epicondylitis: a systematic review. Journal of Hand Therapy. 2004; 17(2): 243-266. doi:10.1197/j.jht.2004.02.011
17. Smidt N, Assendelft W J J, Arola H, Malmivaara A, Greens S, Buchbinder R, et al. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Annals of Medicine. 2003; 35(1): 51-62.

Extracorporeal Shock Wave Therapy (ESWT)

1. Haake M, Konig I, Decker T, et al. Extra-corporeal shock wave therapy in the treatment of lateral epicondylitis: a randomized multicenter trial. Journal of Bone and Joint Surgery (Am). 2002; 84-A(11): 1982-91.
2. Speed N, Nichols D, Richards C, et al. Extra-corporeal shock wave therapy for lateral epicondylitis: a double-blind randomized controlled trial. Journal of Orthopedic Research. 2002; 20: 895-8.
3. Crowther M, Bannister G, Huma H, Rooker G. A prospective, randomized study to compare extra-corporeal shock wave therapy and injection of steroid for the treatment of tennis elbow. Journal of Bone and Joint Surgery (Br). 2002; 84-B: 678-79.
4. Chung B, Wiley JP. Effectiveness of extra-corporeal shock wave therapy in the treatment of previously untreated lateral epicondylitis: a randomized controlled trial. American Journal of Sports Medicine. 2004; 32(7): 1660-7.
5. Rompe J, Decking J. Schoeliner S, Thies C. Repetitive low-energy shock wave therapy for treatment of chronic lateral epicondylitis in tennis layers. American Journal of Sports Medicine. 2004; 32(3): 734-43.
6. Pettrone F, McCall B. Extra-corporeal shock wave therapy without local anesthetic for chronic lateral epicondylitis. Journal of Bone and Joint Surgery (Am). 2005; 87A(6): 1297-1304.
7. Spacca G, Necozine S, Cacchio A. Radial shock wave therapy for lateral epicondylitis: a prospective randomized controlled single-blind study. European Journal of Physical and Rehabilitation Medicine. 2005; 42(1): 17-25.
8. Stasinopoulos D, Johnson M. Effectiveness of extra-corporeal shock wave therapy for tennis elbow (lateral epicondylitis). British Journal of Sports Medicine. 2005; 39(3): 132-6.
9. Buchbinder R, Green S, Youd J, et al. Systematic review of the efficiency and safety of shock wave therapy for lateral elbow pain. Journal of Rheumatology. 2006; 33(7): 1351-63.
10. Rompe J, Muffulli N. Repetitive shock wave therapy for lateral elbow tendinopathy (tennis elbow): a systematic and qualitative analysis. British Medical Bulletin. 2007; 83(1): 355-78.
11. Staples M, Forbes A, Ptasznik R, Gordon J, Buchbinder R. A randomized controlled trial of extracorporeal shock wave therapy for lateral epicondylitis (tennis elbow). Journal of Rheumatology. 2008. 31(10): 2038-46.
12. Ozturan K, Yucell I, Cakici H, Guven M, Sungur I. Autologous blood and corticosteroid injection and extracorporeal shock wave therapy in the treatment of lateral epicondylitis. Orthopedics. 2010; 33: 84-91.
    

Iontophoresis Using Dexamethasone

1. Runeson L, Haker E. Iontophoresis with cortisone for the treatment of lateral epicondylagia (tennis elbow). Scandinavian Journal of Medicine and Science in Sports. 2002; 12: 136-42.
2. Nirschl R, Rodin D, Ochiai D, Martmann-Moe C. Iontophoretic administration of Dexamethasone for acute epicondlyitits: a randomized double-blinded placebo controlled study. American Journal of Sports Medicine. 2003; 31: 915-20.
3. Sefanou A, Marshall N, Holdon W, Siddiqui A. A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epiconylitis. Journal of Hand Surgery. 2012; 37(1): 104-9.

Iontophoresis Using NSAID or Lidocaine

1. Demirtas R, Oner C. Treatment of lateral epicondylitis by ionotophoresis of sodium salicylate and sodium diclofenac. Clinical Rehabilitation. 1998; 12: 23-29.
2. Baskurt F, Ozcan A, Algun C. Comparison of effects of phonophoresis and iontophoresis of naproxen in treatment of lateral epicondylitis. Clinical Rehabilitation. 2003; 17: 96- 100.
3. Yarrobino T, Kalbfleisch J, et al. Lidocaine ion mediates analgesia in lateral epicondylalgia treatment. Physiotherapy Research International. 2006; 11(3): 152-160.

Orthotic Devices

1. Struijs PA, Smidt N, Arola H, Dijk CN, Buchbinder R, Assendelft WJ. Orthotic devices for the treatment of tennis elbow. Cochrane Database of Systematic Reviews. (1):CD001821, 2002.
2. Buchbinder R, Green SE, Struijs P. Tennis elbow. Clinical Evidence (Online). 2011; pii: 1117.
3. Dwars BJ, de Feiter P, Patka P, Haarman HJ. Functional treatment of tennis elbow. A comparative study between an elbow support and physical therapy. Sports, Medicine and Health; Proceedings of the XXIV World Congress of Sports Medicine. 1990; 237-41.
4. Holdsworth LK, Anderson DM. Effectiveness of ultrasound used with a hydrocortisone coupling medium or epicondylitis clasp to treat lateral epicondylitis: Pilot study. Physiotherapy 1993;79:19-25.
5. Erturk H, Celiker R, Sivri A, Cetin A, Cindas A. The efficacy of different treatment regiments that are commonly used in tennis elbow. Journal of Rheumatology and Medical Rehabilitation. 1997; 8:298-301.
6. Burton AK. A comparative trial of forearm strap and topical anti-inflammatory as adjuncts to manipulative therapy in tennis elbow. Manual Medicine. 1988; 3(4): 141-3.
7. Struijs PA, Kerkhoffs GM, Assendelft WJ, Van Dijk CN. Conservative treatment of lateral epicondylitis: brace versus physical therapy or a combination of both-a randomized clinical trial. American Journal of Sports Medicine. Mar 2004; 32(2): 462-9.
8. Garg R, Adamson GJ, Dawson PA, Shankwiler JA, Pink MM. A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis. Journal of Shoulder & Elbow Surgery. Jun 2010; 19(4): 508-12.
9. Altan L, Kanat E. Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices. Clinical Rheumatology. Aug 2008; 27(8): 1015-9.
10. Van De Streek MD, Van Der Schans CP, De Greef MH, Postema K. The effect of a forearm/hand splint compared with an elbow band as a treatment for lateral epicondylitis. Prosthetics & Orthotics International. Aug 2004; 28(2): 183-9.
11. Faes M, van den Akker B, de Lint JA, Kooloos JG, Hopman MT. Dynamic extensor brace for lateral epicondylitis. Archives of Physical Medicine and Rehabilitation. Jul 1998; 79(7): 832-7.
12. Oken O , Kahraman Y, Ayhan F, Canpolat S, Yorgancioglu ZR, Oken OF. The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: a prospective, randomized, controlled trial. Clinical Orthopedics and Related Research. Jan 2006; 442:149-57.
13. Haker E, Lundeberg T. Elbow-band, splintage and steroids in lateral epicondylalgia (tennis elbow). Pain Clinics. 1993; 6:103-112.

Taping

1. Vicenzino B, Brooksbank J, Minto J, Offord S, Paungmali A. Initial effects of elbow taping on pain-free grip strength and pressure pain threshold. Journal of Orthopaedic & Sports Physical Therapy. Jul 2003; 33(7): 400-7.
2. A Shamsoddini, MT Hollisaz. Initial effect of taping technique on wrist extension and grip strength and pain of Individuals with lateral epicondylitis. Iranian Rehabilitation Journal. 2010; 8(11).