Jospt 2022 0302
Jospt 2022 0302
Jospt 2022 0302
ANN M. LUCADO, PT, PhD, CHT • JOSEPH M. DAY, PT, PhD, OCS • JOSHUA I. VINCENT, PT, PhD
JOY C. MACDERMID, PT, PhD, CHT • JANE FEDORCZYK, PT, PhD, CHT
RUBY GREWAL, MD • ROBROY L. MARTIN, PT, PhD
REVIEWERS: John DeWitt, PT, DPT, AT • Steve Paulseth, PT, DPT, SCS, ATC • James A. Dauber, DPT, DSc
Mike Szekeres, PhD, OT Reg (Ontario), CHT • Paul F. Beattie, PhD, PT, OCS, FAPTA, NREMT
For author, coordinator, contributor, and reviewer affiliations, see end of text. ©2022 Academy of Orthopaedic Physical Therapy, Academy of Hand and Upper Extremity
Physical Therapy, American Physical Therapy Association (APTA), Inc, and JOSPT®, Inc. The Academy of Orthopaedic Physical Therapy, Academy of Hand and Upper
Extremity Physical Therapy, APTA, Inc, and JOSPT®, Inc consent to reproducing and distributing this guideline for educational purposes. Address correspondence to Clinical
Practice Guidelines Managing Editor, Academy of Orthopaedic Physical Therapy, APTA, Inc, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: cpg@orthopt.org
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
Summary of Recommendations*
OUTCOME, ACTIVITY LIMITATIONS, free grip strength in individuals with LET, as a stand-alone or ad-
SELF-REPORT MEASURES junctive treatment in improving short-term outcomes for those
Clinicians should use the diagnosis-specific Patient-Rated who can tolerate the specific technique.
A
Tennis Elbow Evaluation (PRTEE) to assess pain/irritability
C Clinicians may use manipulation or mobilization techniques
and function and/or the region-specific Disabilities of the Arm,
directed at the cervical spine, thoracic spine, and/or wrist as
Shoulder and Hand (DASH) to assess upper extremity function at
an adjunct to local treatment for short-term pain relief in individuals
baseline and at least one other follow-up point that includes dis-
with LET when impairments in those regions are identified.
charge for individuals with lateral elbow tendinopathy (LET).
A Clinicians should use the Patient-Specific Functional Scale INTERVENTIONS: MANUAL THERAPY
(PSFS) for patients with high-demand activities and/or should SOFT TISSUE MOBILIZATION
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administer a scale that assesses activity-specific disability (eg, DASH Clinicians may use soft tissue mobilizations, including
work or sports/performing arts module) at baseline and at least one C
manual release therapy, to improve pain and function in
other follow-up point that includes discharge for individuals with LET. individuals with chronic LET.
PHYSICAL IMPAIRMENT MEASURES C Clinicians may use instrument-assisted soft tissue mobili-
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Clinicians should include the physical impairment mea- zation combined with exercise to improve pain and func-
B tion in those with chronic LET.
sures of elbow and wrist range of motion, pressure pain
threshold, pain-free grip strength, and maximum grip strength at Based on conflicting evidence, a recommendation cannot be
baseline and at least one other follow-up point that includes dis- D
made regarding the use of deep transverse tendon cross-fric-
charge for individuals with LET. tion massage to alleviate symptoms in individuals with LET.
cpg2 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
INTERVENTIONS: PHONOPHORESIS
INTEREVENTIONS: ERGONOMICS
C Clinicians should not use phonophoresis with 10% hydro-
E Clinicians may use ergonomic interventions in the man-
cortisone gel, topical prednisolone (2 mg/d), or 1% di-
agement of symptoms in individuals with LET; the imple-
clofenac sodium gel for the treatment of LET.
mentation of education, behavioral modification, ergonomic
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
List of Abbreviations
Journal of Orthopaedic & Sports Physical Therapy®
AHUEPT: Academy of Hand and Upper Extremity LILT: low-intensity laser therapy
Physical Therapy MCID: minimal clinically important difference
APTA: American Physical Therapy Association MD: mean difference
ANOVA: analysis of variance MDC: minimal detectable change
AOPT: Academy of Orthopaedic Physical Therapy MEPI: Mayo Elbow Performance Index
CI: confidence interval MRI: magnetic resonance imaging
CPG: clinical practice guideline MRT: manual release therapy
DASH: Disabilities of the Arm, Shoulder and Hand MVIC: maximum voluntary isometric contraction
DFM: deep friction massage MWM: mobilization with movement
ECRB: extensor carpi radialis brevis NPRS: numeric pain-rating scale
ES: effect size OR: odds ratio
GCS: Global Change Scale PE: percutaneous electrolysis
GROC: Global Rating of Change PFGS: pain-free grip strength
HADS: Hospital Anxiety & Depression Scale PPT: pressure pain threshold
HILT: high-intensity laser therapy PRFEQ: Patient-Rated Forearm Evaluation Questionnaire
ICC: intraclass correlation coefficient PROM: patient-reported outcome measure
ICD: International Classification of Diseases PRTEE: Patient-Rated Tennis Elbow Evaluation
ICF: International Classification of Functioning, Disability PRWE: Patient-Rated Wrist Evaluation
and Health PSFS: Patient Specific Functional Scale
JOSPT: Journal of Orthopaedic & Sports Physical Therapy RCT: randomized clinical trial
LET: lateral elbow tendinopathy RM: Score: Roles and Maudsley Score
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg3
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
Introduction
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practice guidelines for management of patients with mus- and technology advance and patterns of care evolve. These
culoskeletal impairments described in the World Health parameters of practice should be considered guidelines only.
Organization’s International Classification of Functioning, Adherence to them will not ensure a successful outcome in
Disability and Health (ICF).204 every patient, nor should they be construed as including all
proper methods of care or excluding other acceptable meth-
The purposes of these clinical guidelines are to: ods of care aimed at the same results. The ultimate judgment
• Describe evidence-based practice including diagnosis, regarding a particular clinical procedure or treatment plan
prognosis, intervention, and assessment of outcomes of must be made in light of the clinical data presented by the
musculoskeletal disorders commonly managed by ortho- patient, the diagnostic and treatment options available, and
Journal of Orthopaedic & Sports Physical Therapy®
paedic, sports, and hand physical therapists the patient’s values, expectations, and preferences. However,
• Classify and define common musculoskeletal conditions we suggest that significant departures from accepted guide-
using the World Health Organization’s terminology relat- lines should be documented in the patient’s medical records
ed to impairments of body function and body structure, at the time the relevant clinical decision is made.
activity limitations, and participation restrictions
• Identify interventions supported by current best evidence SCOPE AND RATIONALE OF THE GUIDELINE
to address impairments of body function and structure, ac- Lateral elbow tendinopathy (LET) is characterized by pain at
tivity limitations, and participation restrictions associated the common wrist extensors at or near the lateral epicondyle
with common musculoskeletal conditions that is aggravated by loading of the involved muscles.13 The
• Identify appropriate outcome measures to assess changes extensor carpi radialis brevis (ECRB) and extensor digitorum
resulting from physical therapy interventions in body func- muscles are the most frequently injured,16 while the pain is be-
tion and structure as well as in activity and participation of lieved to originate from excessive tensile force on the injured
the individual musculotendinous structures and periosteal junction. Lateral
• Provide a description to policy makers, using internation- elbow tendinopathy is commonly known as tennis elbow, yet
ally accepted terminology, of the practice of orthopaedic, despite the name, many individuals who present with symp-
sports, and hand physical therapists toms of LET are not involved in racquet sports.193 Athletes
• Provide information for payers and claims reviewers re- of all types and individuals who repetitively use their upper
garding the practice of orthopaedic, sports, and hand ther- extremity (UE), particularly involving their wrist extensors,
apy for common musculoskeletal conditions can be at risk for developing LET. Although many describe
• Create a reference publication for clinicians, academic the condition as self-limiting and likely to resolve on its own,
instructors, clinical instructors, students, interns, res- high recurrence rates and extended sick leave highlight the
idents, and fellows regarding the best current practice challenge for the nonsurgical management of individuals
of orthopaedic and sports physical therapy and hand with LET.14,22 Therefore, there is a need to assemble a com-
rehabilitation prehensive set of guidelines for assessing and treating LET.
cpg4 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
As the understanding of the histology underpinning the ten- factors, clinical course, prognosis, differential diagnosis, tests
don pathology associated with LET has evolved, clinicians are and measures, and interventions are included. This CPG ex-
beginning to recognize the complexity of the diagnosis. The cluded studies that addressed pathologies closely related to
interrelationship of histological and structural changes to the LET. For example, cervical radiculopathy, primary peripheral
tendon itself, the associated impairments in motor control, nerve entrapment, and joint pathology including plica syn-
and potential changes in pain processing can all contribute drome, radiocapitellar chondromalacia, and posterolateral
to the presentation of symptoms in any given individual.36,59 rotatory instability as causes of lateral elbow pain were ex-
cluded. Finally, this CPG excluded interventions outside the
This clinical practice guideline (CPG) includes studies re- scope of physical therapist practice including but not limited
porting on LET pertinent to physical therapist practice. Ep- to pharmacological and surgical interventions unless directly
idemiology, functional anatomy and pathophysiology, risk compared to physical therapy management.
Methods
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The AHUEPT and the AOPT of the APTA appointed content provided the final decision for discrepancies that were not
experts to develop CPGs for musculoskeletal conditions of resolved by the review team (see APPENDIX C for the flowchart
elbow, forearm, wrist, and hand. The aims of this review were of articles, available at www.jospt.org). Data extraction and
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
to provide a concise summary of the contemporary evidence assignment of level of evidence was also performed and were
and to develop recommendations to support evidence-based confirmed by members of the CPG development team. For
practice. The authors of this guideline worked with the CPG selected relevant topics for which recommendations were
editors and medical librarians for methodological guidance. not developed, which included incidence, risk factors, differ-
One author (R.L.M.) served as the team’s methodologist. ential diagnosis, imaging, and prognosis, articles were not
Research librarians were chosen for their expertise in sys- subject to systematic review process and were not included
tematic review and rehabilitation literature searching and in the flowchart. Evidence tables for this CPG are available
to perform systematic searches for concepts associated with on the CPG page of the AOPT of the APTA websites: www.
classification, examination, and intervention strategies for orthopt.org and www.handpt.org.
Journal of Orthopaedic & Sports Physical Therapy®
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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
Tool Strategy
JOSPT’s “Perspectives for Patients” and “Perspectives for Practice” articles Patient- and clinician-oriented guideline summaries available at www.jospt.org
Mobile app of guideline-based exercises for patients/clients and health care practitioners Marketing and distribution of app via www.orthopt.org and www.handpt.org
Clinician’s Quick-Reference Guide Summary of guideline recommendations available at www.orthopt.org and www.
handpt.org
JOSPT’s Read for CreditSM continuing education units Continuing education units available for physical therapists at www.jospt.org
Webinars and educational offerings for health care practitioners Guideline-based instruction available for practitioners at www.orthopt.org and www.
handpt.org
Mobile and web-based app of guideline for training of health care practitioners Marketing and distribution of app via www.orthopt.org
Non-English versions of the guidelines and guideline implementation tools Development and distribution of translated guidelines and tools to JOSPT’s international
partners and global audience via www.jospt.org
APTA CPG+ Dissemination and implementation aids
Abbreviations: APTA, American Physical Therapy Association; CPG, clinical practice guideline.
cpg6 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
d4300 Lifting
which a systematic review was conducted and recommenda-
d440 Fine hand use
tions provided include patient-reported outcome measures d4400 Picking up
(PROMs), physical impairment measures, and interventions. d4454 Throwing
For other topics where a systematic review was outside the Participation Restrictions
scope of this CPG, a summary of the literature is provided. d920 Recreation and leisure
This includes incidence/prevalence, pathoanatomical fea- d9201 Sports
tures, risk factors, clinical course, prognosis, diagnostic clas- d840-d859 Work and employment
d850 Remunerative employment
sification, and differential diagnosis, and imaging.
d8500 Self-employment
d8501 Part-time employment
CLASSIFICATION d8502 Full-time employment
The primary International Classification of Diseases 10th d855 Nonremunerative employment
Revision (ICD-10) codes and conditions associated with lat- Abbreviations: ICD, International Classification of Diseases; ICF,
eral elbow pain and muscle function impairments (LET) are International Classification of Functioning, Disability and Health.
outlined in TABLE 4.
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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
Impairment/Function-Based Diagnosis
PREVALENCE/INCIDENCE leave from work is taken in approximately 30% of those in-
A large population-based study suggested an overall annual dividuals with LET.13,17 Additionally, incomplete resolution
incidence of LET in the United States of 3%, although the or recurrence of symptoms at 6-12 months in individuals
rates for those 40-60 years old were higher, ranging between receiving local nonsurgical management has been shown to
7% and 10%.158 The prevalence of LET has been reported to range between 20% and 38%.16 At 2 years follow-up, the rate
be as high as 29% in workers in occupations that required of recurrence has been shown to be as high as 54%.134 In
a high demand of wrist and hand movements.170,198 A 2015 tennis players, the 2-month prevalence has been reported
systematic review of UE work-related musculoskeletal dis- at 14%, with recurrent cases being more common than new
orders reports LET incidence ranges from 0.45 to 7 new cases, and rates increasing in players over 40 years of age.65
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cases per 100 workers and prevalence ranges from 1 to 12.2 A twin study estimated that heritability was 40%, after ad-
new cases per 100 workers.40 An average of 12 weeks of sick justing for age.197
Pathoanatomical Features
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
The lateral epicondyle of the humerus, located just above by tendinopathy from other sources of symptoms such as
the capitellum, is the origin of the extensor-supinator mus- muscle, joint, or nerve pathology.
cles.126,130 The most common site of pathology in LET is the
juncture of the common extensor muscle origin of the lateral There has been a shift in understanding of tendon pathology
epicondyle.99 The enthesis or insertion of the common ex- over the past 20 years. Tendinopathy refers to a nonrupture
Journal of Orthopaedic & Sports Physical Therapy®
tensor tendon is characterized by a load sharing mechanism injury in the tendon or peritendon (paratenon and epitenon)
where fibers of the ECRB tendon fuses with the lateral collat- that is aggravated by mechanical loading.62 The term tendini-
eral ligament of the elbow and joint capsule and subsequent- tis characterizes an acute condition with a cell-mediated in-
ly with the annular ligament of the proximal radial ulnar flammatory response. Tendinosis is a term that has been used
joint.125 Stress is dissipated throughout the entire enthesis to describe chronic degenerative tendon pathology, charac-
organ and may explain the somewhat diffuse distribution of terized by an abundance of fibroblasts, vascular hyperplasia,
pain at the lateral elbow with LET.12 and unstructured collagen. Over time, clinical terminology
has changed from tendinitis or tendinosis to tendinopathy,
The common extensor tendon of the wrist and fingers at the which represents the pain and impaired muscle function re-
elbow may be injured not only by repetitive tensile loading lated to a broad spectrum of potential intratendinous changes
but also by shearing forces against the capitellum with fore- in structure, histology, and chemical mediators of pain and/
arm rotation.23 The ECRB tendon has a unique anatomic lo- or inflammation.58 In those with LET, as with other forms of
cation that makes its undersurface vulnerable to contact and tendinopathy, individuals present somewhere in the continu-
abrasion against the lateral edge of the capitellum during um between acute and chronic conditions that may fluctuate
forearm pronation and supination.275 Relative hypovascular- over an episode of care. Therefore, it is possible that low-grade
ity of the ECRB tendon may further contribute to the sus- inflammation may be intermittent and may occur for short
ceptibility of the tendon to injury and may negatively impact periods after intense tendon loading in chronic situations
healing.8,161 The extensor carpi radialis longus and extensor characterizing an acute-on-chronic condition in some cases.
digitorum tendons may also be involved. This may explain
why repetitive loading of the elbow, forearm, wrist, and/or It has been postulated that LET is acquired by irritation of
digits during work or athletic activities increases the risk of the hypovascular zone of the common extensor tendon at its
LET.48,171 However, similar biomechanical loading can poten- attachment on the lateral epicondyle, which leads to subse-
tially injure adjacent structures; therefore, a thorough exam- quent neovascularization45 that has been described as “an-
ination is required to differentiate lateral elbow pain caused giofibroblastic tendinosis.”99 Chronic LET is characterized by
cpg8 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
disorganization of collagen fibers, an increase in the number classify and subgroup individuals with LET in a single/simple
of vessels and sensory nerves, disorganized (smaller) type III classification system and may also explain why its symptoms
collagen fibers,161 and areas of hypocellularity or fibroblast are sometimes difficult to bring to full resolution. It is import-
reaction.13,162 It is important to recognize that, despite the ant to assess the intensity, irritability, and distribution of the
lack of consistent evidence relating to the presence or ab- individual’s symptoms while considering their history and their
sence of inflammatory cells locally,88 other proinflammatory required activity levels to properly manage the condition.113
chemical agents including inflammatory cytokines, growth
factors, prostaglandins, and neuropeptides have been detect- SUMMARY
ed in cases of chronic tendinopathy.62 Neurochemicals are Most pathological changes in LET occur within the common
important in the regulation of local tendon vascular supply extensor tendon origin at the lateral epicondyle, common-
but are also believed to contribute to neurogenic inflamma- ly within the fibers associated with the ECRB muscle. It is
tion. More recent evidence also points to altered nociceptive known that structural, cellular, and chemical alterations in
processing as a contributor to persistent pain associated with the tendon can all exist with tendinopathy, but do not nec-
LET.15,37 Preliminary evidence highlights the association of essarily correspond with the severity of clinical presentation.
nervous system sensitization in patients with chronic ten- Clinicians should recognize that histological confirmation of
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dinopathy.147 It is important to appreciate the hypothesized the underlying pathophysiology in LET for any patient is not
underlying tissue pathology in the context of the complex realistic in practice settings. Therefore, the acuity, irritability,
processes related to the neuromodulation of pain, both pe- and the severity of LET symptoms at any given time should
ripherally and centrally.59 guide management of this condition. In chronic cases of LET,
intense loading of the tendon with activity may result in low
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
The complex underlying pathophysiologic mechanisms asso- grades of inflammation creating an acute aggravation of a
ciated with LET may explain why it is difficult to accurately chronic condition.
Risk Factors
Journal of Orthopaedic & Sports Physical Therapy®
For this CPG, the term risk will be reserved specifically for hours/day) (men OR = 5.6; 95% CI: 2.8, 11.3 and women OR
risk factors for new onset of LET, whereas prognosis (dis- = 2.9; 95% CI: 1.3, 6.5) was found to be significant risk factors
cussed later) will refer to the predicted course of the condi- for LET.78 In a population-based study, significant associa-
tion after onset. A systematic review of 5 prospective cohort tions between LET and repetitive movements of the hand or
studies found a significant association between combined wrist for at least 2 hours/day for those with 9 to 19 years ex-
biomechanical exposure involving the wrist and elbow and posure (OR = 2.4; 95% CI: 1.2, 4.9) and for 20 or more years
incidence of LET (pooled odds ratio [OR] = 2.6; 95% CI: of exposure (OR = 2.8; 95% CI: 1.4, 5.8) were identified.171
1.9, 3.5).47 A case-control study that included the general
population with a diagnosis of LET reported a higher risk Park et al,141 in their case-control study that included 937 par-
for women for handling tools >1 kg (women OR = 3.0; 95% ticipants from a rural agricultural setting, found significant
CI: 1.6, 5.5; men OR = 2.1; 95% CI: 1.1, 3.8).68 Shiri et al,171 in associations between LET and dominant-side involvement
their cross-sectional cohort study, found a significant associ- (OR = 3.21; 95% CI: 2.24, 4.60), female sex (OR = 2.47; 95%
ation between LET and jobs that involve handling loads >20 CI: 1.78, 3.43), manual labor (OR = 2.25; 95% CI: 1.48, 3.43),
kg at least 10 times/day for more than 20 years in a cohort and ipsilateral rotator cuff tear (OR = 2.77; 95% CI: 1.96,
of working population from a national registry (OR = 2.6; 3.91).141 Another study that included 1824 workers found a
95% CI: 1.3, 5.1). significant association between cardiovascular disease and
LET symptoms (OR = 3.81; 95% CI: 2.11, 6.85), positive ex-
After adjusting for age, lack of social support, and obesity in amination findings for LET (OR = 2.85; 95% CI: 1.59, 5.12),
a cohort of more than 1000 newly employed workers without and combined symptoms and physical examination (OR =
symptoms of LET, those who reported wrist bending/twist- 6.20; 95% CI: 2.04, 18.82).76
ing and forearm twisting/rotating/screwing motion were at
elevated risk of developing LET.48 Hard perceived physical In a case-control study183 of 4998 patients with LET matched
exertion combined with elbow flexion/extension (>2 hours/ by age/sex from general practice settings, a multivariate
day) (men OR = 2.6; 95% CI: 1.9, 3.7) and wrist bending (>2 analysis identified significant association between LET and
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg9
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
rotator cuff pathology (OR = 4.95; 95% CI: 3.64, 6.71), De SUMMARY
Quervain’s disease (OR = 2.48; 95% CI: 1.14, 5.37), carpal Female sex, dominant-side involvement, previous smoking
tunnel syndrome (OR = 1.50; 95% CI: 1.14, 1.98), oral corti- history, rotator cuff injuries, De Quervain’s disease, carpal
costeroid therapy (OR = 1.68; 95% CI: 1.47, 1.92), and pre- tunnel syndrome, and oral corticosteroid therapy use rep-
vious smoking history (OR = 1.20; 95% CI: 1.06, 1.36). In resent nonmodifiable risk factors for LET. Modifiable risk
addition, diabetes mellitus, current smoking, trigger finger, factors for LET include low job control, low social support,
rheumatoid arthritis, alcohol intake, and obesity were deter- handling heavy tools greater than 20 kg, repetitive elbow/
mined not to be associated with LET.183 An earlier systematic wrist flexion/extension for more than 2 hours a day, and
review190 of 13 studies identified associations between LET repetitive forearm twisting/rotating/screwing movements.
and the psychosocial risk factors of low control over work Diabetes, trigger finger, rheumatoid arthritis, alcohol in-
duties (OR = 2.2; 95% CI: 1.4, 3.2) and low social support take, and obesity were not associated with the incidence
(OR = 1.8; 95% CI: 1.2, 2.7).190 of LET.
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Clinical Course
Lateral elbow tendinopathy can be a source of lasting pain About 1 in 10 patients with persistent symptoms at 6 months
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
and disability for many individuals. The clinical course of were treated with surgery.158
LET depends heavily on the extent to which individuals are
exposed to repetitive irritation of the involved structures. The course of the tendinopathy is important to consider as a
While some experience full and expedient resolution of descriptive element as this can range from a single isolated
symptoms with nonsurgical care, more than half of patients initial episode to a re-occurrence, to an episodic condition, or
seeking general medical care continue to report symptoms it may be persistent. In persistent chronic LET, exacerbations
after 1 year.14 Regardless of past treatments, up to 20% of in- are typically associated with an activity that in some cases
dividuals report persistent pain for 3-5 years after care.35 Ex- may be predicted based on the amount and nature of the
posure to various occupational or sports-specific stresses, as activity. Determining level of irritability by using pain level,
Journal of Orthopaedic & Sports Physical Therapy®
in tennis, may negatively impact prognosis and can result in distribution of pain, and level of disability can be useful in
lost work time due to injury.198 Up to 55% of individuals with directing treatment.
LET have been shown to have lingering pain and functional
loss for more than 2 years after the onset of symptoms.133 SUMMARY
Therefore, LET may not always follow the typical course and Although many believe the condition to be benign, LET can
time frames of the normal healing process. By the time an be debilitating for some individuals, resulting in an inability
individual seeks medical care, the inflammatory process has to fully perform their job, household tasks, or athletic in-
often resolved, yet symptoms remain. terests. Nonsurgical interventions are the mainstay of LET
management. While some individuals can fully and quickly
The age- and sex-adjusted annual incidence of LET in the recover, many experience persistent pain or recurrence of
general population has decreased significantly over time symptoms, contributing to a poor prognosis regarding pro-
from 4.5/1000 people in 2000 to 2.4/1000 in 2012.158 On longed discomfort. Protection from repetitive irritation may
the other hand, the proportion of surgically treated cases has help minimize or eliminate exacerbations or recurrence of
tripled (1.1% in 2000-2002 to 3.2% from 2009 to 2011).158 symptoms.
cpg10 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
Prognosis
Prognosis refers to the predicted course of LET after its self-stretching and use of a counterforce brace.153 Increased
onset. Some factors may assist the clinician in predicting patient-reported disability on the DASH at 6 months was
short-term physical therapy treatment outcome, as well as associated with initial lower pain thresholds to pressure (β =
the eventual long-term outcome of LET management. −1.28; 95% CI: −1.79, −0.78), initial higher (increased) pain
sensitivity (Pain Sensitivity Questionnaire) scores (β = 1.69;
Analysis of data from a randomized control trial (RCT) with 95% CI: 0.92, 2.49), and involvement in a manual labor job
62 subjects (mean age = 48.2 years) undergoing physical (β = 1.12; 95% CI: 0.84, 1.41). These 3 factors accounted for
therapy that consisted of 5 treatment sessions of mobilization 36% of the variance in 6-month DASH scores.153
with movement (MWM) and exercise, found several factors
at baseline associated with improved outcomes.195 Age <49 Analysis from an RCT of 266 subjects (163 were >40 years of
years, pain-free grip strength (PFGS) >112 N on the affected age; 144 females, 122 males) found that the primary factor
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side, and PFGS <336 N on the unaffected side predicted a associated with pain reduction less than 50% at 1-year fol-
self-report of symptoms being improved at 3 weeks (P<.01, low-up was LET on the dominant side (OR = 3.1; 95% CI:
Nagelkerke’s R2 = 0.45). The probability of improvement was 1.4, 6.8). Age, being greater or less than 40 years of age, and
87%, 93%, and 100% if one, two, or three of the indicators sex were not significant prognostic factors.67 Similarly, Hol-
were present, respectively.195 medal et al81 also found when looking at 177 subjects (mean
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
0.34, 0.66), sex (female) (β = 8.92; 95% CI: 3.3, 14.5), and care setting. These authors noted a combination of 20 prog-
self-reported nerve symptoms (β = 7.32; 95% CI: 0.8, 13.8). nostic variables, including the covariates country and treat-
Predictors for higher pain visual analog scale (VAS) scores ment, contributed to only 12% of the variance in predicting
(r2 = 0.31, P = .0003) included baseline pain VAS (β = .19; pain intensity at 12-month follow-up.205
95% CI: 0.01, 0.37), sex (female) (β = 9.26; 95% CI: 0.4,
18.2), and self-reported nerve symptoms (β = 15.08; 95% SUMMARY
CI: 4.7, 25.5). Age, duration of symptoms, elbow joint signs, When looking at the effect of physical therapy interventions
cervical joint signs, and jobs with repetition did not contrib- in short term follow-up, grip strength and age were found
ute to the prognostic models (P>.05).201 Follow-up on these to be useful in predicting 3-week outcomes, whereas base-
subjects at 6 months found performing a repetitive job to line disability, female sex, and self-reported nerve symptoms
be the best predictor for higher DASH (r2 = 0.52, P = .0001) may be useful in predicting 8-week outcomes. For 6-month
and pain VAS (r2 = 0.14, P = .0151) scores.200 Similar findings follow-up, occupation may be important to consider as re-
related to type of occupation were noted by Paoloni et al140 petitive and manual labor jobs may help in predicting those
and Lewis et al,107 as those performing manual labor jobs with a potential for poorer outcomes. When looking at all
were less likely to improve by 6 months. individuals independent of treatment, the involvement of the
dominant arm may be useful in predicting outcomes at 1 year.
Prognostic factors were examined in 131 subjects (mean However, predicting long-term outcomes may generally be
age = 44 years; 80 females, 51 males) who were followed challenging, as prognostic variables do not seem to accurately
after initiation of conservative treatment that consisted of predict outcomes.
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg11
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
Diagnosis/Classification
OVERVIEW
An accurate diagnosis of LET is very important to provide ade- Resisted Wrist Extension
quate and appropriate treatment. Diagnosis and classification of TABLE 6 Test or Cozen’s Test
LET is based on adequate history taking, physical findings, and or LET Test 117
special tests (TABLES 5-7). An accurate diagnosis with a better un-
derstanding of the classification of LET may aid in planning a re- ICF Category Measurement of Impairment of Body Function
turn to work and activity and may help prevent future reinjuries. Description Special test to assist with the diagnosis of LET
Measurement method Patient position:
The patient can be in sitting or standing with the elbow
CLASSIFICATION fully extended, forearm pronated, and the wrist
Classification systems are typically designed as descriptive extended to 30°.
tools, although ideally, they would be useful in directing ap- Test:
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propriate treatment or predicting outcomes. However, limited The patient’s elbow is stabilized by the examiner’s
research exists to support the use of reported classification thumb, which rests on the patient’s lateral epicon-
dyle. The examiner then provides pressure to the
systems related to tendinopathy in general and LET in specif-
dorsum of the second and third metacarpals using
ic. Most classification systems proposed are based on the acu- the other hand to resist active wrist extension.
ity, severity, and irritability of LET individually as stand-alone Positive test:
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
classifications or a combination of these dimensions.20,135,162,203 Reproduction of pain at the lateral epicondyle of the hu-
merus or within 2 cm distal to the common extensor
tendon insertion site.
Making the classification of LET even more challenging, in-
Nature of variable Nominal/dichotomous
dividuals with different occupational or athletic demands and
Units of measurement None
those with multiple recurrences tend to vary in their response
Measurement properties Cozen’s test showed fair association with pressure pain
threshold (β = .436).145
Sensitivity = 84%159
Resisted Middle Sensitivity = 91%; 95% CI: 81%, 96%51
TABLE 5 Finger Extension Test
Journal of Orthopaedic & Sports Physical Therapy®
cpg12 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
Sensitivity = 76%; 95% CI: 63%, 85%51 extensors can be done while return to function can be the
Abbreviations: ICF, International Classification of Functioning, Dis- focus of treatment for those with mild-absent pain, type 1-2
ability and Health; LET, lateral elbow tendinopathy.
distribution, and mild-absent disability. It should be noted
that shifting between categories is fluid and patients may of-
ten fit more than one category at a given time.
<20/50), moderate disability (score between 21 and 34/50),
or severe disability (score >30). The presentation of symp- DIFFERENTIAL DIAGNOSIS
toms can fluctuate widely depending on the individual’s oc- Physical therapists should be able to identify other musculo-
cupational or athletic demands during treatment. skeletal and nonmusculoskeletal conditions that mimic the
Journal of Orthopaedic & Sports Physical Therapy®
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg13
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
◽ Type 1: Unilateral signs/symptoms localized to lateral elbow ◽ Level 1: Mild pain* occurring after exercise/work, Mild
◽ Type 2: Bilateral signs/symptoms that are localized to lateral elbows lasts <6 hours
◽ Type 3 : Elbow + Cervical: Lateral elbow symptoms/signs combined with ◽ Level II: Mild pain* occurring after exercise/work
cervical signs/symptoms or neuropathic pain that lasts 7-48 hours
◽ Level III: Mild pain* occurring during exercise/
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
pathologies. The advanced imaging modality most widely thy and patient-reported pain and disability. When combined
used is magnetic resonance imaging (MRI), followed by US.71 with an appropriate clinical assessment, MRI can be useful in
establishing a plan of care for individuals with LET.87
The sensitivity of MRI in detecting LET is reported to range
between 90% and 100% and specificity from 83% to 100%.123 Ultrasound can also be used to evaluate LET.71 Findings in-
Classic MRI findings include increased signal within or clude tendon thickening and tendon heterogeneity, tendon
around the common extensor tendon, a discrete collection of tears (hypoechoic regions), and tendon discontinuity.31 Sur-
fluid between the common extensor tendon and radial col- rounding fluid and calcification can also be detected. A sys-
lateral ligament, and tendon thickening.149 A meta-analysis tematic review52 examining the diagnostic accuracy of US in
demonstrated that MRI signal change occurred in 90% of el- LET found that hypoechogenicity of the common extensor
bows with a clinical diagnosis of LET compared to only 14% of origin was both moderately sensitive (0.64; 95% CI: 0.56,
controls.142 Magnetic resonance imaging is often used to grade 0.72) and highly specific (0.82; 95% CI: 0.72, 0.90) in deter-
the severity of disease (mild, moderate, and severe).26 While mining which elbows had LET. Ultrasound features of chron-
some authors report no statistically significant association ic LET that showed high specificity included neovascularity
between imaging measures and symptoms,31,199 Qi et al149 re- (specificity, 1.00; 95% CI: 0.97, 1.00), calcifications (0.97;
ported a positive correlation between the grade of tendinopa- 95% CI: 0.94, 0.99), and cortical irregularities (0.96; 95%
cpg14 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
CI: 0.88, 0.99).52 Although US represents a less costly imag- using electrodiagnostic studies, including electromyography
ing option than MRI, its diagnostic accuracy is ultimately de- and nerve conduction studies, may also be used to rule out
pendent on numerus variables such as operator experience, compressive neuropathy involving the radial nerve as a cause
equipment, and stage of pathology.71 Nonimaging techniques of lateral elbow pain.
Examination
OUTCOME, ACTIVITY LIMITATIONS, objectively over time. Optional work and sports/performing
SELF-REPORT MEASURES arts modules of the DASH may also provide valid, reliable,
Overview and responsive measures of important functional tasks in-
Several outcome measures have been developed to assess volving the UE. The clinician-based outcome measures
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patients with LET. The PROMs that are most widely used (MEPI and RM Score) have demonstrated acceptable levels
are the Patient Rated Tennis Elbow Evaluation (PRTEE), the of clinical measurement properties; however, there is a pau-
DASH questionnaire, the numeric pain-rating scale (NPRS), city of evidence in terms of the number of studies. Neither
and the Patient-Specific Functional Scale (PSFS) (TABLES 9-12). the RM Score or the MEPI have been validated extensively
The commonly used clinician-based outcome measures are in a population of individuals with LET. Validated outcome
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
the Mayo Elbow Performance Index (MEPI) and Roles and measure(s) should be administered at baseline and discharge
Maudsley score (RM Score) (TABLES 13-14). with other follow-up points being obtained as needed to as-
sess change for all patients with LET.
ACTIVITY LIMITATIONS PHYSICAL
PERFORMANCE MEASURES Gaps in Knowledge
Activity limitation measures have not been reported in the lit- More high-quality studies are required to evaluate the
erature, other than what is indicated for the patient self-report clinical measurement properties, especially construct va-
questionnaires. The objective quantification of the following lidity and responsiveness, including MCID of the DASH,
activities can help the clinician to assess changes in the pa- PSFS, and VAS in the LET population. The clinical mea-
Journal of Orthopaedic & Sports Physical Therapy®
tient’s level of function over time: hand and arm use; turning surement properties of the RM Score and MEPI need to be
or twisting the hands or arms; lifting and carrying objects; fine evaluated in the LET population to further support their
motor use of hand; throwing, bat, and racket activity in sport. use and effectiveness in an LET population. Studies are
also needed to support the interpretation of objective and
Clinicians can utilize easily reproducible activity limitation reproducible measures of activity limitation and perfor-
and participation restriction measures associated with their mance measures.
patients’ elbow pain to assess the changes in the patient’s
level of UE function over the episode of care. RECOMMENDATION
Clinicians should use the diagnosis-specific PRTEE
Evidence Synthesis
Based on the results from high-quality clinical measurement
A to assess pain/irritability and function and/or the
region-specific DASH to assess UE function at
studies, the PRTEE, DASH, PSFS, and VAS all have demon- baseline and at least one other follow-up point, which in-
strated excellent test-retest reliability, moderate to high levels cludes discharge, for individuals with LET.
of construct validity, high levels of sensitivity to change, and
responsiveness in several populations. However, except for Clinicians should use the PSFS for patients with
the PRTEE, all the other self-report measures lack validation
in an LET population. Because the PSFS assesses restriction
A high-demand activities and/or should administer a
scale that assesses activity-specific disability (eg,
of functional activities important to each individual, rigorous DASH work or sports/performing arts module) at baseline
activities that are not assessed in other self-report measures and at least one other follow-up point, which includes dis-
(eg, work, hobbies, or athletic endeavors) can be monitored charge, for individuals with LET.
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg15
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
cpg16 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
nopathy; MCID, minimal clinically important difference; MDC, minimal detectable change; SEM, standard error of measurement; SRM, standardized
response mean; UE, upper extremity; PRTEE, Patient-Rated Tennis Elbow Evaluation.
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg17
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
disorders)75
Note: calculated for a sum of 3 administrations scores range from 0 to 30
MCID 1 point (chronic musculoskeletal pain)157
2 points (chronic pain)57
Abbreviations: ICC, intraclass correlation coefficient; ICF, International Classification of Functioning, Disability and Health; LET, lateral elbow tend-
inopathy; MCID: minimal clinically important difference; MDC, minimal detectable change; PRTEE, Patient-Rated Tennis Elbow Evaluation; PSFS,
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Patient-Specific Functional Scale; UE, upper extremity; VAS, visual analog scale.
cpg18 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
Abbreviations: DASH, Disabilities of the Arm, Shoulder and Hand; ICF, International Classification of Functioning, Disability and Health; LET, lateral
elbow tendinopathy; M-ASES-e, Modified American Shoulder and Elbow Surgeons patient self-evaluation form.
PHYSICAL IMPAIRMENT MEASURES Commonly used impairment measures are the elbow, fore-
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Overview arm, and wrist ROM (TABLES 15-18), pressure pain thresh-
Activities that involve overloading of the wrist and digit old (TABLE 19), PFGS (TABLE 20), and maximal grip strength
extensor muscles are associated with LET and may result (TABLE 21). Measurement of wrist extension strength may be
in impairments including pain with motion of the elbow, performed but little research supports its use as an outcome
forearm, wrist, and hand, and with resisted activity such as measure. Rather, pain with resisted wrist extension is as-
gripping. Range of motion (ROM) loss could also point to sessed through special tests. Measurement of grip strength
another pathology related to joint dysfunction and, there- may serve as an indicator of function and strength of the
fore, may be useful in determining a differential diagnosis. wrist stabilizers.
Journal of Orthopaedic & Sports Physical Therapy®
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg19
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
MDC90:
4.90° (NK Goniometer); 5.23° (JTECH goniometer) (UE musculoskeletal disorders)9
MDC95:
5.82° (NK Goniometer); 6.21° (JTECH goniometer) (UE musculoskeletal disorders)9
Supination
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ICC (3,1) = 0.96 to 0.98 (SEM 1.9° to 2.2°) (UE musculoskeletal disorders and normal subjects)91
ICC (2,1 )= 0.94 (95% CI: 0.85, 0.96) (SEM 3.20°) NK goniometer (UE musculoskeletal disorders)9
ICC (2,1) = 0.95 (95% CI: 0.90, 0.97) (SEM 1.95°) JTECH goniometer (UE musculoskeletal disorders)9
ICC = 0.91 (95% CI: 0.78, 0.96) SEM 8° (Normal subjects)212
MDC90:
5.13° (NK Goniometer); 4.55° (JTECH goniometer) (UE musculoskeletal disorders)9
MDC95:
6.10° (NK Goniometer); 5.40° (JTECH goniometer) (UE musculoskeletal disorders)9
Interrater reliability:
Pronation
ICC (2,3) = 0.92 to 0.95 (SEM 2.4°) (UE musculoskeletal disorders and normal subjects)91
Journal of Orthopaedic & Sports Physical Therapy®
ICC (2,1) = 0.76 to 0.93 (UE musculoskeletal disorders and normal subjects)33
ICC (2,1) = 0.83 (95% CI: 0.71, 0.90) (SEM 3.11°) NK goniometer (UE musculoskeletal disorders)9
ICC (2,1) = 0.79 (95% CI: 0.69, 0.89) (SEM 3.02°) JTECH goniometer (UE musculoskeletal disorders)9
ICC = 0.92 (95% CI: 0.47, 0.98) SEM 3° (Normal subjects)211
MDC90:
7.26° (NK goniometer); 7.05° (JTECH goniometer) (UE musculoskeletal disorders)9
MDC95:
8.62° (NK goniometer); 8.37° (JTECH goniometer) (UE musculoskeletal disorders)9
Supination
ICC (2, 3) = 0.94 to 0.96 (SEM 2.9° to 3.9°) (UE musculoskeletal disorders and normal subjects)91
ICC (2, 1) = 0.92 to 0.97 (UE musculoskeletal disorders and normal subjects)33
ICC (2, 1) = 0.87 (95% CI: 0.73, 0.93) (SEM 3.78°) NK goniometer (UE musculoskeletal disorders)9
ICC (2, 1) = 0.84 (95% CI: 0.49, 0.94) (SEM 3.96°) JTECH goniometer (UE musculoskeletal disorders)9
ICC = 0.87 (95% CI: 0.56, 0.97) SEM 3° (Normal subjects)211
MDC90:
8.82° (NK goniometer); 9.24° (JTECH goniometer) (UE musculoskeletal disorders)9
MDC95:
10.48° (NK Goniometer); 10.98° (JTECH goniometer) (UE musculoskeletal disorders)9
Pronation 10° (UE musculoskeletal disorders)6
Supination 11° (UE musculoskeletal disorders) 6
Instrument variations Fluid goniometer,143 NK goniometer,6 JTECH goniometer,9 and pronation-supination goniometer6
Abbreviations: ICC, intraclass correlation coefficient; ICF, International Classification of Functioning, Disability and Health; MDC, minimal detectable
change; SEM, standard error of measurement; UE, upper extremity.
cpg20 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
MDC95:
5.49° (NK goniometer); 7.18° (JTECH goniometer) (UE musculoskeletal disorders)9
Extension
ICC (1,1) = 0.96 (lower limit of 95% CI: 0.94) (SEM 3.65°) (UE musculoskeletal disorders)83
ICC (3,l) = 0.80 to 0.94 (SEM 5.57° to 7.82°) (UE musculoskeletal disorders)102
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ICC (2,1) = 0.95 (95% CI: 0.91, 0.97) (SEM 2.06°) NK goniometer (UE musculoskeletal disorders)9
ICC (2,1) = 0.94 (95% CI: 0.72, 0.94) (SEM 2.47°) JTECH goniometer (UE musculoskeletal disorders)9
MDC90:
4.81° (NK goniometer); 5.76° (JTECH Goniometer) (UE musculoskeletal disorders)9
MDC95:
5.71° (NK goniometer); 6.85° (JTECH goniometer) (UE musculoskeletal disorders)9
Interrater reliability:
Flexion
ICC (1,1) = 0.90 (lower limit of 95% CI: 0.85) (SEM 6.57°) (UE musculoskeletal disorders)83
ICC (2,l) = 0.88 to 0.93 (SEM 5.54° to 6.56°) (UE musculoskeletal disorders)102
ICC = 0.94 (95% CI: 0.89, 0.97) (SEM 2.12°) (Normal subjects)42
Journal of Orthopaedic & Sports Physical Therapy®
ICC = 0.89 (95% CI: 0.80, 0.94) (SEM 3.65°) (electrogoniometer) (Normal subjects)42
ICC (2,1) = 0.97 (95% CI: 0.95, 0.98) (SEM 3.64°) NK goniometer (UE musculoskeletal disorders)9
ICC (2,1) = 0.87 (95% CI: 0.88, 0.97) (SEM 3.48°) JTECH goniometer (UE musculoskeletal disorders)9
MDC90:
8.49° (NK goniometer); 8.12°(JTECH goniometer) (UE musculoskeletal disorders)9
MDC95:
10.09° (NK goniometer); 11.86° (JTECH goniometer) (UE musculoskeletal disorders)9
Extension
ICC (1,1) = 0.85 (lower limit of 95% CI: 0.77) (SEM 7.00°) (UE musculoskeletal disorders)83
ICC (2,l) = 0.80 to 0.84 (SEM 6.00° to 7.69°) (UE musculoskeletal disorders)102
ICC = 0.90 (95% CI: 0.83, 0.95) (SEM 1.67°) (Normal subjects)42
ICC = 0.91 (95% CI: 0.83, 0.95) (SEM 3.10°) (electrogoniometer) (Normal subjects)42
ICC (2,1) = 0.95 (95% CI: 0.91, 0.97) (SEM 2.06°) NK goniometer (UE musculoskeletal disorders)9
ICC (2,1) = 0.93 (95% CI: 0.90, 0.97) (SEM 2.82°) JTECH goniometer (UE musculoskeletal disorders)9
MDC90:
4.81° (NK Goniometer); 6.58° (JTECH goniometer) (UE musculoskeletal disorders)9
MDC95:
9.65° (NK Goniometer); 7.82° (JTECH goniometer) (UE musculoskeletal disorders)9
Instrument variations Fluid goniometer,143 JTECH goniometer,9 and NK goniometer6
Abbreviations: ICC, intraclass correlation coefficient; ICF, International Classification of Functioning, Disability and Health; MDC, minimal detectable
change; SEM, standard error of measurement; UE, upper extremity.
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg21
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
TABLE 18 Wrist Range of Motion, and Radial and Ulnar Deviation of the Wrist
MDC95:
2.66° (NK goniometer); 3.49° (JTECH goniometer) (UE musculoskeletal disorders)9
Ulnar deviation
ICC (1,1) = 0.92 (lower limit of 95% CI: 0.88) (SEM 3.48°) (UE musculoskeletal disorders)83
ICC (2,1) = 0.91 (95% CI: 0.85, 0.95) (SEM 1.98°) NK goniometer (UE musculoskeletal disorders)9
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ICC (2,1) = 0.93 (95% CI: 0.89, 0.96) (SEM 2.06°) JTECH goniometer (UE musculoskeletal disorders)9
MDC90:
4.62° (NK goniometer); 4.81° (JTECH goniometer) (UE musculoskeletal disorders)9
MDC95:
5.49° (NK goniometer); 5.71° (JTECH goniometer) (UE musculoskeletal disorders)9
Interrater reliability:
Radial deviation
ICC (1,1) = 0.86 (lower limit of 95% CI: 0.78) (SEM 3.03°) (UE musculoskeletal disorders)83
ICC = 0.86 (95% CI: 0.76, 0.93) (SEM 1.79°) (Normal subjects)42
ICC = 0.90 (95% CI: 0.82, 0.95) (SEM 2.13°) (electrogoniometer) (Normal subjects)42
ICC (2,1) = 0.84 (95% CI: 0.73, 0.91) (SEM 2.16°) NK goniometer (UE musculoskeletal disorders)9
Journal of Orthopaedic & Sports Physical Therapy®
ICC (2,1) = 0.87 (95% CI: 0.72, 0.93) (SEM 1.94°) JTECH goniometer (UE musculoskeletal disorders)9
MDC90:
5.04° (NK goniometer); 4.53° (JTECH goniometer) (UE musculoskeletal disorders)9
MDC95:
5.99° (NK goniometer); 5.76° (JTECH goniometer) (UE musculoskeletal disorders)9
Ulnar deviation
ICC (1,1) = 0.78 (lower limit of 95% CI: 0.67) (SEM 5.77°) (UE musculoskeletal disorders)83
ICC = 0.81 (95% CI: 0.66, 0.90) (SEM 2.29°) (Normal subjects)42
ICC = 0.93 (95% CI: 0.88, 0.96) (SEM 1.93°) (electrogoniometer) (Normal subjects)42
ICC(2,1) = 0.82 (95% CI: 0.51, 0.92) (SEM 2.60°) NK goniometer (UE musculoskeletal disorders)9
ICC (2,1) = 0.93 (95% CI: 0.89, 0.96) (SEM 2.06°) JTECH goniometer (UE musculoskeletal disorders)9
MDC90:
6.07° (NK Goniometer); 4.81° (JTECH goniometer) (UE musculoskeletal disorders)9
MDC95:
7.17° (NK Goniometer); 5.38° (JTECH goniometer) (UE musculoskeletal disorders)9
Instrument variations Fluid goniometer,143 JTECH goniometer,9 and NK goniometer6
Abbreviations: ICC, intraclass correlation coefficient; ICF, International Classification of Functioning, Disability and Health; MDC, minimal detectable
change; SEM, standard error of measurement; UE, upper extremity.
cpg22 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
national study that aimed at developing a core outcome set terms of the optimal method of testing and its validity, reliabil-
for lateral elbow tendinopathy (COS-LET)10 using the best ity, responsiveness, and diagnostic utility in the clinical setting.
available evidence and an international consensus process,
recommended the use of PFGS measurements and did not RECOMMENDATION
include wrist extension strength in the core outcome mea- Physical Impairment Measures
sures for LET. Measurement of physical impairments pro- Clinicians should include the physical impairment
vide objective measures of impairment deficits, can assist in B measures of elbow and wrist range of motion, PPT,
PFGS, and maximum grip strength at baseline and
monitoring change throughout the course of care, and can
provide information regarding the individual’s prognosis. at least one other follow-up point, that includes discharge,
Potential harms include having the individual with irritable for individuals with LET.
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg23
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
ICF Category Measurement of Impairment of Body Function: The Strength of the Muscles
Description The amount of force that a patient can generate before any pain is felt during a grip strength test using a handgrip dynamometer. The
patient should be seated with the elbow extended, the forearm pronated, and the wrist in slight wrist extension. The handle position of
the dynamometer is set consistently for the individual patient, and the mean of 3 successive trials should be used.
Measurement properties Individuals with LET:
Interobserver 95% limits of agreement: −5.09, 6.6 kg-force173
Interobserver reliability: ICC = 0.97 (95% CI: 0.94, 0.98)173
Intratester reliability ICC (3,1) = 0.89193
Between-session reliability:
Elbow flexed
ICC (2,3) = 0.86; 95% CI: 0.69, 0.9472
ICC (2,1) = 0.89; 95% CI: 0.75, 0.9579
Elbow extended
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Validity:
With VAS r = 0.47179
With PRTEE r = −0.36138
Sensitivity 65%180
Specificity 97%180
Clinically Important Change 7 kg-force180
Abbreviations: ICC, intraclass correlation coefficient; ICF, International Classification of Functioning, Disability and Health; LET, lateral elbow tendinopa-
thy; MDC, minimal detectable change; PRTEE, Patient-Rated Tennis Elbow Evaluation; SMD, standardized mean difference; VAS, visual analog scale.
ICF Category Measurement of Impairment of Body Function: The Strength of the Muscles
Description The maximum amount of force that a patient can generate during a grip strength test using a handgrip dynamometer. The patient
should be seated with the shoulder adducted and neutrally rotated, the elbow extended, and the forearm and wrist in neutral position.
The second handle position of the dynamometer and the mean of 3 successive trials should be used. Clinicians may measure
maximum grip strength in both elbow flexed and extended positions.
Measurement properties Individuals with LET:
Interobserver 95% limits of agreement: −4.73, 3.11 kg173
SMD (similar to MDC95) = 0.8 kg173
Abbreviations: ICF, International Classification of Functioning, Disability and Health; LET, lateral elbow tendinopathy; MDC, minimal detectable
change; SMD, standardized mean difference; VAS, visual analog scale.
cpg24 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
Interventions
OVERVIEW more effective when compared to other forms of strength-
Multiple investigations, including randomized clinical tri- ening and pain-relieving modalities in reducing pain (SMD,
als (RCTs), systematic reviews, and meta-analyses, have 1.12; 95% CI: 0.31, 1.93) and improving function (SMD,
been conducted examining the effect of various treatment 1.22; 95% CI: 0.25, 2.18) in the short term. The evidence for
approaches and interventions on LET. The goals of LET intermediate-term effectiveness was inconclusive for all
management are to minimize pain, improve strength, and outcomes.29
restore function of the UE. Interventions range from exercise
prescription, manual therapy techniques, and various elec- A systematic review and meta-analysis of 30 stud-
trotherapeutic modalities. Supportive devices and ergonomic
interventions are also used to off-load the common extensor
II ies92 evaluated the effectiveness of exercise com-
pared with other nonsurgical interventions in the
tendon. The following section provides an overview of the in- management of LET on pain and function. In the long term,
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vestigations examining the effect of interventions commonly exercise was better than corticosteroid injection in improving
used to treat individuals with LET. PFGS (MD, 12.15 kg; 95% CI: 1.69, 22.6), pain reduction
(SMD, −0.56; 95% CI: −0.78, –0.34), and disability reduc-
EXERCISE tion (SMD, −0.64; 95% CI: −0.86, –0.42). Similar observa-
Exercise in Isolation tions were noted for short term and the midterm, except for
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Forty participants with LET for 6 weeks or longer short-term pain reduction. When exercise was compared to
I were randomly allocated to either an unsupervised
isometric exercise group (n = 21) or a wait-and-see
a wait-and-see approach, only short-term pain reduction
(SMD, −0.33; 95% CI: −0.60, –0.05) and long-term elbow
group (n = 19).196 The primary outcomes were pain (worst/ disability (SMD, −0.27; 95% CI: −0.47, –0.06) were statisti-
rest using a NPRS), disability (PRTEE), global improvement cally significant, in favor of exercise. There is only evidence
(GROC), and PFGS. The unsupervised exercise group report- of low to very low quality to support the effectiveness of ex-
ed a decrease in worst pain (standardized mean difference ercise over corticosteroid injections and the wait-and-see
[SMD], −0.80; 95% CI: −1.45, −0.14) and disability (SMD, approach in the long term.92
−0.92; 95% CI: −1.58, −0.26), but not in perceived rating of
Journal of Orthopaedic & Sports Physical Therapy®
change or PFGS when compared with wait and see at 8 Hoogvliet et al82 conducted a systematic review up
weeks. No serious adverse effects were reported.196 II to February 2010 examining any type of exercise
and mobilization techniques compared to a variety
Yoon et al208 conducted a systematic review and of interventions in individuals with LET. High-quality evi-
II meta-analysis on the effects of eccentric exercises
in the management of LET and included 6 trials.
dence supports the use of stretching plus strengthening ex-
ercises for the reduction of pain over the use of therapeutic
All studies compared eccentric exercise in isolation to other US and friction massage at 8-week follow-up (SMD, 0.95;
physical therapy interventions. A significant improvement 95% CI: 0.26, 1.64).146 Lower quality, defined as less than
in the VAS score after eccentric exercise (SMD, −0.63; 95% 50% on the 12-item source of risk of bias scale, evidence sup-
CI: −0.90, −0.36) relative to the comparison group was ob- ports the use of progressive strengthening and stretching
served in the 4 studies that looked at VAS. Four studies re- over US alone for the reduction of pain at an average of
ported outcomes of muscle strength, 3 studies with grip 36-month follow-up (MD −3.1 cm; 95% CI: −5.6, −0.5).144
strength, and 1 study with eccentric muscle strength. A sig- Low-quality evidence demonstrates no differences in the
nificant improvement in muscle strength in the eccentric long-term effect on pain or function (DASH) of stretching
exercise group (SMD, 1.05; 95% CI: 0.78, 1.33) relative to alone compared with stretching plus concentric exercises or
the comparison group was observed. Eccentric exercise eccentric exercises at 6-week follow-up.122 However, signifi-
combined with adjuvant therapy showed beneficial effects cant differences in grip strength in favor of eccentric exercise
with regard to pain reduction and muscle strength improve- over contract relax stretching techniques were found at
ment. Comparison between eccentric exercise and other 6-month follow-up but not at 12-month follow-up for chron-
exercises showed positive effects of eccentric exercise with ic LET (Svernlov, 2001).
regard to pain reduction; however, the differences in muscle
strength and function between the groups were not signifi- Raman et al150 performed a systematic review per-
cant.208 A similar meta-analysis also published in 2021
found similar results finding that eccentric exercises were
II taining to using any type of strengthening com-
pared to a variety of nonsurgical interventions to
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg25
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
detail specific dosage parameters to guide therapists in the effect on pain intensity, PFGS, and function compared to
optimal prescription of exercise for individuals with LET. No other nonsurgical interventions. No studies described how
quantitative data in summary form were reported in this re- load was determined or how it was progressed. Unsupervised
view. Eccentric exercise was the most studied of all resistance daily isometric progressive resisted exercises to the wrist ex-
types. It is unclear whether strengthening leads to additional tensors have also been shown to be effective in reducing pain
improvement of these outcomes in a multimodal treatment and disability over no intervention for individuals with 6 or
regimen due to conflicting results in the studies reviewed. more weeks of LET symptoms. Stretching of the wrist ex-
For either isotonic or eccentric strengthening, the following tensors alone appears to have no long-term effect on pain or
dosing parameters were suggested: 3 sets of 15 repetitions for function compared to stretching plus concentric or eccen-
6-12 weeks based on moderate evidence. No studies de- tric strengthening to the wrist extensors at the midterm. At
scribed determination of load or its progression.150 1-year follow-up, eccentric strengthening to the wrist exten-
sors may be more effective at reducing pain and increasing
Bisset et al16 reported on an additional low-quality strength when compared to concentric exercises. Based on
II RCT163 written in Italian performed in 2003, not
included in subsequent systematic reviews. Eccen-
the best available evidence and expert opinion, either isomet-
ric, isotonic, or eccentric strengthening of the wrist extensors
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
tric exercise plus strengthening in individuals with LET had may be prescribed using the following suggested dosing pa-
a significant positive effect on patient satisfaction and return rameters: 3 sets of 15 repetitions for 6-12 weeks. However,
to activity over sham US at 6-month follow-up (relative risk loads that are applied should not exacerbate symptoms and
[RR], 21.97; 95% CI: 3.17, 152.20). No harms or adverse ef- loading should be progressed from isometric to isotonic and
fects related to the exercise programs were reported.16 from isotonic to eccentric as tolerated without exacerbation
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
centric pain-free contractions using relatively low resistance appropriate for individuals who have LET symptoms with
(between approximately 20%-40% of maximum voluntary high-demand occupations, hobbies, performing arts, or ath-
isometric contraction [MVIC]) to start. Loading is advanced letic interests.
between phases 2 and 3 by gradually increasing resistance to
above 40% MVIC to induce a strengthening response. Fur- Gaps in Knowledge
ther progressions in phase 3 focus on gradually increasing Although eccentric exercises to the wrist extensors were the
the length of lever arms, UE weight-bearing, and weight or most studied of all resistance types, more evidence is need-
resistance of the exercises. Finally, exercises to re-establish ed on which type of strengthening, which muscle groups
high-level neuromuscular control and anticipatory reactions should be addressed along the UE kinetic chain, and which
(eg, UE plyometric exercises) are introduced while incorpo- dosage parameters are most effective in improving outcomes
rating function-specific tasks correcting faulty mechanics as for LET. Specifically, studies are needed to determine opti-
needed into the program.43,44 It is the opinion of the CPG mal loading and its progression. Comparison to true con-
team that clinicians may incorporate the use of a phased ap- trol groups is needed to discern the effects of natural history
proach to reintroducing stress, increasing strength, improv- and/or placebo. Additionally, examination of the effects of
ing endurance, and restoring optimal motor control exercise on various naturally occurring subgroups (based on
particularly for individuals who have LET symptoms with acuity and irritability, presence or absence of periscapular
high-demand occupations, hobbies, performing arts, or ath- dysfunction, etc) of individuals with LET is needed. Large,
letic interests. high-quality RCTs with clearly defined strengthening re-
gimes are needed to determine optimal dosage to maximize
Evidence Synthesis treatment effect. It is unclear whether exercise in isolation is
Despite limitations in study designs including the lack of pla- more effective than other treatment such as manual therapy.
cebo control groups in many studies and the lack of uniformi-
ty in exercise and dosage parameters, it does appear that both While CPG team members recommend the use of a phased
concentric and eccentric resistance exercises have a positive re-introduction of strengthening, endurance training, and
cpg26 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
high-level neuromuscular re-education for the return-to-func- 20.78 points; 95% CI: 16.41, 25.14 at discharge = 9.41 points
tion phase of rehabilitation, research studies that examine the 95% CI: 6.22,12.61). There was no significant difference be-
effectiveness of these exercise strategies and progressions in tween groups from evaluation to discharge (average visits = 8
those with LET who have high-demand occupations, hob- +/− 2.2 over 4-6 weeks). Following discharge, pain and func-
bies, performing arts, or athletic performance requirements tional gains were maintained, suggesting that the interven-
are needed. tions had positive long-term effects in both groups.43 The
addition of scapular muscle strengthening does not appear to
RECOMMENDATION add value for improving pain and function in the context of a
Clinicians should use isometric, concentric, and/or multimodal treatment program.
B eccentric therapeutic resisted exercises of the wrist
extensors in the treatment of individuals with sub- Twelve clinical trials of varying quality were includ-
acute or chronic LET.
II ed in a systematic review of eccentric exercise in
combination with other treatments compared to
Clinicians may use a phased approach to reintro- reference groups not receiving eccentric exercise as a part of
F duce stress, increase strength, improve endurance, the treatment.39 Data were not pooled due to the variability
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
and restore optimal motor control in individuals in measurement methods of the outcomes, and insufficient
who have LET symptoms with high-demand occupations, evidence was available to estimate. When compared to other
hobbies, performing arts, or athletic interests. treatment therapies, qualitative assessment of the evidence
supports the use of multimodal treatment programs includ-
MULTIMODAL INTERVENTIONS INCLUDING EXERCISE ing eccentric exercise for improving pain and function in the
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Mostafee et al127 completed an RCT to compare the midterm management of LET (less than 24 weeks after
I effects of shoulder and scapular muscle training
plus multimodal physical therapy consisting of
discharge).39
transcutaneous electrical nerve stimulation (TENS), US, Olaussen et al137 performed a systematic review and
deep friction massage (DFM), and a combination of isomet-
ric and isotonic strengthening of the wrist extensors with a
II meta-analysis of RCTs on the effectiveness of corti-
costeroid injection and nonelectrotherapeutic ther-
group who received multimodal physical therapy only. For- apy compared with control for treating LET. Eleven RCTs
ty-eight patients with LET were randomly allocated to the were included in the review assessing RR or for overall im-
2 groups and received treatment for 4 weeks. The primary provement, pain, and grip strength at 4-, 12-, 26-, and 52-
Journal of Orthopaedic & Sports Physical Therapy®
outcomes were pain measured using VAS, PFGS, and week follow-up. Corticosteroid injection and MWM along
self-reported function (PRTEE and QuickDASH). The pro- with exercise gave a short-term benefit (4-12 weeks) in over-
gram that combined multimodal physical therapy with all improvement compared with control with RR of 2.27
shoulder and scapular muscle training was more effective (95% CI: 1.04, 4.97) and 2.75 (2.09, 3.62), respectively. How-
in improving pain (MD, 2.20; 95% CI: 1.32, 3.09) and func- ever, for the intermediate term (3-6 months), outcomes for
tion using the PRTEE (MD, 21.25; 95% CI: 11.07, 31.43) individuals treated with corticosteroid injections were worse
and QuickDASH (MD, 15.36; 95% CI: 5.94, 24.78), when (0.66; 0.53, 0.81), whereas MWM with exercise was not dif-
compared with multimodal physical therapy at 4-month ferent from control (0.99; 0.75, 1.30). In the long term
follow-up. (greater than 6 months), both treatments showed no benefit
over control.137 One study showed a short-term positive effect
Day and Lucado43 randomized 35 patients with a on pain (SMD, 4.45; 95% CI: 3.51, 5.40) and grip strength
II clinical presentation of LET into 2 groups: local
therapy (LT) and local therapy plus scapular muscle
(SMD, 3.16; 95% CI: 2.40, 3.92) for eccentric exercises and
stretching.163 Long-term follow-up also showed a positive
strengthening (LT+SMS). The LT protocol included educa- effect on pain (SMD, 4.65; 95% CI: 3.68, 5.63) and grip
tion, counterforce bracing, physical agents, manual therapy, strength (SMD, 3.65; 95% CI: 2.82, 4.47).163
and therapeutic exercise, whereas the LT+SMS treatment
included the same but with scapular muscle strengthening. Sethi et al164 conducted an RCT examining the ef-
The PRTEE was the main outcome measure collected at base-
line, 4-6 weeks, and 6- and 12-month follow-up. There was a
II fect of scapular muscle strengthening plus physical
therapy addressing the elbow/wrist region (n = 13)
significant main effect for time for the PRTEE measures of with physical therapy only addressing the elbow/wrist region
both pain and function. Ultimately, both groups changed at (n = 13) for 3 times a week for 6 weeks on pain (VAS), PFGS,
the same rate (average PTREE pain LT at evaluation = 20.50 function (PRTEE), scapular muscle strength, scapular posi-
points; 95% CI: 17.05, 23.95 at discharge = 6.79 points; 95% tioning, and electromyography in adults with chronic LET.
CI: 3.57, 10.0. Average PTREE pain LT+SMS at evaluation = Both groups received multimodal physical therapy while the
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg27
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
experimental group also received a scapular muscle strength- individuals with LET. No harm or adverse effects were re-
ening protocol. The scapular muscle strengthening group ported in the studies describing exercise in the context of a
demonstrated greater improvement than the other group for multimodal treatment approach.
all outcomes except scapular positioning over the 6 weeks.
The ultimate positive effect (d) of scapular muscle strength- Gaps in Knowledge
ening when added to physical therapy addressing the elbow/ Given the variety of treatments included in the multimod-
wrist region on pain (d = 0.29), PFGS (d = 0.36), and func- al physical therapy approaches described in these studies,
tion (d = 0.18) was small, while the effect on scapular strength the effect of specific and standardized multimodal treat-
was moderate, ranging from 0.57 to 0.68.164 ment combinations is not clear. Classification subgroups of
individuals who most benefit from multimodal treatments
Coombes et al38 conducted a cost effectiveness plus exercise have not been elucidated in the literature. The
II analysis comparing a multimodal intervention,
including exercise and corticosteroid injections
muscle groups included, and the optimal type(s) and dosage
parameters of exercise are not yet known for the successful
over a 1-year period in participants with LET symptoms treatment of LET. More studies comparing interventions to
greater than 6 weeks. Participants were randomly allocated true control groups are needed.
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
exercise received a standard protocol of manual therapy at manual therapy, in the treatment of patients with subacute
the elbow with gripping, concentric and eccentric wrist ex- or chronic LET.
ercises, motor control retraining, and global UE strength-
ening exercises. The exercise intervention had greater initial Clinicians may include shoulder and scapular sta-
costs but was the only intervention that resulted in signifi- C bilizer muscle training exercises, when impair-
ments are identified, in conjunction with other
cantly greater quality of life after 1-year. The probability of
being more cost effective than placebo was 81% for includ- forms of localized resisted exercises in individuals with LET.
ing exercise, 53% for corticosteroid, and 24% for the com-
bination corticosteroid+exercise.38 MANUAL THERAPY JOINT MOBILIZATIONS/
Journal of Orthopaedic & Sports Physical Therapy®
MANIPULATIONS
Evidence Synthesis Lucado et al111 conducted a meta-analysis of clinical
Several studies demonstrate a positive short-term but no net
long-term effect of wrist extensor strengthening plus elbow
II trials that examined the effect of joint mobiliza-
tions on pain, grip strength, and disability in adults
joint mobilization/manipulation on outcomes compared to diagnosed with LET. Twenty studies of varying quality met
control groups. A few studies demonstrate eccentric strength- the inclusion criteria and broadly comprises studies examin-
ening, and stretching of the wrist extensors appears to produce ing the effects of either a lateral glide MWM technique to the
positive gains compared to other forms of physical therapy in- elbow, Mill’s manipulation, or regional mobilization tech-
tervention. The efficacy of wrist extensor strengthening exer- niques. Only 7 trials were appropriate for the meta-analysis.
cises on reducing pain and disability may be enhanced by the The MWM technique to the elbow demonstrated a moderate
addition of manual therapy, including MWM or Mill’s manip- positive mean effect (SMD, 0.43; 95% CI: 0.15, 0.71) on pain
ulation techniques, to the elbow. However, the evidence for and a moderate positive effect on PFGS (SMD, 0.31; 95% CI:
the duration of patient-reported improvements is limited to 0.11, 0.51). One study reported a moderate positive effect
less than 24 weeks. The probability of being more cost effec- (SMD, 0.77; 95% CI: 0.81, 1.37) of MWM on pain and dis-
tive was highest in individuals receiving a multimodal physical ability compared to groups receiving placebo or other non-
therapy treatment including exercise compared with a “wait- surgical interventions as measured by the PRTEE in the
and-see” control group or cortisone injection groups. short term.35 Mill’s manipulation technique to the elbow
demonstrated a moderate positive effect (SMD, 0.47; 95%
Additionally, weak evidence supports the use of shoulder and CI: 0.11, 0.82) on pain (VAS), but no appreciable effect
scapula muscle training exercises in conjunction with other (SMD, 0.01; 95% CI: −0.27, 0.26) on PFGS. Regional mobi-
forms of localized isotonic exercises and stretching. The pub- lization, including cervical manipulation59,60 or side glides194
lished literature provides little information regarding specific to C5-6, cervical or thoracic mobilization,34 ventral scaphoid
rehabilitation guidelines that address optimizing return to manipulation to the wrist,89,181 and radial head manipula-
function while minimizing risk of recurrent symptoms in tion,84 each demonstrated effectiveness over control groups
cpg28 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
in reducing pain, increasing grip strength, and improving significantly decreased in both groups, mean (SD) 1.93 ± 0.74
function in the short term.111 and 1.70 ± 0.79, respectively (P = .2). Grip strength results at
posttreatment level for the Cyriax and Mulligan MWM
Hoogvliet et al82 conducted a systematic review ex- groups were 53.5 lbs ± 2.13 and 42.3 lbs ± 1.97, respectively
II amining the use of exercise therapy and mobiliza-
tion techniques for the treatment of lateral and
(P<.01). After 8 weeks of treatment, Cyriax manual therapy
and Mulligan’s MWM intervention were both equally effec-
medial elbow tendinopathy; 1 systematic review and 12 RCTs tive in improving pain; however, because there was no con-
met the inclusion criteria. There was conflicting evidence for trol group, the improvements made in both groups could
the effectiveness of manipulation of the cervical spine com- have been due to the passage of time. Cyriax manual therapy
pared with a placebo or control group for improving pain and improved grip strength more than the Mulligan technique.3
functional outcome immediately after treatment. Moderate
quality evidence supported the benefit on PFGS when using In an RCT, the effects of an MWM lateral glide
manipulation of the cervical and thoracic spine as an adjunct
to concentric and eccentric exercises and mobilization of the
II technique to the elbow (n = 20) were compared to
the effects of a standard physical therapy program
wrist and forearm at 6 weeks (MD, 14.6 kg; 95% CI: 9.3, (n = 20) on pain (VAS), PFGS, and function (PRTEE) in
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
19.9) and at 6 months (MD, 19.6 kg; 95% CI: 1.6, 37.6) com- adults with LET.151 Both groups received a standardized pro-
pared with local treatment only. There was limited evidence gram of exercise, cryotherapy, and education 5 days a week
that manipulation of the wrist has a positive impact on pain for 2 weeks. In addition, the experimental group received
when compared with a group who received US plus friction MWM lateral glides to the elbow. At 12 weeks, between-group
massage, stretching, and strengthening exercises for the differences in PFGS were significant (P<.05) with higher val-
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
wrist extensors at 6-week follow-up. Local mobilization or ues in the experimental group (mean, SD) 29.60 kg ± 8.85
manipulation to the elbow were also examined in the review. compared to the control group 26.47 kg ± 9.58. Be-
There was limited evidence for the short-term effectiveness tween-group differences in PRTEE were also significant, in
on outcomes as a result of using MWM as an adjunct to US favor of the experimental group receiving MWM (MD,
and progressive resisted exercise and when comparing the −15.00 points; 95% CI: −35.00, −10.00) compared with the
technique to a placebo or control treatment (P<.05, no exact control group (MD, −16.50 points; 95% CI: −38.00, −12.00).
data given).82 The addition of the MWM lateral glide technique to exercise,
cryotherapy, and education appears to have a small positive
Bisset at al16 found low-quality evidence that sup- effect on PFGS and pain and function, as measured by the
Journal of Orthopaedic & Sports Physical Therapy®
(SMD, 1.28; 95% CI: 0.84, 1.73). Low-quality evidence also Zunke et al210 completed an RCT to investigate the
supports elbow manipulation when combined with US for
reducing pain at 3 weeks (P<.01) and at 12 weeks (P<.05).
II effect of manual therapy to the thoracic spine on
PFGS and sympathetic activity in patients. Patients
Studies that included mobilizations as a multimodal treat- with pain duration of less than 6 months were randomly al-
ment to improve pain, global improvement, and function located to either the thoracic spine mobilization group (n =
were of higher quality.16 15) where they received a one-time 2-minute T5 costoverte-
bral mobilization (2 Hz), or a placebo group (n = 15) who
In the low-quality, qualitative systematic review by received a one-time 2-minute sham US therapy. The out-
II Herd and Meserve,77 one reviewer assessed the
quality of the 13 articles that met the inclusion cri-
comes measured were PFGS, skin conductance, and periph-
eral skin temperature. The thoracic spine mobilization group
teria. In the studies examining the effects of manipulative demonstrated a significant increase in PFGS 4.6 kg (95% CI:
therapy on adults with LET, it appears that MWM offers both 1.8, 6.92 kg) when compared to the control group. A thoracic
short- and long-term benefit in reducing pain and increasing costovertebral T5 mobilization at a frequency of 2 Hz had an
function and that both cervical and wrist manipulation im- immediate positive effect on PFGS and sympathetic activity
proved short-term outcomes.77 in patients with LET.210
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg29
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
MWM technique described is performed with the clinician functioning level, and quality of life. Myofascial release ther-
providing a lateral glide of the proximal forearm on a stabi- apy was defined as any of the following: direct pressure MRT
lized humerus while the patient (in supine, elbow extended, releases, indirect “stretching” MRT releases, and self-MRT
and forearm pronated) performs an active pain-free gripping releases. The authors excluded techniques on trigger point
action. Mobilization with movement is often administered therapy or releases. Related to LET, the authors found 2
with 6-10 repetitions of the glide for 3-5 sets in 1 treatment RCTs2,95 (n = 95) that met the criteria. The raw mean differ-
session. The Mill’s manipulation technique described is per- ence in PRTEE improvement between the control and LET
formed with high-velocity, low-amplitude thrust manipula- group was (−47 points; 95% CI: −44.64, −49.36)2 and (−19.3
tion into elbow extension while the individual is seated and points; 95% CI: –22.92, –15.68),95 both in favor of the MRT
the shoulder is held in abduction and internal rotation, the group.101
forearm is in pronation, and the wrist is in flexion. Mill’s
manipulation is performed once in a treatment session. Nu- Yi et al207 examined the effects of a 1-time DFM
merous regional mobilization techniques are described at
the thoracic or cervical spine, radial head, or the wrist for
II coupled with a local lidocaine injection in patients
with LET symptoms >6 weeks. The authors ran-
those with identified impairments in those regions. As long domly allocated treatment into 3 groups; splinting and
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
as these techniques are providing symptom relief, they may stretching, cortisone injection, and DFM plus lidocaine in-
be repeated at subsequent visits (8-12 visits over a time peri- jection. Along with the above individual treatments, all
od of 4-8 weeks have been described most commonly). The groups received a standardized ROM exercise protocol. Only
short-term effectiveness that mobilizations have on individu- the group receiving DFM plus lidocaine injection demon-
als with pain and pain-limited function associated with LET strated significant improvements in outcomes at the 6-month
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
lasting more than 2 weeks may point toward the role that the follow-up compared to the other 2 groups. Although the sam-
nervous system sensitization has on the presentation of LET. ple size was small (total n = 17) for the follow-up data, there
No adverse effects or harms were reported. was a statistically significant greater effect on VAS, DASH,
and grip strength (P<.05) for the DFM plus lidocaine injec-
Gaps in Knowledge tion group at 6 months compared with the other 2 groups.207
The current literature does not address which type of joint No between-group comparison data were given other than P
mobilization technique is superior to others. The midterm value for analysis of variance (ANOVA). The use of DFM ap-
and long-term outcomes of joint mobilization on outcomes pears to hold some merit for midterm functional outcomes,
in LET are unknown. Joint mobilizations/manipulations but the simultaneous lidocaine intervention likely played a
Journal of Orthopaedic & Sports Physical Therapy®
may contribute to diminishing pain and improving motor large role in its effect and may not be feasible for most phys-
function via neurophysiologic mechanisms. Although these ical therapists.
mechanisms are not completely understood, joint mobili-
zations/manipulations may involve reflex inhibition of pain Sevier and Stegink-Jansen165 randomized 113 pa-
mediated through joint mechanoreceptors. II tients with clinical signs of chronic (symptoms last-
ing more than 12 weeks) LET into 2 groups. Both
RECOMMENDATION groups were prescribed eccentric exercises for the common
Clinicians should use local elbow joint manipula- wrist extensors, but the experimental group also received in-
B tion or mobilization techniques to reduce pain and
increase PFGS in individuals with LET as a stand-
strument-assisted soft tissue mobilization. DASH and pain
VAS (0-100) were collected at baseline, 6 weeks, and 6- and
alone or adjunctive treatment in improving short-term out- 12-month follow-up. Participants in the instrument-assisted
comes for those who can tolerate the specific technique. soft tissue mobilization group demonstrated greater gains in
the DASH (standardized ES, 0.40; 95% CI: 0.00, 0.84) and
Clinicians may use manipulation or mobilization grip strength (standardized ES, 0.62; 95% CI: 0.16, 1.07) com-
C techniques directed at the cervical spine, thoracic
spine, and/or wrist as an adjunct to local treatment
pared to the eccentric strengthening group at 6 weeks. How-
ever, there were no differences between the groups at 6- and
for short-term pain relief in individuals with LET when im- 12-month follow-up; no adverse effects were reported.165 The
pairments in those regions are identified. primary investigator declared a conflict of interest being the
Medical Director of the instruments used in the study.
MANUAL THERAPY SOFT TISSUE MOBILIZATIONS
Laimi et al101 compiled a systematic review of RCTs Loew et al110 conducted a systematic review of RCTs
II to evaluate the evidence related to the effectiveness
of myofascial release therapy (MRT) to relieve
II comparing deep transverse tendon cross-friction
massage to control groups or groups with other
chronic musculoskeletal pain and to improve joint mobility, active interventions. The authors reviewed 2 low-quality
cpg30 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
studies, one of which included an RCT on nonsurgical treat- tissue manual therapy techniques and the midterm to long-
ments for common wrist extensor tendinopathy. Pooled term impact of these techniques on symptoms of LET.
MDs of the VAS for pain and function scales (0-100) with
95% CIs were assessed. The mean difference between groups RECOMMENDATION
in pain was −6.6 mm (−28.6, 15.4) and in function was −1.8 Clinicians may use soft tissue mobilizations, includ-
points (−18.6, 15.04) showing no difference between inter- C ing MRT, to improve pain and function in individ-
uals with chronic LET.
ventions. Adverse events and withdrawals due to adverse
events were not assessed or reported.110
Clinicians may use instrument-assisted soft tissue
Blanchette et al19 documented, in their pilot study, C mobilization combined with exercise to improve
II no difference in improvements of PFGS, pain, and
function between a control group (n = 12) and a
pain and function in those with chronic LET.
group receiving instrument-assisted soft tissue mobilization Based on conflicting evidence, a recommendation
(n = 15) after 6 weeks. The control group received education D cannot be made regarding the use of deep trans-
verse tendon cross-friction massage to alleviate
and advice on strategies to reduce stresses to the lateral el-
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
bow, while the experimental group received the instru- symptoms in individuals with LET.
ment-assisted soft tissue mobilization twice a week for 5
weeks. No adverse effects were noted other than temporary DRY NEEDLING
bruises. Upon critical review, it was observed that the study Ugyur et al187 completed an RCT (n = 108) to com-
was underpowered and needed a total of 116 participants to I pare the effectiveness of dry needling (DN) near the
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
achieve a power of .80.19 lateral epicondyle and throughout the ECRB muscle
and corticosteroid injection (CS) in the management of LET.
Evidence Synthesis The PRTEE measuring pain and function was administered
A variety of soft tissue techniques were examined in these at baseline, 3 weeks, and 6 months. Dry needling was more
few studies. Two low-quality studies have demonstrated effective than CS (P<.01) at the 3-week and 6-month fol-
positive effects of MRT on pain and function in individuals low-up and with fewer complications. No ESs were reported.
with chronic LET. Manual release therapy was administered Complications from CS included skin atrophy and whitening
with and without other physical therapy treatments 3 times a (4 individuals), and there was 1 individual who withdrew
week for 4 weeks. Manual release therapy may decrease pain from the study because of pain with the DN procedure.
Journal of Orthopaedic & Sports Physical Therapy®
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg31
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
pain, related-disability, pressure pain sensitivity, and strength lateral counterforce orthosis on pain. In the short term, the
in LET. This meta-analysis included 320 patients from 7 counterforce orthosis did not have a statistically significant
moderate quality studies. Dry needling facilitated a decrease effect (SMD, 0.02; 95% CI: −0.85, 0.80) on pain compared
in pain (SMD, –1.13; 95% CI: –1.64, –0.62), decrease in dis- with other physical therapy interventions for all patients.
ability (SMD, –2.17; 95% CI: –3.34, –1.01), and increase in Similarly, in younger patients (<45 years), there was no sta-
PPT (SMD, 0.98; 95% CI: 0.30, 1.67) with larger ESs mainly tistically significant effect on pain (SMD, −0.86; 95% CI:
in the short term when compared to the control group. One −2.45, 0.72). In the long term, other physical therapy inter-
study specifically examined tendon DN, which demonstrated ventions seemed to have a greater positive effect than the
a large effect on function (MD, −15.91 points; 95% CI: counterforce orthosis as a stand-alone treatment (SMD, 1.17;
−27.28, −4.54; SMD, −0.81) compared with a standard phys- 95% CI: 0.00, 2.34).167 Similar results supporting the use of
ical therapy group consisting of US, DFM, and exercise.56 other physical therapy interventions over the use of a coun-
Grip strength improved when compared to the control group terforce orthosis alone to improve pain and function were
but with a small effect (SMD, 0.48; 95% CI: 0.16, 0.81). also reported in an earlier systematic review.16
There was considerable heterogeneity across all studies, but
overall, there was positive effect of DN on LET symptoms in Heales et al73 completed a systematic review to eval-
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
procedures alone and in conjunction with other therapies (SMD range: −0.83 to −0.65) and improvements in PFGS
reduces pain and improves function in individuals with LET (SMD range: 0.24-0.38) with a forearm counterforce ortho-
and associated trigger points. However, PE demonstrated a sis compared to a control or placebo. Borkholder et al21 also
moderate positive effect on pain and PPT over TDN when found, in their systematic review including 11 low quality
both treatments were combined with eccentric exercise. studies, that use of a counterforce brace, regardless of style,
There is not sufficient evidence to confidently outline the resulted in increased grip and wrist extensor strength in
optimal dosage parameters, needling technique, or depth of symptomatic individuals. In participants wearing a wrist
insertion due to the variety of techniques used in the various support orthosis, the difference in pain decrease during ex-
studies. Frequency of treatment varied from a one-time ses- tensor muscle contraction was greater than in those using a
Journal of Orthopaedic & Sports Physical Therapy®
sion to up to between 2 and 3 times a week for up to 3 weeks. placebo orthosis (MD, −0.48 cm; 95% CI: −0.96, −0.01).73
The available studies suggest minimal to no harmful side ef- Use of a wrist support orthosis has also demonstrated reduc-
fects of the procedure to treat symptoms of LET; however, tions in wrist extensor muscle activity in normal individu-
those with a fear of needles may not tolerate this treatment. als.21 Both systematic reviews supported the use of a
counterforce orthosis to provide an immediate decrease in
Gaps in Knowledge pain and an increase in PFGS; both reviews reported reduc-
More high-quality evidence is needed examining the efficacy tion in pain with contraction, with the use of a wrist support
of both tendon and TDN on symptoms of LET compared orthosis in participants with LET.21,73 However, the partici-
with a true control group. More clear evidence is needed on pants’ gripping ability was impaired while using a wrist sup-
the characteristics of the individuals with LET that would port orthosis.21,73
most benefit from the different DN techniques. Studies
should clearly operationalize the DN technique and dosage Healy et al74 reported on 2 studies examining the
parameters used. The long-term effect of DN on symptoms
in patients with LET is unknown.
II difference between a laser intervention and fore-
arm counterforce orthosis application. One study136
reported a greater reduction in pain in a group receiving laser
RECOMMENDATION when compared to a group receiving a forearm counterforce
Clinicians should use either tendon or TDN for the orthosis (ES, 1.04; 95% CI: 0.35, 1.73), whereas a more re-
B treatment of pain and functional deficits associated
with LET.
cent study53 reported that a group receiving a forearm coun-
terforce orthosis demonstrated greater reduction of pain
than a group receiving sham laser therapy (ES, −0.8; 95% CI:
ORTHOSES −1.45, −0.15). The systematic review calculated the odds of
Shahabi et al167 conducted a meta-analysis that in- treatment success for a group receiving a forearm counter-
II cluded 17 studies (most of low quality), with 1145
participants with LET examining the effect of a
force orthosis alone compared to a group receiving the ortho-
sis plus physical therapy, which was not statistically different
cpg32 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
between groups (OR = 1.44; 95% CI: 0.49, 4.23) at 26 and been shown to improve pain and decrease muscle activity in
52 weeks. the wrist extensors in the immediate term. Although some
reported a decreased ability to grasp with use of a wrist
The systematic review by Bisset et al16 demonstrat- support orthosis no studies reported any adverse effects of
II ed that cortisone injections had a better effect than
either type of orthosis (forearm counterforce or
either counterforce or wrist support orthoses. It should be
noted that the reported studies included individuals with
wrist support) in the short term (RR, 2.9; 95% CI: 1.8, 5.7) symptom duration between 6 weeks and 12 months. Based
on global improvement scores; however, there was no differ- on expert opinion, a forearm counterforce or wrist support
ence in effect on global improvement scores at the interme- orthosis may be appropriate for individuals who have LET
diate (RR, 0.70; 95% CI: 0.46, 1.05) or long term (RR, 0.90; symptoms with high irritability and difficulty performing
95% CI: 0.60, 1.03) time frames.16 Similar results have been functional activities.
reported in another systematic review.172 However, the use of
a forearm counterforce orthosis was more effective in en- Gaps in Knowledge
abling a group of individuals with LET to perform daily ac- Future studies will need to consistently include a true control
tivities in the short term when compared to a group receiving group comparison to ascertain the effect of orthoses on pain,
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
pulsed US plus friction massage and exercise measured on strength, and function in those with LET. Characteristics of
an activity improvement scale ranging from 0 to 100 (MD,11 those individuals who would most benefit from orthosis in-
points; 95% CI: 1, 21).16 terventions need to be studied to determine the true utility of
the forearm counterforce or wrist support orthosis according
A survey of practice patterns of hand therapists (n = to their irritability of symptoms. The use of similar research
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Evidence Synthesis
D cannot be made regarding the use of a forearm
counterforce or wrist support orthosis to alleviate
There is conflicting evidence on whether the use of an or- intermediate or long-term symptoms in individuals with
thosis alone (forearm counterforce or wrist support ortho- LET.
sis) or as adjunct with other treatments provides relief of
symptoms related to LET according to published systematic Clinicians may use a forearm counterforce or wrist
reviews. As a stand-alone treatment, the use of an orthosis
does not appear to be as effective in improving pain and
F support orthosis to be worn during activity for im-
mediate improvement of pain and strength in those
function when compared to other physical therapy inter- with LET whose symptoms are aggravated with activity.
vention or cortisone injections in the long term, although
conflicting evidence exists regarding its benefit compared TAPING
with laser application. The odds for success were no different Two main types of tape and numerous therapeutic taping
whether the orthosis was administered alone or as an ad- techniques are described in the literature. Tape with elastic
junct to physical therapy interventions in the midterm and properties, such as generic kinesiology tape, theoretically de-
long-term time points. creases pain through cutaneous stimulation, which is thought
to alter pain mechanisms and may improve proprioception.63
However, use of a forearm counterforce orthosis appears Rigid tape is a tape with no elastic properties that provides
to diminish pain severity and strength in the immediate support that is primarily thought to help off-load tissues, par-
term compared with a sham counterforce orthosis. The use ticularly for LET, the wrist extensor muscle group. A variety
of a forearm counterforce orthosis may be more effective of techniques of tape application has been used each with
in enabling individuals with LET to perform daily activi- the authors’ purported goal of either pain relief, off-loading
ties in the short term when compared to US plus friction tissue, stimulating or inhibiting muscle function, and/or im-
massage plus exercise. Use of a wrist support orthosis has proving movement patterns.63
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg33
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
Zhong et al209 conducted a meta-analysis to evalu- were presented as percent change in outcomes and unable to
I ate the efficacy and safety of kinesiology tape for
improving outcomes in patients with LET. Five
be pooled. There is evidence to support the immediate effec-
tiveness of the tape on pain and grip strength. However, there
studies with low risk of bias were included and included 168 is conflicting evidence on the medium- and long-term effec-
patients who either received kinesiology tape or a control tiveness of the therapeutic tape.
condition. There were improvements in pain (weighted mean
difference [WMD]: −0.46; 95% CI: −0.90, −0.02), grip Özmen et al139 completed an RCT of 40 patients
strength (WMD, 1.63; 95% CI: 0.27, 3.00), function as mea- II clinically diagnosed with LET to compare the clin-
ical and sonographic effects of US therapy, ESWT,
sured by the Modified Mayo Performance Index (WMD,
4.23; 95% CI: 2.80, 5.65), and function as measured by the and kinesiology tape in LET. The VAS, PRTEE, and grip
DASH score (WMD, −5.25; 95% CI: −9.10, −1.39) in the ki- strength were measured at baseline, 2 weeks, and 8 weeks.
nesiology tape group over the control groups. Each trial in- The VAS score improved in all groups significantly (P<.05).
cluded in the meta-analysis reported skin irritation; however, Only the kinesiology tape groups showed significantly in-
the calculated risk difference in the meta-analysis (0.022; creased grip strength at the 8-week follow-up (P<.05).
95% CI: −0.049, 0.092) did not demonstrate an increase in PRTEE scores significantly decreased after 2 weeks and after
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
risk of skin irritation.209 8 weeks in the US group and ESWT groups, and after 8
weeks in the kinesiology tape group (P<.05). However, at
Bisset et al17 included 1 high-quality study in their 8-week follow-up, no significant differences in improvements
I meta-analysis that examined the immediate effects
of a rigid taping technique on pain and grip strength
in pain, function, or grip strength were demonstrated be-
tween any of the groups.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Improvements in PPT were statistically significant in the rigid cebo using a 5-cm-wide white athletic bandage with no ten-
diamond-deloading taping group compared with the control sion applied for the comparison group. Overall, there was no
group, but not statistically significant when compared to the immediate effect noted across all the outcome measures with
placebo group. Based on the one study, rigid taping in the the application of kinesiology and placebo tape (P>.05 for all
shape of a diamond over the lateral epicondyle to deload the comparisons). The application of kinesiology tape alone was
wrist extensor muscles for the treatment of LET has been not immediately effective in wrist extensor or grip facilitation
demonstrated to improve PFGS in the immediate and short in those with LET.121
term.17
Eighty-seven individuals with a clinical diagnosis of
The evidence on the efficacy of the therapeutic tape II LET and duration of symptoms of at least 3 months
II in the management of LET was systematically re-
viewed.63 The final review included 8 studies, with
were randomized into either a control group or ki-
nesiology tape experimental group.118 Both groups took oral
risk of bias ranging from low to high, which examined rigid naproxen and were instructed in activity modification and a
taping, kinesiology tape, and placebo taping techniques. The home exercise program. Additionally, in the kinesiology tape
immediate- and short-term improvements of rigid strapping group, the tape was applied 3 times a week for 2 weeks for a
on pain and grip strength were generally higher when com- total of 6 sessions using inhibitor (tape placed at the radial
pared to kinesiology tape and placebo. Rigid diamond-de- styloid process to the lateral epicondyle with 25% tension)
loading taping technique demonstrated significantly greater and mechanical correction (tape stretched with 50%-75%
improvement in strength outcomes compared with unaffect- tension targeting the most painful area, and the remaining
ed extremities in multiple studies.168,169,194 Transverse rigid placed without stretching) taping techniques. Clinical (VAS,
taping technique demonstrated significantly greater im- PRTEE) and ultrasonographical (common extensor tendon
provement in joint position and force reproduction error thickness, radial nerve cross-sectional area) measures were
than healthy extremities. Most studies did not report adverse assessed before and after treatment (second week, sixth week,
effects; one study reported no adverse effects.105 The data and 14th week). The common extensor tendon thickness and
cpg34 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
radial nerve cross-sectional area at the level of prebifurca- niques to improve pain and function, as long it controls their
tion significantly improved (decreased) for the kinesiology symptoms and does not cause skin irritation.
tape group compared to the control group at the second,
sixth, and 14th weeks (P<.001). In the kinesiology tape Gaps in Knowledge
group, the decrease in VAS, PRTEE-pain, and PRTEE func- Current evidence examines the immediate and short-term
tion was significant for the fourteenth week (P<.001) but effects of either rigid tape or kinesiology taping applica-
not for the control group. Nonsteroidal anti-inflammatory tion; additional information is needed on the midterm and
drug therapy plus kinesiology tape reduced pain and im- long-term effects of any type of taping. The application of
proved functional status, as well as decreasing the common therapeutic taping may be enhanced by exercise in the long
extensor tendon thickness and radial nerve cross-sectional term, but more evidence is needed. Not enough information
area.118 is available to make a definitive recommendation regard-
ing types of taping strategies or optimal dosages. While no
Tezel et al182 completed a randomized placebo-con- studies suggested a harmful effect of taping, skin irritation
II trolled trial to evaluate short-term effects of kine-
siology tape on pain, function, grip strength, and
is a risk.
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
meta-analysis demonstrated a positive effect of generic ki- controlled trials have investigated their use. Cold is tradi-
nesiology tape over control conditions. Generic kinesiology tionally used to mediate pain and the inflammatory process.
tape plus physical therapy had a positive effect on pain and Theoretically, heat modalities may be used to increase soft
function when compared to sham tape plus physical therapy, tissue extensibility to facilitate stretching and increase local
to physical therapy alone, or to physical therapy plus ESWT. blood flow to enhance healing. No research of acceptable
However, a similar kinesiology tape technique alone was no quality was found related to the effectiveness of hot packs
better in improving outcomes compared with sham taping for symptoms of LET.
alone. Therefore, generic kinesiology tape appears to be more
effective when used as part of a multimodal treatment pro- Macedo et al116 randomized 112 female volunteers
gram compared to being used on its own. II into 1 of 7 groups including a control (rest), ice ap-
plication alone (700-g crushed ice pack on the lat-
Several studies only reported on the immediate effects of tape eral region of the elbow), and conventional and burst TENS
application, which supports the immediate effectiveness of the groups with and without ice application to the lateral elbow.
tape on pain and grip strength. However, there is conflicting Pressure pain threshold was measured immediately before
evidence on the medium and long-term effectiveness of the and after treatment application. In the immediate short
therapeutic tape. The application of tape ranged from 1-time term, those groups who received cryotherapy alone, burst
application to 2-3 times over 2 weeks; the mean duration of TENS alone, and a combination of the 2 improved signifi-
symptoms of individuals included in studies ranged from ap- cantly. The burst TENS + cryotherapy group showed signifi-
proximately 5 weeks to 14 months. No serious adverse effects cantly superior pain tolerances (MD, 4.9; 95% CI: 4.8, 5.0)
were reported; the most common minor adverse effect was compared with all other groups.116
mild skin irritation with the use of tape.
Agostinucci et al1 reported a blinded controlled study
Individuals who have LET symptoms with high irritability
may benefit from either rigid or kinesiology taping tech-
III in which 71 individuals with symptoms of LET
greater than 3 months were randomized into 1 of 4
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg35
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
home program treatment groups: exercise only, gel cold pack 1.65) at 3-month follow-up.17 Later systematic reviews found
plus exercise, an extended-release cold pack plus exercise, and limited evidence that US was more effective in providing pain
an extended-release cold pack only. Each treatment regimen relief and improving pain-free function than chiropractic
was performed twice a day, at least 4 days a week, for 6 weeks. care and exercise in the short term (6 weeks)82 and that US
All 4 treatment groups demonstrated similar improvements was more effective at reducing pain than a placebo treatment
in pain, grip strength, and function as measured by the DASH; at 13 weeks (SMD, −0.98; 95% CI: −1.64, −0.33).50 In a more
however, no significant differences in improvement were ob- recent study, 51 subjects with LET symptoms for less than
served between groups (P>.05).1 Without a control group as a 6 months were randomized into 3 groups: continuous US (1.5
comparison, we are unable to determine effectiveness of the MHz, 1 W/cm2, 5-cm applicator), pulsed US (1:4), and sham
different interventions included in this study. US.85 All participants received 10 treatments once per day for
over 2 weeks. Although no differences between groups was
Evidence Synthesis seen at 2 weeks (P<.05), both continuous and pulsed US
Burst TENS + cryotherapy to the lateral elbow appears to groups demonstrated greater improvements in pain (VAS)
improve immediate pain thresholds compared with no treat- and function (PRTEE) compared with the sham US group
ment and the application of either modality alone in partici- (P<.05) at 6-week follow-up.85 Mean differences and effect
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
pants with greater than 3 months symptom duration. The use sizes were not reported.
of gel and extended-release cold packs with or without exer-
cise demonstrated similar improvement in outcomes when Studies comparing US to ESWT have had conflict-
compared to exercise alone. There is no evidence to suggest
that the use of cryotherapy has any adverse effect when used
II ing results. A clinical trial109 compared the analge-
sic effects of ESWT to those receiving US therapy
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
with patients who have LET. Moreover, no evidence that ex- (1 MHz, 0.8 W/cm2 for <10 minutes) in patients with chronic
amined the effect of cryotherapy on individuals with irritable LET (>12 months duration of symptoms). Patients were ran-
symptoms of LET was located. Given the known effects on domized to receive ESWT (5 treatments, once per week) or
the inflammatory process, the use of cryotherapy in irritable therapeutic US (10 treatments, 3 times a week). There was a
symptoms may be more impactful. significantly greater reduction in pain in the group receiving
ESWT (88% reporting good or excellent pain reduction)
Gaps in Knowledge compared to the US group (28% reporting good or excellent
No evidence examining the use of heat for the treatment of pain reduction) immediately posttreatment.109 However, re-
LET was located. No evidence examining the effects of cryo- sults differed in later studies. Yalvac et al206 compared ESWT
Journal of Orthopaedic & Sports Physical Therapy®
therapy on pain and function, specifically in individuals with and therapeutic US (1.5 MHz, 1 W/cm2 for 5 minutes) once
irritable symptoms, was located. There were no trials exam- per day for 10 days for the treatment of LET. A total of 44
ining the effects of ice massage. High-quality clinical trials patients with chronic (>3 months) LET were included. Pa-
that include a control group or placebo group to compare tients were evaluated before therapy, immediately after ther-
with cryotherapy interventions are needed to fully elucidate apy, and 1 month after treatment on the PRTEE, Short
the benefit of ice. Additionally, identifying subgroups of pa- Form-36 (SF-36), VAS for pain, grip strength, and Quick-
tients with LET who would most likely benefit from cryother- DASH. Both ESWT and therapeutic US were equally effec-
apy, based on behavior of symptoms, is needed. tive in treating LET in the short term especially with
improving VAS pain scores (MDs > 22/100 for both treat-
RECOMMENDATION ments) and QuickDASH scores (MDs > 15/100 for both
Clinicians may use cryotherapy combined with treatments).206 However, no differences in improvement in
C burst TENS to reduce pain in the short term in in-
dividuals with symptoms of LET for greater than
any of the outcomes were demonstrated in either group; the
benefits over a placebo or control group were not evaluated.
30 days. In a similar study, Özmen et al139 also found that US was not
superior to either ESWT in reducing symptoms of pain (P =
Clinicians may use cryotherapy to reduce pain in .112), function (P = .450), or grip strength (P = .956) in pa-
E individuals with irritable symptoms of LET. tients with LET.
Evidence Synthesis
THERAPEUTIC ULTRASOUND There is conflicting evidence for US as a stand-alone treat-
When looking at US as a stand-alone treatment, a ment in decreasing pain and improving function. When com-
II 2005 meta-analysis of 4 studies found that the
pooled effect for global improvement was not sta-
pared to ESWT, US does not appear to have better outcomes.
However, as identified in earlier sections, exercise and mobi-
tistically different between groups (RR, 1.01; 95% CI: 0.62, lization sections were more effective than US as a stand-alone
cpg36 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
treatment. It should be noted that a variety of parameters rest (P = .07), PPT (P = .89), grip strength in elbow extension
were used in studies with 1, 1.5, or 3 MHz frequency; 0.5 to (P = .06), or function (P = .97).7 No control group was used
1 W/cm2 intensities; 3 to 5 cm2 applicators; continuous or as a comparison; therefore, improvements could have been a
pulsed US (1:4); and treatment times between 5 and 10 min- result of natural history. Although, symptom acuity and se-
utes applied directly over the lateral epicondyle. Ultrasound verity were not described, participants reported average
was most commonly administered for 10 treatments ranging symptom duration of between 44 and 48 weeks and were
from daily to 3 times a week. While there does not seem to be presumably not in an inflammatory state. The administra-
a benefit for US as a stand-alone treatment over exercise and tion of anti-inflammatory medications delivered through
mobilization, no studies suggested a harmful effect from US. both phonophoresis and iontophoresis may not have been as
effective as if they were administered in the early inflamma-
Gaps in Knowledge tory stages of LET.
US parameters differed among studies making compari-
sons difficult. High-quality controlled studies on the effects Nagrale et al128 compared 2 groups (n = 60) with
of both thermal and pulsed US in individuals with LET are
needed. Examination of the optimal parameters including
II LET with a duration of symptoms of 1 month or
more, who were randomly assigned to receive either
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US wave frequency, magnitude of application time, and clear 10 minutes of deep transverse friction massage plus a single
delineation of treatment area is needed in this patient popu- application of Mill’s manipulation for each session or phono-
lation. Studies should include control or placebo groups and phoresis using a 1% diclofenac sodium gel plus supervised
should identify subgroups of patients with LET who would exercise. Phonophoresis was applied using continuous mode,
most likely benefit from US, based on acuity, and behavior of 1 MHz, at 0.8 W/cm2 over the area of the lateral epicondyle
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
symptoms. Study designs to determine whether US is most for 5 minutes. The supervised exercise program consisted of
effective when performed in isolation or as an adjunct to oth- static stretching followed by eccentric strengthening of the
er treatments are also needed. wrist extensors. Both groups demonstrated improvement in
pain, PFGS, and function as measured by the PTREE at 4 and
RECOMMENDATION 8 weeks. However, the group receiving transverse friction
Based on conflicting evidence, a recommendation massage and manipulation demonstrated significantly better
D cannot be made for the use of US as a stand-alone
treatment.
scores on all measures (P<.05) than the group receiving pho-
nophoresis plus supervised exercise at all follow-up periods
except day 1. The calculated effect size of this group at the
Journal of Orthopaedic & Sports Physical Therapy®
PHONOPHORESIS 8-week follow-up was 0.74 for PFGS, −0.74 for function, and
Baktir et al7 in 2018 conducted an RCT to compare −0.81 for VAS.128 The average symptom duration in the group
II the effectiveness of low-intensity laser therapy
(LILT), phonophoresis, and iontophoresis. Fifteen
receiving manipulation was 14.5 and 12.5 weeks in the pho-
nophoresis group. It may have been more appropriate for the
participants were randomized to each group; however, 3 par- investigators to select a subgroup of individuals with a more
ticipants each in the LILT and phonophoresis groups and 2 acute, inflammatory phase of LET to assess the effectiveness
participants in the iontophoresis group discontinued treat- of the anti-inflammatory medication administration through
ment for unreported reasons. The LILT group received laser phonophoresis.
applied with a wavelength of 904 nm, 50 Hz, and a maxi-
mum peak power of 0.12 mW to the lateral epicondyle, and The low-quality evidence presented in the system-
4 painful points surrounding it for an unknown amount of
time; the phonophoresis group received prednisolone (2
II atic review by Bisset et al16 indicates that there does
not appear to be a positive effect of phonophoresis
mg/d) mixed with water-based US gel applied with a 5-cm2 when compared to US in individuals with LET. There was no
applicator at 1 W/cm2 and 1 MHz for 7 minutes to the lateral significant difference between groups in global improvement
epicondyle; and the iontophoresis group received direct cur- (RR, 2.7; 95% CI: 0.34, 21.53), pain (SMD, 0.25; 95% CI:
rent electrical stimulation using 5 mL of 0.4% prednisolone –0.66, 1.15), or in PFGS (SMD, 0.32; 95% CI: −0.59, 1.23) in
to the active negative electrode placed over the lateral epi- the short term (5 weeks) when US was compared to phono-
condyle for 40 mA min. All participants received treatment phoresis using a hydrocortisone coupling gel in individuals
5 times a week for 3 weeks. The pain VAS, PPT algometer, with LET.17,178 A second study70 reported no statistically sig-
the PRTEE, and grip strength dynamometer were used to nificant difference in pain (McGill Pain Questionnaire) be-
measure outcomes at baseline and at the end of 15 sessions. tween a home exercise program and each of the following
Within-group mean change in scores were reported for each conditions: US, phonophoresis (10% hydrocortisone), TENS,
outcome. Although all groups improved, there were no sig- or injection (reported as not significant; P value not report-
nificant differences between group improvements in pain at ed). However, all groups were reported to have improved
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg37
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
significantly from baseline to the last day of treatment (day in the galvanic current group reduced from 3.50 ± 2.11 to
5). Evidence in this systematic review does not support the 2.50 ± 1.57 (P = .032) and the iontophoresis group demon-
use of phonophoresis for short-term relief of symptoms due strated pain reduction from 3.83 ± 1.80 to 0.58 ± 0.99
to LET. (P<.001). Pain with exertion and PTREE scores were also less
in the iontophoresis group compared with the galvanic cur-
Evidence Synthesis rent group (P<.001). No significant differences in grip
A preponderance of level 2 studies, including 1 systematic strength were seen between groups.41 The authors did not
review and 2 RCTs, demonstrate no benefit of phonophoresis mention adverse effects of either modality.
application (with 10% hydrocortisone gel, topical predniso-
lone [2 mg/d], or 1% diclofenac sodium gel) over US alone, As part of the RCT by Baktir et al7 described in the
TENS, LILT, iontophoresis, cortisone injection, or friction
massage plus Mill’s manipulation to the elbow. Weak evi-
II section on phonophoresis, evidence supports the
efficacy of iontophoresis delivered with predniso-
dence suggests that other interventions, such as massage and lone-saline solution (5 mL of 0.4% prednisolone), after ap-
manipulation, may be more effective than phonophoresis in proximately 15 treatment sessions over 3 weeks of
the management of LET. Studies examining the effects of an- iontophoresis as a stand-alone modality in patients with an
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
ti-inflammatory medications delivered through phonopho- average duration of symptoms equal to 12 months. Along
resis have not consistently targeted subgroups of individuals with improvements in pain (ES = 1.22), improvements in
with acute or highly irritable symptoms who may benefit function and grip strength were also associated with the ion-
from the delivery of these medications. No adverse effects or tophoresis group (PRTEE: P = .006, ES = 0.78; grip strength
complications were reported in any of the studies. with elbow extension, P = .011, ES = 1.03; grip strength with
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
cpg38 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
demonstrated no significant differences between groups re- of symptoms), in individuals presenting with highly irritable
ceiving a corticosteroid solution administered by iontophore- symptoms of LET.
sis when compared to those receiving a placebo in the short
term (1-3 months) (RR, 1.09; 95% CI: 0.77, 1.53) or in the TENS
long term (6-12 months) (RR, 1.52; 95% CI: 0.97, 2.38). One Macedo et al116 randomized 112 female volunteers,
study examined the effect of a nonsteroidal anti-inflammatory II with mean age of 22 years, into 1 of 7 groups for a
1-time intervention: (1) control (rest for 25 min-
medication (pirprofen) delivered by iontophoresis at both
high and low doses compared to saline or sham iontophoresis. utes), (2) placebo TENS (TENS unit turned on, but with zero
The iontophoresis groups demonstrated significant improve- amplitude), (3) conventional TENS (symmetrical biphasic
ments in pain (VAS) and function (a functional impairment pulsed current, with frequency of 100 Hz, pulse duration of
rating scale) in the short term.17 100 μs, and sensory-level amplitude), (4) burst TENS (car-
rier frequency of 100 Hz burst modulated at 4 Hz, pulse
In a systematic review by Kohia et al,98 2 of the 12 duration of 200 μs, and motor-level amplitude), (5) cryo-
II articles examined the effectiveness of iontophore-
sis. The first compared naproxen iontophoresis to
therapy (700-g crushed ice pack on the lateral region of the
elbow), (6) cryotherapy in combination with burst TENS,
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naproxen phonophoresis with both groups receiving a stan- and (7) cryotherapy in combination with conventional
dard physical therapy program after application of the mo- TENS. A pressure algometer was used to obtain the pain
dality. The other study compared sodium diclofenac and threshold and tolerance of each volunteer during initial
sodium salicylate iontophoresis with both groups receiving (pre) and final (post)assessments. Immediate results indi-
infrared treatment (no data provided). Weak evidence (no cated that the groups receiving burst TENS alone (pain tol-
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
data provided) supported the use of sodium diclofenac over erance; MD, 3.8; 95% CI: 3.7, 3.9), cryotherapy alone (pain
sodium salicylate iontophoresis for reducing symptoms of tolerance; MD, 1.9; 95% CI: 1.8, 2.0), and burst TENS in
LET in the short term (less than 6 months). Naproxen ionto- combination with cryotherapy (pain tolerance; MD, 4.9;
phoresis and phonophoresis both resulted in similar im- 95% CI: 4.8, 5.0) improved significantly with pain thresh-
provements in grip strength and pain.98 This systematic olds and tolerance. In addition, burst TENS + cryotherapy
review was not included in the review by Bisset et al.16 produced significantly (P<.001) superior pain tolerances
across all other groups.116
Evidence Synthesis
Weak evidence demonstrates a benefit of using iontophoresis Dingemanse et al50 in their systematic review of
Journal of Orthopaedic & Sports Physical Therapy®
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg39
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
At final examination (6 weeks), the between-group MD in pain A recent systematic review and meta-analysis by
was −0.33 (95% CI: −0.96, 0.31).30 II Lian et al108 pooled data from 6 randomized pla-
cebo-controlled trials that included some form of
Evidence Synthesis laser therapy (high intensity, low intensity, Ga-As, He-Ne).
One level 2 study supports the use of burst-modulated TENS When assessing grip strength, there was no significant dif-
using a frequency of 100 Hz, burst modulated at 4 Hz, pulse ference (SMD, 0.284; 95% CI: −0.147, 0.714) in follow-up
duration of 200 μs, and motor-level amplitude for 25 min- periods ≤4 weeks. However, there was significant improve-
utes, with or without cryotherapy, to manage pain over no ment in grip strength (SMD, 0.576; 95% CI: 0.286, 0.866)
treatment, cryotherapy alone, or conventional TENS alone when looking at follow-up periods 5-26 weeks. Laser ther-
or applied with an ice pack for immediate pain relief in indi- apy was also found to demonstrate significant analgesic
viduals with LET. Weak evidence supports the use of high- or effects (SMD, 1.313; 95% CI: 0.514, 2.111) between 5 and
low-frequency TENS applied to acupuncture points for pain 26 weeks.108
relief over placebo TENS for 20 minutes, 3 times a week for
2 weeks. One level 2 study demonstrates no difference be- Baktir et al7 compared LILT (904 nm), phonopho-
tween high-frequency TENS application plus education and
II resis (1 W/cm2, 1 MHz with 2 mg/d prednisolone),
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exercise instruction, and education and exercise instruction and iontophoresis (0.4% prednisolone 40 mA/min)
alone. As with any electrical modality, contraindications and in an RCT with 37 subjects with pain for at least 1 month.
precautions should be considered before the application of After 15 treatment sessions (5 times a week for 3 weeks) the
TENS. No consistent description of which individuals with LLIT and iontophoresis groups were found to have a signifi-
LET may benefit most from the addition of TENS to treat- cant reduction in pain VAS (P = .016-0.008; ES, 0.58-1.49)
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ment was found. No study reported any adverse responses to and PRTEE (P = .04-0.0006; ES, 0.78-0.92) scores. Howev-
the application of TENS. er, the differences between the 3 groups were not significant
(P = .07-.97). All subjects were treated 5 times a week for
Gaps in Knowledge 3 weeks.
High-quality clinical trials are needed to further substantiate
the benefit of TENS for short-term, midterm, and long-term Six earlier systematic reviews have also assessed the effec-
pain relief in patients with symptoms of LET. It is unclear as tiveness of LILT on LET.17,19,27,50,172,185 refvariety of parame-
to which subgroups of patients with LET based on behavior ters were noted,17,19,50,172,185 Bisset et al19 and Tumilty et al185
of symptoms would best benefit from the use of TENS for identified that a 904-nm wavelength applied directly over
Journal of Orthopaedic & Sports Physical Therapy®
pain control. The effect of specific parameters and differences the common extensor tendon may have a positive effect on
in placement of TENS electrodes on pain has not been clearly short-term pain and functional outcomes that may not last
established. beyond 6 weeks. Chang et al27 found that when looking at
pain reduction with LILT applied to tender points or myo-
RECOMMENDATION fascial trigger points, there was an immediate effect (pooled
Clinicians may use burst TENS applied to the pain- ES, −0.71; 95% CI: −0.82,~−0.60), as well as at follow-up
C ful region or high- or low-frequency TENS applied
to acupuncture points, for short-term pain relief in
time between 3 and 8 weeks (pooled ES, −1.05; 95% CI:
−1.16,~−0.94). Low-intensity laser therapy application was
individuals with LET. also able to increase the grip force (pooled ES, 1.09; 95% CI:
0.91, 1.27) and ROM (pooled ES, 0.72; 95% CI: 0.50,0.94)
LASER at follow-up ranging between 4 to 8 weeks.
Kaydok et al94 randomized 60 patients with symp-
I toms greater than 4 weeks into 2 groups to com-
pare the short-term effectiveness of HILT (1064
Evidence Synthesis
Five of six systematic reviews/meta-analyses from 2005 to
nm; Phase I: 3 sessions 6 J/cm2 and Phase II: 6 sessions 2014 report conflicting results and significant heterogeneity
120-150 J/cm2) and LILT (904 nm, 2.4 J/cm2). Along with of LILT parameters in studies examining its effect on out-
laser treatments being applied 3 times a week for 3 weeks, comes in patients with LET greater than 4 weeks symptom
both groups received a lateral counterforce brace. While both duration. Recommended parameters for laser included LILT
groups showed significant improvements in VAS, Quick- with 904-nm wavelength directly over the common extensor
DASH, SF-36, and handgrip strength measured at 3 weeks tendon or most painful area of the lateral epicondyle for 9
(P<.001), the HILT had better handgrip strength (27.3 vs treatment sessions applied over a period of 2 to 3 consecutive
22.5 kg, P = .018), QuickDASH scores (24.2 vs 30.1 kg, P = weeks. More recent studies have looked at 3-week outcomes
.046), and SF-36 (physical component) scores (63.3 vs 59.4 to find LILT, phonophoresis, and iontophoresis not being sig-
kg, P = .014) at 3 weeks. nificantly different and HILT being more effective than LILT.
cpg40 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
A 2019 meta-analysis showed, in 6 randomized placebo-con- cles28,46,67 pertained to LET; however, due to the lack of
trolled studies of adequate quality, a moderate positive effect of high-quality evidence on workplace management of LET, no
LILT on pain and grip strength in follow-up times 5 weeks to 6 recommendations specific to LET were made.
months. Most studies gave no information on adverse effects;
the studies that did reported no adverse events occurred. Evidence Synthesis
The addition of a workplace-based educational interven-
Gaps in Knowledge tion to standard hand therapy intervention did not result
More high-quality placebo-controlled trials are needed to in improved outcomes over standard hand therapy alone in
elucidate the effect of LILT; additionally, it is possible that workers with work-related LET. Ergonomic interventions
specific subgroups of patients with symptoms of LET would including education, behavioral modification, ergonomic
benefit from the treatment based on behavior of symptoms. equipment, and workstation adjustments to improve postur-
Considerable heterogeneity continues to exist in the param- al and UE alignment were not sufficient to reduce symptoms
eters used to deliver LILT, and therefore, studies to deter- in an administrative assistant with LET, in the absence of
mine optimal LILT parameters for mitigating symptoms of other interventions. Very little evidence pertains specifically
LET are needed. More research is needed to directly compare to LET in the literature relating to the effects of ergonomic
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LET. Activity modifications to diminish stress on the wrist adjustments, and ergonomic equipment, such as nonstan-
extensors are an important aspect of rehabilitation. Modi- dardized or alternative keyboards and computer mice in
fiable risk factors including repetitive motions of the elbow, individuals with LET whose symptoms are suspected to be
forearm, wrist, and hand that aggravate symptoms should be associated with workplace overuse.
minimized, as should lifting objects with the forearm rotated
in a pronated position. RECOMMENDATION
Clinicians may use ergonomic interventions in the
Tran et al184 examined the impact of the addition of E management of symptoms in individuals with LET;
II a workplace-based education intervention to a stan-
dardized hand therapy intervention in workers with
the implementation of education, behavioral modi-
fication, ergonomic equipment, and workstation adjustments
either acute or chronic unilateral LET. Forty-nine workers is moderately supported by best practice/standard of care.
were randomized into a control group of standardized hand
therapy alone (n = 25) or into the experimental group who Interventions Conclusions
also received the workplace education (n = 24). Six individuals Despite multiple RCTs, systematic reviews, and meta-analyses,
in the experimental group did not receive the treatment as investigating physical therapist management of LET, there is
allocated. Both groups demonstrated improvements in pain not one intervention that stands out as superior to others. The
(NPRS), PFGS, and in function (PRTEE and PSFS); however, need for multiple interventions seems to reflect the multifacto-
no statistically significant differences were detected between rial etiology of the condition. Moreover, most studies designate
groups pain-free grip ES = −.087 and PRTEE combined ES = broad inclusion criteria, resulting in heterogeneous samples.
.182 (P<.05). The study was likely underpowered. Few attempts are made to utilize subgroups of patients (eg,
based on acuity, distribution, severity, and irritability of symp-
Dick et al49 conducted a systematic review of stud- toms) who are most likely to benefit from any given interven-
II ies examining the use of workplace interventions
for a variety of disorders of the UE. Three arti-
tion. This may also contribute to the lack of conclusive evidence
on optimal treatment approaches for individuals with LET.
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg41
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
Individuals who present with symptoms that are unpredict- acute to chronic phases of the condition) are more likely to
able, are easily irritated with activity, are severe in terms of benefit from progressive initiation of therapeutic exercise
intensity, and/or are deemed by the clinician to be either including strengthening and a gradual weaning from inter-
acute in nature or are an acute exacerbation of persistent/ ventions aimed at reducing pain.
chronic LET should be monitored closely for their response
to treatment. Management with physical agents that target The context in which the individual is required to function (eg,
inflammation (eg, cryotherapy or iontophoresis to admin- household, work, and/or athletic activities) in addition to the
ister anti-inflammatory medications) and/or interventions presentation of symptoms should be considered when establish-
that mitigate pain (eg, manual therapy techniques, orthoses, ing the plan of care for an individual with LET. Efforts to off-
taping, electrophysical agents) may be beneficial to stabilize load the irritated tissues should be initiated within the context
symptoms in the early phase (first 1-2 weeks) of the acute of the individual’s environment through education and activity
presentation or exacerbation of symptoms. Using physical modifications related to modifiable risk factors, particularly bio-
agents that target the inflammatory process are only appro- mechanical overloading of the wrist and digit extensors is im-
priate for patients who are exhibiting symptoms that are de- portant throughout the course of care. Gradual reintroduction
termined to be acute or inflammatory in nature. of tissue loading to optimize tissue health is needed to restore
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cpg42 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Journal of Orthopaedic & Sports Physical Therapy®
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Decision Tree
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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
cpg43
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cpg44
|
december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
PhD Center for Sports Medicine Assistant Professor and Field Leader, Clinical Practice Guidelines
Professor Upper Extremity Rehabilitation,
University of Pittsburgh Medical Center Academy of Orthopaedic Physical
CIHR Chair in Gender, Work and Health Western University
Pittsburgh, PA Therapy, APTA, Inc
Dr. James Roth Chair in Musculoskeletal Associate Scientist, Lawson Health
martinr280@duq.edu
Measurement and Knowledge Research Institute La Crosse, WI
Translation London, Canada and
Co-director, Hand and Upper Limb REVIEWERS mszeker3@uwo.ca Professor
Centre Clinical Research Laboratory John DeWitt, PT, DPT, AT
Physical Therapy
Hand and Upper Limb Centre, St Board-Certified Clinical Specialist in Paul F. Beattie, PhD, PT, OCS, FAPTA,
Joseph’s Health Centre Sports Physical Therapy NREMT Marquette University
London, Canada Associate Director, Education and Distinguished Clinical Professor Marquette, WI
jmacderm@uwo.ca Professional Development, Wexner Emeritus guy.simoneau@marquette.edu
Journal of Orthopaedic & Sports Physical Therapy®
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg45
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
patient rated tennis elbow evaluation. Rheumatol Int. 2010;30:1049- Rheum Dis. 2005;64:118-123. https://doi.org/10.1136/ard.2003.019349
1054. https://doi.org/10.1007/s00296-009-1101-6
23. Bunata ER. Anatomic factors related to the cause of tennis el-
6. Armstrong AD, MacDermid JC, Chinchalkar S, Stevens RS, King GJ.
bow. J Bone Jt Surg (American). 2007;89:1955. https://doi.
Reliability of range-of-motion measurement in the elbow and fore-
org/10.2106/00004623-200709000-00010
arm. J Shoulder Elb Surg. 1998;7:573-580. https://doi.org/10.1016/
S1058-2746(98)90003-9 24. Cacchio A, Necozione S, MacDermid JC, et al. Cross-cultural adap-
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
cpg46 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
SDFGSDFGSDFGDFG
35. Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of cortico- 52. Dones VC, Grimmer K, Thoirs K, Suarez CG, Luker J. The diagnos-
steroid injection, physiotherapy, or both on clinical outcomes in patients tic validity of musculoskeletal ultrasound in lateral epicondylalgia:
with unilateral lateral epicondylalgia: a randomized controlled trial. a systematic review. BMC Med Imaging. 2014;14:10. https://doi.
JAMA. 2013;309:461-469. https://doi.org/10.1001/jama.2013.129 org/10.1186/1471-2342-14-10
36. Coombes BK, Bisset L, Vicenzino B. A new integrative model of lat- 53. Dundar U, Turkmen U, Toktas H, Ulasli AM, Solak O. Effectiveness
eral epicondylalgia. Br J Sports Med. 2009;43:252-258. https://doi. of high-intensity laser therapy and splinting in lateral epicondyli-
org/10.1136/bjsm.2008.052738 tis; a prospective, randomized, controlled study. Lasers Med Sci.
37. Coombes BK, Bisset L, Vicenzino B. Cold hyperalgesia associated with 2015;30:1097-1107. https://doi.org/10.1007/s10103-015-1716-7
poorer prognosis in lateral epicondylalgia: a 1-year prognostic study of 54. Ekstrom RA, Holden K. Examination of and intervention for a patient with
physical and psychological factors. Clin J Pain. 2015;31:30-35. https:// chronic lateral elbow pain with signs of nerve entrapment. Phys Ther.
doi.org/10.1097/AJP.0000000000000078 2002;82:1077-1086. https://doi.org/10.1093/ptj/82.11.1077
38. Coombes BK, Connelly L, Bisset L, Vicenzino B. Economic evaluation 55. Esmaeilzadeh S, Ozcan E, Capan N. Effects of ergonomic intervention on
favours physiotherapy but not corticosteroid injection as a first-line work-related upper extremity musculoskeletal disorders among comput-
intervention for chronic lateral epicondylalgia: evidence from a ran- er workers: a randomized controlled trial. Int Arch Occup Environ Health.
domised clinical trial. Br J Sports Med. 2016;50:1400-1405. https://doi. 2014;87:73-83. https://doi.org/10.1007/s00420-012-0838-5
org/10.1136/bjsports-2015-094729 56. Etminan Z, Razeghi M, Ghafarinejad F. The effect of dry needling of
39. Cullinane FL, Boocock MG, Trevelyan FC. Is eccentric exercise an effec- trigger points in forearm’s extensor muscles on the grip force, pain
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
tive treatment for lateral epicondylitis? a systematic review. Clin Rehabil. and function of athletes with chronic tennis elbow. J Rehabil Sci Res.
2014;28:3-19. https://doi.org/10.1177/0269215513491974 2019;6:27-33.
40. da Costa JT, Baptista JS, Vaz M. Incidence and prevalence of upper-limb 57. Farrar JT, Young JP, LaMoreaux L, Werth JL, Poole RM. Clinical impor-
work related musculoskeletal disorders: a systematic review. Work. tance of changes in chronic pain intensity measured on an 11-point
2015;51:635-644. https://doi.org/10.3233/WOR-152032 numerical pain rating scale. Pain. 2001;94:149-158. https://doi.
41. da Luz DC, de Borba Y, Ravanello EM, Daitx RB, Döhnert MB. Ionto- org/10.1016/S0304-3959(01)00349-9
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
phoresis in lateral epicondylitis: a randomized, double-blind clinical 58. Fenwick SA, Hazleman BL, Riley GP. The vasculature and its role in the
trial. J Shoulder Elb Surg. 2019;28:1743-1749. https://doi.org/10.1016/j. damaged and healing tendon. Arthritis Res. 2002;4:252-260. https://doi.
jse.2019.05.020 org/10.1186/ar416
42. da Silva Camassuti PA, Marcolino AM, Tamanini G, Barbosa RI, 59. Fernández-Carnero J, Cleland JA, Arbizu RLT. Examination of motor
Barbosa AM, de Cássia Registro Fonseca M. Inter-rater, intra-rater and hypoalgesic effects of cervical vs thoracic spine manipulation in
and inter-instrument reliability of an electrogoniometer to mea- patients with lateral epicondylalgia: a clinical trial. J Manip Physiol Ther.
sure wrist range of motion. Hand Ther. 2015;20:3-10. https://doi. 2011;34:432-440. https://doi.org/10.1016/j.jmpt.2011.05.019
org/10.1177/1758998315570681 60. Fernández-Carnero J, Fernández-de-las-Peñas C, Cleland JA. Immediate
43. Day JM, Lucado AM, Dale RB, Merriman H, Marker CD, Uhl TL. The effect hypoalgesic and motor effects after a single cervical spine manipu-
of scapular muscle strengthening on functional recovery in patients with lation in subjects with lateral epicondylalgia. J Manip Physiol Ther.
lateral elbow tendinopathy: a pilot randomized controlled trial. J Sport 2008;31:675-681. https://doi.org/10.1016/j.jmpt.2008.10.005
Journal of Orthopaedic & Sports Physical Therapy®
Rehabil. 2021;30:744-753. https://doi.org/10.1123/jsr.2020-0203 61. Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. Validity of four
44. Day JM, Lucado AM, Uhl TL. A comprehensive rehabilitation pro- pain intensity rating scales. Pain. 2011;152:2399-2404. https://doi.
gram for treating lateral elbow tendinopathy. Int J Sports Phys Ther. org/10.1016/j.pain.2011.07.005
2019;14:818-834. https://doi.org/10.26603/ijspt20190818 62. Fredberg U, Stengaard-Pedersen K. Chronic tendinopathy tissue pathol-
45. De Smedt T, de Jong A, Van Leemput W, Lieven D, Van Glabbeek F. ogy, pain mechanisms, and etiology with a special focus on inflamma-
Lateral epicondylitis in tennis: update on aetiology, biomechanics and tion: chronic tendinopathy tissue pathology. Scand J Med Sci Sports.
treatment. Br J Sports Med. 2007;41:816-819. https://doi.org/10.1136/ 2008;18:3-15. https://doi.org/10.1111/j.1600-0838.2007.00746.x
bjsm.2007.036723 63. George CE, Heales LJ, Stanton R, Wintour S-A, Kean CO. Sticking to the
46. Derebery VJ, Devenport JN, Giang GM, Fogarty WT. The effects of facts: a systematic review of the effects of therapeutic tape in lateral epi-
splinting on outcomes for epicondylitis. Arch Phys Med Rehabil. condylalgia. Phys Ther Sport. 2019;40:117-127. https://doi.org/10.1016/j.
2005;86:1081-1088. https://doi.org/10.1016/j.apmr.2004.11.029 ptsp.2019.08.011
47. Descatha A, Albo F, Leclerc A, et al. Lateral epicondylitis and physical 64. Goodman G, Kovach L, Fisher A, Elsesser E, Bobinski D, Hansen J. Effec-
exposure at work? a review of prospective studies and meta-analysis. tive interventions for cumulative trauma disorders of the upper extremity
Arthritis Care Res. 2016;68:1681-1687. https://doi.org/10.1002/acr.22874 in computer users: practice models based on systematic review. Work
48. Descatha A, Dale AM, Jaegers L, Herquelot E, Evanoff B. Self-report- (Read Mass). 2012;42:153-172. https://doi.org/10.3233/WOR-2012-1341
ed physical exposure association with medial and lateral epicon- 65. Gruchow HW, Pelletier D. An epidemiologic study of tennis el-
dylitis incidence in a large longitudinal study. Occup Environ Med. bow. Incidence, recurrence, and effectiveness of prevention
2013;70:670-673. https://doi.org/10.1136/oemed-2012-101341 strategies. Am J Sports Med. 1979;7:234-238. https://doi.
49. Dick FD, Graveling RA, Munro W, Walker-Bone K. Workplace management org/10.1177/036354657900700405
of upper limb disorders: a systematic review. Occup Med (Oxf Engl). 66. Guyatt GH, Sackett DL, Sinclair JC, Hayward R, Cook DJ, Cook RJ. Users’
2011;61:19-25. https://doi.org/10.1093/occmed/kqq174 guides to the medical literature. IX. A method for grading health care
50. Dingemanse R, Randsdorp M, Koes BW, Huisstede BMA. Evidence for recommendations. JAMA. 1995;274:1800-1804. https://doi.org/10.1001/
the effectiveness of electrophysical modalities for treatment of me- jama.1995.03530220066035
dial and lateral epicondylitis: a systematic review. Br J Sports Med. 67. Haahr JP, Andersen JH. Prognostic factors in lateral epicondylitis: a
2014;48:957-965. https://doi.org/10.1136/bjsports-2012-091513 randomized trial with one-year follow-up in 266 new cases treated with
51. Dones VC, Grimmer K, Milanese S, Kumar S. The sensitivity of the prov- minimal occupational intervention or the usual approach in general
ocation tests in replicating pain on the lateral elbow area of participants practice. Rheumatology. 2003;42:1216-1225. https://doi.org/10.1093/
with lateral epicondylalgia. J Case Rep. 2014;1:1. rheumatology/keg360
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg47
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
68. Haahr JP, Andersen JH. Physical and psychosocial risk factors for lateral trial with 8-week follow-up. Evid-Based Complement Altern Med.
epicondylitis: a population based case-referent study. Occup Environ 2016;2016:3079247. https://doi.org/10.1155/2016/3079247
Med. 2003;60:322-329. https://doi.org/10.1136/oem.60.5.322 85. Hüseyin Ünver H, Bakilan F, Berkan Tasçioglu F, Armagan O, Özgen M.
69. Hagert CG, Lundborg G, Hansen T. Entrapment of the posterior interos- Comparing the efficacy of continuous and pulsed ultrasound therapies
seous nerve. Scand J Plast Reconstr Surg. 1977;11:205-212. https://doi. in patients with lateral epicondylitis: a double-blind, randomized, place-
org/10.3109/02844317709025519 bo-controlled study. Turk J Phys Med Rehabil. 2021;67:99-106. https://
70. Halle JS, Franklin RJ, Karalfa BL. Comparison of four treatment ap- doi.org/10.5606/tftrd.2021.4789
proaches for lateral epicondylitis of the elbow*. J Orthop Sports Phys 86. Jafarian F-S, Barati H, Sadeghi-Demneh E. The Patient-Rated Tennis
Ther. 1986;8:62-69. https://doi.org/10.2519/jospt.1986.8.2.62 Elbow Evaluation Questionnaire was successfully translated to Persian.
71. Hayes C, Bencardino J, Appel M, et al. ACR Appropriateness Crite- J Hand Ther. 2021;34:127-130. https://doi.org/10.1016/j.jht.2019.12.005
ria® Chronic Elbow Pain. Reston, VA: American College of Radiology 87. Jeon S, Miller WM, Ye X. A comparison of motor unit control strategies
(ACR); 2015. between two different isometric tasks. Int J Environ Res Public Health.
72. Heales LJ, Hill C, Kean C, Stanton R. Within- and between-session 2020;17:E2799. https://doi.org/10.3390/ijerph17082799
test-retest reliability of pain-free grip strength in individuals with 88. Jomaa G, Kwan C-K, Fu S-C, et al. A systematic review of inflammatory
lateral elbow tendinopathy. J Sci Med Sport. 2021;24:S79. https://doi. cells and markers in human tendinopathy. BMC Musculoskelet Disord.
org/10.1016/j.jsams.2021.09.196 2020;21:78. https://doi.org/10.1186/s12891-020-3094-y
73. Heales LJ, McClintock SR, Maynard S, et al. Evaluating the immediate 89. Joshi S, Metgud S, Ebnezer C. Comparing the effects of manipulation of
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
effect of forearm and wrist orthoses on pain and function in individuals wrist and ultrasound, friction massage and exercises on lateral epicon-
with lateral elbow tendinopathy: a systematic review. Musculoskelet Sci dylitis: a randomized clinical study. Indian J Physiother Occup Ther Int J.
Pract. 2020;47:102147. https://doi.org/10.1016/j.msksp.2020.102147 2013;7:205. https://doi.org/10.5958/j.0973-5674.7.3.093
74. Healy A, Farmer S, Pandyan A, Chockalingam N. A systematic review 90. Kalainov DM, Cohen MS. Posterolateral rotatory instability of
of randomised controlled trials assessing effectiveness of prosthetic the elbow in association with lateral epicondylitis. A report of
and orthotic interventions. PLOS One. 2018;13:e0192094. https://doi. three cases. J Bone Jt Surg. 2005;87:1120-1125. https://doi.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
org/10.1371/journal.pone.0192094 org/10.2106/00004623-200505000-00027
75. Hefford C, Abbott JH, Arnold R, Baxter GD. The patient-specific func- 91. Karagiannopoulos C, Sitler M, Michlovitz S. Reliability of 2 functional
tional scale: validity, reliability, and responsiveness in patients with goniometric methods for measuring forearm pronation and supination
upper extremity musculoskeletal problems. J Orthop Sports Phys Ther. active range of motion. J Orthop Sports Phys Ther. 2003;33:523-531.
2012;42:56-65. https://doi.org/10.2519/jospt.2012.3953 https://doi.org/10.2519/jospt.2003.33.9.523
76. Hegmann KT, Thiese MS, Kapellusch J, et al. Association between 92. Karanasios S, Korakakis V, Whiteley R, Vasilogeorgis I, Woodbridge S,
epicondylitis and cardiovascular risk factors in pooled occupational co- Gioftsos G. Exercise interventions in lateral elbow tendinopathy have better
horts. BMC Musculoskelet Disord. 2017;18:227. https://doi.org/10.1186/ outcomes than passive interventions, but the effects are small: a systemat-
s12891-017-1593-2 ic review and meta-analysis of 2123 subjects in 30 trials. Br J Sports Med.
77. Herd CR, Meserve BB. A systematic review of the effectiveness of ma- 2021;55:477-485. https://doi.org/10.1136/bjsports-2020-102525
Journal of Orthopaedic & Sports Physical Therapy®
nipulative therapy in treating lateral epicondylalgia. J Man Manip Ther. 93. Kaux J-F, Delvaux F, Schaus J, et al. Cross-cultural adaptation and val-
2008;16:225-237. https://doi.org/10.1179/106698108790818288 idation of the Patient-Rated Tennis Elbow Evaluation Questionnaire on
78. Herquelot E, Bodin J, Roquelaure Y, et al. Work-related risk factors lateral elbow tendinopathy for French-speaking patients. J Hand Ther.
for lateral epicondylitis and other cause of elbow pain in the working 2016;29:496-504. https://doi.org/10.1016/j.jht.2016.06.007
population. Am J Ind Med. 2013;56:400-409. https://doi.org/10.1002/ 94. Kaydok E, Ordahan B, Solum S, Karahan A. Short-term efficacy
ajim.22140 comparison of high-intensity and low-intensity laser therapy in the
79. Hill CE, Heales LJ, Stanton R, Kean CO. Pain-free grip strength in indi- treatment of lateral epicondylitis: a randomized double-blind clinical
viduals with lateral elbow tendinopathy: between- and within-session study. Arch Rheumatol. 2020;35:60-67. https://doi.org/10.5606/
reliability of one versus three trials. Physiother Theory Pract. 2022;1-9. ArchRheumatol.2020.7347
https://doi.org/10.1080/09593985.2022.2030445 95. Khuman PR, Trivedi P, Devi S, Sathyavani D, Nambi G, Shah K. Myofascial
80. Hjermstad MJ, Fayers PM, Haugen DF, et al. Studies comparing Numeri- release technique in chronic lateral epicondylitis: a randomized con-
cal Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for trolled study. Int J Health Sci Res. 2013;3:45-52
assessment of pain intensity in adults: a systematic literature review. 96. Kietrys DM, Gerg MJ, Dropkin J, Gold JE. Mobile input device type,
J Pain Symptom Manag. 2011;41:1073-1093. https://doi.org/10.1016/j. texting style and screen size influence upper extremity and trape-
jpainsymman.2010.08.016 zius muscle activity, and cervical posture while texting. Appl Ergon.
81. Holmedal Ø, Olaussen M, Mdala I, Natvig B, Lindbæk M. Predictors 2015;50:98-104. https://doi.org/10.1016/j.apergo.2015.03.003
for outcome in acute lateral epicondylitis. BMC Musculoskelet Disord. 97. Koh K-H, Lee KW, Cho JH, Park D, Yeom JW, Lee HI. The patient-rated
2019;20:375. https://doi.org/10.1186/s12891-019-2758-y tennis elbow evaluation questionnaire was successfully translated to
82. Hoogvliet P, Randsdorp MS, Dingemanse R, Koes BW, Huisstede BMA. Korean. J Hand Ther. 2021. https://doi.org/10.1016/j.jht.2021.04.007
Does effectiveness of exercise therapy and mobilisation techniques offer 98. Kohia M, Brackle J, Byrd K, Jennings A, Murray W, Wilfong E. Effective-
guidance for the treatment of lateral and medial epicondylitis? A system- ness of physical therapy treatments on lateral epicondylitis. J Sport
atic review. Br J Sports Med. 2013;47:1112-1119. https://doi.org/10.1136/ Rehabil. 2008;17:119-136. https://doi.org/10.1123/jsr.17.2.119
bjsports-2012-091990 99. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical
83. Horger MM. The reliability of goniometric measurements of active and features and findings of histological, immunohistochemical, and elec-
passive wrist motions. Am J Occup Ther. 1990;44:342-348. https://doi. tron microscopy studies. J Bone Jt Surg. 1999;81:259-278. https://doi.
org/10.5014/ajot.44.4.342 org/10.2106/00004623-199902000-00014
84. Hsu C-Y, Lee K-H, Huang H-C, Chang Z-Y, Chen H-Y, Yang T-H. Manip- 100. Krey D, Borchers J, McCamey K. Tendon needling for treatment of ten-
ulation therapy relieved pain more rapidly than acupuncture among dinopathy: a systematic review. Physician Sportsmed. 2015;43:80-86.
lateral epicondylalgia (tennis elbow) patients: a randomized controlled https://doi.org/10.1080/00913847.2015.1004296
cpg48 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
SDFGSDFGSDFGDFG
101. Laimi K, Mäkilä A, Bärlund E, et al. Effectiveness of myofascial release randomized-single blind study. EXPLORE. 2021:17;327-333. https://doi.
in treatment of chronic musculoskeletal pain: a systematic review. Clin org/10.1016/j.explore.2020.07.008
Rehabil. 2018;32:440-450. https://doi.org/10.1177/0269215517732820 119. Mansoori A, Noorizadeh Dehkordi S, Mansour Sohani S, Nodehi
102. LaStayo PC, Wheeler DL. Reliability of passive wrist flexion and ex- Moghadam A. Cross-cultural adaptation and determination of the
tension goniometric measurements: a multicenter study. Phys Ther. validity and reliability of the Persian version of the Patient-Rated
1994;74:162-174. https://doi.org/10.1093/ptj/74.2.162 Tennis Elbow Evaluation (PRTEE) Questionnaire in Iranian tennis
103. Lee A, Lee-Robinson A. Evaluating concomitant lateral epicondylitis and players. Funct Disabil J. 2019;2:17-26. https://doi.org/10.30699/
cervical radiculopathy: a correlation was found, suggesting comanage- fdisj.1.4.17
ment of the disorders. J Musculoskelet Med. 2010;27:111-115. 120. Marks M, Rickenbacher D, Audigé L, Glanzmann MC. Patient-Rated
104. Antuna SA, O’Driscoll SW. Snapping plicae associated with radiocapitel- Tennis Elbow Evaluation (PRTEE). Zeitschrift für Orthopädie und Unfall-
lar chondromalacia. Arthrosc: J Arthrosc Relat Surg. 2001;17:491-495. chirurgie. 2021;159:391-396. https://doi.org/10.1055/a-1107-3313
https://doi.org/10.1053/jars.2001.20096 121. Martínez-Beltrán MJ, Rodríguez-Sanz D, Pérez-Mallada N. Are there any
105. Lee W-H, Kwon O-Y, Yi C-H, Jeon H-S, Ha S-M. Effects of taping on wrist changes in strength after the application of Kinesio taping in lateral epi-
extensor force and joint position reproduction sense of subjects with and condylalgia? J Back Musculoskelet Rehabil. 2021;34:775-781. https://doi.
without lateral epicondylitis. J Phys Ther Sci. 2011;23:629-634. https:// org/10.3233/BMR-200325
doi.org/10.1589/jpts.23.629 122. Martinez-Silvestrini JA, Newcomer KL, Gay RE, Schaefer MP, Kortebein
106. Leung HB, Yen CH, Tse PYT. Reliability of Hong Kong Chinese version of P, Arendt KW. Chronic lateral epicondylitis: comparative effectiveness of
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
the Patient-rated Forearm Evaluation Questionnaire for lateral epicondy- a home exercise program including stretching alone versus stretching
litis. Hong Kong Med J. 2004;10:172-177. supplemented with eccentric or concentric strengthening. J Hand Ther.
107. Lewis M, Hay EM, Paterson SM, Croft P. Effects of manual work on 2005;18:411-419. https://doi.org/10.1197/j.jht.2005.07.007
recovery from lateral epicondylitis. Scand J Work Environ Health. 123. Miller TT, Shapiro MA, Schultz E, Kalish PE. Comparison of so-
2002;28:109-116. https://doi.org/10.5271/sjweh.654 nography and MRI for diagnosing epicondylitis. J Clin Ultrasound.
108. Lian J, Mohamadi A, Chan JJ, et al. Comparative efficacy and safety of 2002;30:193-202. https://doi.org/10.1002/jcu.10063
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
nonsurgical treatment options for enthesopathy of the extensor carpi 124. Mills PG. Treatment of tennis elbow. Br Med J. 1937;2:212-213.
radialis brevis: a systematic review and meta-analysis of randomized 125. Milz S, Tischer T, Buettner A, et al. Molecular composition and pathology
placebo-controlled trials. Am J Sports Med. 2019;47:3019-3029. https:// of entheses on the medial and lateral epicondyles of the humerus: a
doi.org/10.1177/0363546518801914 structural basis for epicondylitis. Ann Rheum Dis. 2004;63:1015-1021.
109. Lizis, Pawel. Analgesic effect of extracorporeal shock wave therapy https://doi.org/10.1136/ard.2003.016378
versus ultrasound therapy in chronic tennis elbow. J Phys Ther Sci. 126. Morrey FB. The Elbow and Its Disorders. 2nd ed. Philadelphia, PA: W.B.
2015;27:2563-2567. https://doi.org/10.1589/jpts.27.2563 Saunders Co; 1993.
110. Loew LM, Brosseau L, Tugwell P, et al. Deep transverse friction massage 127. Mostafaee N, Divandari A, Negahban H, et al. Shoulder and scapula
for treating lateral elbow or lateral knee tendinitis. Cochrane Data- muscle training plus conventional physiotherapy versus conventional
base Syst Rev. 2014;CD003528. https://doi.org/10.1002/14651858. physiotherapy only: a randomized controlled trial of patients with lateral
CD003528.pub2
Journal of Orthopaedic & Sports Physical Therapy®
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg49
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
135. Nirschl PR. The epidemiology and health care burden of tennis elbow: litis. J Back Musculoskelet Rehabil. 2020;33:99-107. https://doi.
a population-based study. Ann Transl Med. 2015;3:133. https://doi. org/10.3233/BMR-181135
org/10.3978/j.issn.2305-5839.2015.05.05 152. Rodríguez-Huguet M, Góngora-Rodríguez J, Lomas-Vega R, et al. Per-
136. Oken O, Kahraman Y, Ayhan F, Canpolat S, Yorgancioglu ZR, Oken OF. The cutaneous electrolysis in the treatment of lateral epicondylalgia: a sin-
short-term efficacy of laser, brace, and ultrasound treatment in lateral gle-blind randomized controlled trial. J Clin Med. 2020;33:2068. https://
epicondylitis: a prospective, randomized, controlled trial. J Hand Ther. doi.org/10.3390/jcm9072068
2008;21:63-67. https://doi.org/10.1197/j.jht.2007.09.003 153. Roh YH, Gong HS, Baek GH. The prognostic value of pain sensitization in
137. Olaussen M, Holmedal O, Lindbaek M, Brage S, Solvang H. Treating later- patients with lateral epicondylitis. J Hand Surg. 2019;44:250.E1-250.E7.
al epicondylitis with corticosteroid injections or non-electrotherapeutical https://doi.org/10.1016/j.jhsa.2018.06.013
physiotherapy: a systematic review. BMJ Open. 2013;3:e003564. https:// 154. Roles NC, Maudsley RH. Radial tunnel syndrome: resistant tennis elbow
doi.org/10.1136/bmjopen-2013-003564 as a nerve entrapment. J Bone Jt Surg. 1972;54:499-508. https://doi.
138. Overend TJ, Wuori-Fearn JL, Kramer JF, MacDermid JC. Reliability of a org/10.1302/0301-620X.54B3.499
patient-rated forearm evaluation questionnaire for patients with lateral 155. Rompe JD, Overend TJ, MacDermid JC. Validation of the Patient-rated
epicondylitis. J Hand Ther. 1999;12:31-37. https://doi.org/10.1016/ Tennis Elbow Evaluation Questionnaire. J Hand Ther. 2007;20:3-11.
S0894-1130(99)80031-3
https://doi.org/10.1197/j.jht.2006.10.003
139. Özmen T, Koparal SS, Karatas Ö, Eser F, Özkurt B, Gafuroglu TÜ. Compari-
156. Ruch DS, Papadonikolakis A, Campolattaro RM. The posterolateral
son of the clinical and sonographic effects of ultrasound therapy, extracor-
plica: a cause of refractory lateral elbow pain. J Shoulder Elb Surg.
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
poreal shock wave therapy, and Kinesio taping in lateral epicondylitis. Turk
2006;15:367-370. https://doi.org/10.1016/j.jse.2005.08.013
J Med Sci. 2021;51:76-83. https://doi.org/10.3906/sag-2001-79
157. Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimal clinically
140. Paoloni JA, Murrell GAC. Identification of prognostic indica-
important changes in chronic musculoskeletal pain intensity measured
tors for patient outcomes in extensor tendinopathy at the
on a numerical rating scale. Eur J Pain. 2004;8:283-291. https://doi.
elbow. Scand J Med Sci Sports. 2004;14:163-167. https://doi.
org/10.1016/j.ejpain.2003.09.004
org/10.1111/j.1600-0838.2004.00358.x
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
158. Sanders TL, Maradit Kremers H, Bryan AJ, Ransom JE, Smith J, Morrey
141. Park HB, Gwark J-Y, Im J-H, Na J-B. Factors associated with lateral epi-
BF. The epidemiology and health care burden of tennis elbow: a popu-
condylitis of the elbow. Orthop J Sports Med. 2021;9:232596712110077.
lation-based study. Am J Sports Med. 2015;43:1066-1071. https://doi.
https://doi.org/10.1177/23259671211007734
org/10.1177/0363546514568087
142. Pasternack I, Tuovinen EM, Lohman M, Vehmas T, Malmivaara A. MR
159. Saroja G, Aseer ALP, Reader in physiotherapy SRU, et al. Diagnostic ac-
findings in humeral epicondylitis. A systematic review. Acta Radiol
curacy of provocative tests in lateral epicondylitis. Int J Physiother Res.
(Stockh Swed 1987). 2001;42:434-440.
2014;2:815-823. https://doi.org/10.16965/ijpr.2014.699
143. Petherick M, Rheault W, Kimble S, Lechner C, Senear V. Concurrent valid-
160. Schmitt JS, Di Fabio RP. Reliable change and minimum important differ-
ity and intertester reliability of universal and fluid-based goniometers for
ence (MID) proportions facilitated group responsiveness comparisons
active elbow range of motion. Phys Ther. 1988;68:966-969. https://doi.
org/10.1093/ptj/68.6.966 using individual threshold criteria. J Clin Epidemiol. 2004;57:1008-1018.
https://doi.org/10.1016/j.jclinepi.2004.02.007
Journal of Orthopaedic & Sports Physical Therapy®
cpg50 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
SDFGSDFGSDFGDFG
169. Shamsoddini A, Hollisaz MT, Hafezi R. Initial effect of taping technique 186. Turchin DC, Beaton DE, Richards RR. Validity of observer-based
on wrist extension and grip strength and pain of Individuals with lateral aggregate scoring systems as descriptors of elbow pain, func-
epicondylitis. Iran Rehabil J. 2010;8:24-28. tion, and disability. J Bone Jt Surg. 1998;80:154-162. https://doi.
170. Shiri R, Viikari-Juntura E. Lateral and medial epicondylitis: role of occu- org/10.2106/00004623-199802000-00002
pational factors. Best Pract Res Clin Rheumatol. 2011;25:43-57. https:// 187. Uygur E, Aktas B, Yilmazoglu EG. The use of dry needling vs. corticoste-
doi.org/10.1016/j.berh.2011.01.013 roid injection to treat lateral epicondylitis: a prospective, randomized,
171. Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and de- controlled study. J Shoulder Elb Surg. 2021;30:134-139. https://doi.
terminants of lateral and medial epicondylitis: a population study. Am J org/10.1016/j.jse.2020.08.044
Epidemiol. 2006;164:1065-1074. https://doi.org/10.1093/aje/kwj325 188. Valdes K, LaStayo P. The value of provocative tests for the wrist and
172. Sims SEG, Miller K, Elfar JC, Hammert WC. Non-surgical treatment of elbow: a literature review. J Hand Ther. 2013;26:32-42. https://doi.
lateral epicondylitis: a systematic review of randomized controlled trials. org/10.1016/j.jht.2012.08.005
HAND. 2014:419-446. https://doi.org/10.1007/s11552-014-9642-x 189. van Ark M, Zwerver J, Diercks RL, van den Akker-Scheek I. Cross-cultural
173. Smidt N, van der Windt DA, Assendelft WJ, et al. Interobserver repro- adaptation and reliability and validity of the Dutch Patient-Rated Tennis
ducibility of the assessment of severity of complaints, grip strength, Elbow Evaluation (PRTEE-D). BMC Musculoskelet Disord. 2014;15:270.
and pressure pain threshold in patients with lateral epicondylitis. https://doi.org/10.1186/1471-2474-15-270
Arch Phys Med Rehabil. 2002;83:1145-1150. https://doi.org/10.1053/ 190. Van Rijn RM, Huisstede BMA, Koes BW, Burdorf A. Associations between
apmr.2002.33728 work-related factors and specific disorders at the elbow: a system-
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
174. Sölveborn SA, Olerud C. Radial epicondylalgia (tennis elbow): atic literature review. Rheumatology. 2009;48:528-536. https://doi.
measurement of range of motion of the wrist and the elbow. J Or- org/10.1093/rheumatology/kep013
thop Sports Phys Ther. 1996;23:251-257. https://doi.org/10.2519/ 191. Varatharajan S, Côté P, Shearer HM, et al. Are work disability prevention
jospt.1996.23.4.251 interventions effective for the management of neck pain or upper ex-
175. Stasinopoulos D, Papadopoulos C, Antoniadou M, Nardi L. Greek adapta- tremity disorders? A systematic review by the Ontario Protocol For Traffic
tion and validation of the Patient-Rated Tennis Elbow Evaluation (PRTEE). Injury Management (OPTIMa) Collaboration. J Occup Rehabil. 2014.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg51
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
the treatment of tennis elbow pain. Biomed Eng: Appl Basis Commun. systematic review and meta-analysis. J Clin Med. 2021;10:3968. https://
2005;17:236-242. doi.org/10.3390/jcm10173968
203. Wixom SM, Lastayo P. A potential classification model for individ- 209. Zhong Y, Zheng C, Zheng J, Xu S. Kinesio tape reduces pain in patients
uals with tennis elbow. J Hand Ther. 2012;25:418-420. https://doi. with lateral epicondylitis: a meta-analysis of randomized controlled
org/10.1016/j.jht.2012.06.007 trials. Int J Surg (Lond Eng). 2020;76:190-199. https://doi.org/10.1016/j.
204. Word Health Organization. International Classification of Functioning, ijsu.2020.02.044
Disability and Health: ICF. Geneva, Switzerland: World Health Organiza-
210. Zunke P, Auffarth A, Hitzl W, Moursy M. The effect of manual therapy to
tion; 2009.
the thoracic spine on pain-free grip and sympathetic activity in patients
205. Smidt N, Assendelft W, Arola H, et al. Effectiveness of physiotherapy
with lateral epicondylalgia humeri. A randomized, sample sized planned,
for lateral epicondylitis: a systematic review. Ann Med. 2003;35:51-62.
placebo-controlled, patient-blinded monocentric trial. BMC Musculoskel-
https://doi.org/10.1080/07853890310004138
et Disord. 2020;21:186
206. Yalvaç B, Mesci N, Geler Külcü D, Yurdakul OV. Comparison of ultrasound
and extracorporeal shock wave therapy in lateral epicondylosis. Acta 211. Zwerus EL, Somford MP, Maissan F, Heisen J, Eygendaal D, van den
Orthop Traumatol Turc. 2018;52:357-362. https://doi.org/10.1016/j. Bekerom MP. Physical examination of the elbow, what is the evidence?
aott.2018.06.004 A systematic literature review. Br J Sports Med. 2018;52:1253-1260.
207. Yi R, Bratchenko WW, Tan V. Deep friction massage versus steroid in- https://doi.org/10.1136/bjsports-2016-096712
jection in the treatment of lateral epicondylitis. HAND. 2018;13:56-59. 212. Zwerus EL, Willigenburg NW, Scholtes VA, Somford MP, Eygendaal D,
Downloaded from www.jospt.org at on April 12, 2023. For personal use only. No other uses without permission.
https://doi.org/10.1177/1558944717692088 van den Bekerom MP. Normative values and affecting factors for the
208. Yoon SY, Kim YW, Shin IS, Kang S, Moon HI, Lee SC. The beneficial effects elbow range of motion. Shoulder Elbow. 2019;11:215-224. https://doi.
of eccentric exercise in the management of lateral elbow tendinopathy: a org/10.1177/1758573217728711
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Journal of Orthopaedic & Sports Physical Therapy®
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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
APPENDIX A
SEARCH STRATEGIES AND SEARCH RESULTS (JANUARY 1, 2001, THROUGH NOVEMBER 30, 2021)
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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
APPENDIX A (CONTINUED)
Self-report measures DASH OR Disabilities of the arm shoulder and the “DASH” OR “Disabilities of the arm DASH OR Disabilities of the arm shoulder and the
hand[tw] OR Quick DASH OR Visual analog shoulder and the hand” OR “Quick hand OR Quick DASH OR VAS OR Visual Analog
scale[tw] OR VAS OR Visual Analog Scale[tw] DASH” OR “Visual analog scale” OR Scale OR NRS OR Numeric Rating Scale OR
OR NRS OR Numeric Rating Scale[tw] OR “VAS” OR “Visual Analog Scale” OR NPRS OR Numeric pain rating scale OR PRFEQ
NPRS OR Numeric pain rating scale[tw] OR “NRS” OR “Numeric Rating Scale” OR Patient rated tennis elbow evaluation OR
PRFEQ OR Patient rated tennis elbow evalua- OR “NPRS” OR “Numeric pain rating Patient rated forearm evaluation question-
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tion[tw] OR Patient rated forearm evaluation scale” OR “PRFEQ” OR “Patient naire OR PRTEE OR PSFS OR Patient Specific
questionnaire[tw] OR PRTEE OR PSFS OR rated tennis elbow evaluation” OR Functional Scale
“Patient Specific Functional Scale”[tw] “Patient rated forearm evaluation
questionnaire” OR “PRTEE” OR
PSFS OR “Patient Specific Functional
Scale”
Impairment measures “strength test”[tw] OR “Manual muscle test”[tw] “strength test” OR “Manual muscle test” strength test OR Manual muscle test OR range of
OR “range of motion”[tw] OR “elbow range OR “range of motion” OR “elbow motion OR elbow range of motion OR forearm
of motion”[tw] OR “forearm range of mo- range of motion” OR “forearm range range of motion OR wrist range of motion OR
tion”[tw] OR “wrist range of motion”[tw] OR of motion” OR “wrist range of mo- flexibility OR grip strength OR pain-free grip
Journal of Orthopaedic & Sports Physical Therapy®
flexibility[tw] OR full movement[tw] OR “grip tion” OR flexibility OR full movement strength OR Mayo Elbow Performance Index
strength”[tw] OR “pain-free grip strength”[tw] OR “grip strength” OR “pain-free OR MEPI OR Roles and Maudsley score OR RM
OR “Mayo Elbow Performance Index”[tw] grip strength” OR “Mayo Elbow Score OR Pressure pain threshold OR PPT
OR “MEPI”[tw] OR “Roles and Maudsley Performance Index” OR “MEPI” OR
score”[tw] OR “RM Score”[tw] OR “Pressure “Roles and Maudsley score” OR “RM
pain threshold”[tw] OR PPT[tw] Score” OR “Pressure pain threshold”
OR PPT
Abbreviation: CINAHL, Cumulative Index to Nursing and Allied Health Literature.
Interventions
Search Topic Terms PubMed Terms CINAHL Terms Cochrane Library
“Tennis Elbow”[Mesh] OR “tennis elbow”[tw] OR MH “Tennis Elbow” OR “tennis elbow” [mh “Tennis Elbow”] OR “tennis elbow”:ti,ab,kw
“lateral elbow tendinopathy”[tw] OR “lateral OR “lateral elbow tendinopathy” OR OR “lateral elbow tendinopathy”:ti,ab,kw OR
elbow tendinitis”[tw] OR “lateral epicondyli- “lateral elbow tendinitis” OR “lateral “lateral elbow tendinitis”:ti,ab,kw OR (“lateral”
t*”[tw] OR “lateral epicondylos*”[tw] OR “lateral epicondylit*” OR “lateral epicondy- NEXT epicondylit*):ti,ab,kw OR (“lateral” NEXT
epicondylalgia”[tw] OR “lateralis epicondylitis los*” OR “lateral epicondylalgia” OR epicondylos*):ti,ab,kw OR “lateral epicon-
humeri”[tw] OR “lateralis epicondylalgia hu- “lateralis epicondylitis humeri” OR dylalgia”:ti,ab,kw OR “lateralis epicondylitis
meri”[tw] OR “lateral humeral epicondylit*”[tw] “lateralis epicondylalgia humeri” OR humeri”:ti,ab,kw OR “lateralis epicondylalgia
OR “lateral elbow tendinopathy”[tw] OR ((“Elbow “lateral humeral epicondylit*” humeri”:ti,ab,kw OR (“lateral humeral” NEXT
Tendinopathy”[Mesh] OR epicondyl*[tw] OR OR “lateral elbow tendinopathy” OR epicondylit*):ti,ab,kw OR “lateral elbow tendinop-
“Tendinopathy”[Mesh] OR tendinitis[tw] OR ((MH “Elbow Injuries” OR epicondyl* athy”:ti,ab,kw OR (([mh “Elbow Tendinopathy”]
tendonitis[tw] OR tendinopathy[tw] OR tendino- OR MH “Tendinopathy” OR tendinitis OR epicondyl*:ti,ab,kw OR [mh Tendinopathy]
sis[tw] OR tendinalgia[tw] OR peritendinitis[tw] OR tendonitis OR tendinopathy OR tendinitis:ti,ab,kw OR tendonitis:ti,ab,kw OR
OR enthesopathy[tw]) AND lateral[tw]) OR tendinosis OR tendinalgia OR tendinopathy:ti,ab,kw OR tendinosis:ti,ab,kw OR
peritendinitis OR enthesopathy) tendinalgia:ti,ab,kw OR peritendinitis:ti,ab,kw OR
AND lateral) enthesopathy:ti,ab,kw) AND lateral:ti,ab,kw)
Table continues on next page.
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APPENDIX A (CONTINUED)
trol-group OR AB control-group) OR
(TI prospective OR AB prospective)
OR (TI cohort OR AB cohort) OR
(TI groups OR AB groups) OR (TI
longitudinal OR AB longitudinal)) OR
(PT “meta analysis” OR PT “meta
synthesis” OR PT “systematic re-
view” OR PT review OR PT “practice
guidelines” OR TI systematic-review
OR TI meta-analysis OR TI scop-
Journal of Orthopaedic & Sports Physical Therapy®
ing-review OR TI literature-review OR
TI protocol)
Exercise (“Exercise”[Mesh] OR “Muscle Contraction”[Mesh] (MH “Exercise+” OR OR MH “Thera- ([mh Exercise] OR [mh “Muscle Contraction”]
OR “Muscle Stretching Exercises”[Mesh] OR peutic Exercise” OR MH “Muscle OR [mh “Muscle Stretching Exercises”] OR
exercis*[tw] OR stretch*[tw] OR plyometric*[tw] Contraction+” OR MH “Stretching” exercis*:ti,ab,kw OR stretch*:ti,ab,kw OR
OR resist*[tw] OR eccentric[tw] OR concen- OR exercis* OR stretch* OR plyometric*:ti,ab,kw OR resist*:ti,ab,kw OR
tric[tw] OR isometric*[tw] OR isotonic*[tw] OR plyometric* OR resist* OR eccentric eccentric:ti,ab,kw OR concentric:ti,ab,kw OR
activat*[tw] OR contract*[tw] OR condition- OR concentric OR isometric* OR isometric*:ti,ab,kw OR isotonic*:ti,ab,kw OR
ing[tw] OR training[tw] OR “neuromuscular isotonic* OR activat* OR contract* activat*:ti,ab,kw OR contract*:ti,ab,kw OR
facilitation”[tw]) OR conditioning OR training OR conditioning:ti,ab,kw OR training:ti,ab,kw OR
“neuromuscular facilitation”) “neuromuscular facilitation”:ti,ab,kw)
Manual therapy (“Musculoskeletal Manipulations”[Mesh] OR (MH “Manual Therapy” OR MH ([mh “Musculoskeletal Manipulations”] OR [mh
“Manipulation, Chiropractic”[Mesh] OR “Manipulation, Chiropractic” OR “Manipulation, Chiropractic”] OR manipu-
manipulat*[tw] OR “manual therap*”[tw] OR MH “Manipulation, Orthopedic” OR lat*:ti,ab,kw OR (“manual therap*”):ti,ab,kw OR
chiropract*[tw] OR mobilis*[tw] OR mobiliz*[tw] MH “Manipulation, Osteopathic” OR chiropract*:ti,ab,kw OR mobilis*:ti,ab,kw OR
OR cyriax[tw]) manipulat* OR “manual therap*” mobiliz*:ti,ab,kw OR cyriax:ti,ab,kw)
OR chiropract* OR mobilis* OR
mobiliz* OR cyriax)
Soft tissue (“Massage”[Mesh] OR massag*[tw] OR mas- (MH “Massage+” OR MH “Myofas- ([mh Massage] OR massag*:ti,ab,kw OR mas-
seuse*[tw] OR massotherap*[tw] OR “trans- cial Release” OR massag* OR seuse*:ti,ab,kw OR massotherap*:ti,ab,kw OR
verse friction”[tw] OR “myofascial release”[tw] masseuse* OR massotherap* OR “transverse friction”:ti,ab,kw OR “myofascial
OR “soft tissue technique*”[tw] OR “soft tissue “transverse friction” OR “myofascial release”:ti,ab,kw OR (“soft tissue tech-
mobilis*”[tw] OR “soft tissue mobiliz*”[tw] OR release” OR “soft tissue technique*” nique*”):ti,ab,kw OR (“soft tissue mobil-
“soft tissue therap*”[tw]) OR “soft tissue mobilis*” OR “soft is*”):ti,ab,kw OR (“soft tissue mobiliz*”):ti,ab,kw
tissue mobiliz*” OR “soft tissue OR (“soft tissue therap*”):ti,ab,kw)
therap*”)
Table continues on next page.
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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
APPENDIX A (CONTINUED)
OR immobiliz* immobiliz*:ti,ab,kw)
Taping (“Athletic Tape”[Mesh] OR tape[tw] OR tapes[tw] MH “Taping and Strapping” OR MH ([mh “Athletic Tape”] OR tape:ti,ab,kw OR
OR taping[tw] OR kinesiotap*[tw] OR KT[tiab] “Tapes” OR MH “Athletic Tape” tapes:ti,ab,kw OR taping:ti,ab,kw OR kinesio-
OR Rocktap*[tw] OR bandag*[tw] OR wrap*[tw] OR MH “Kinesiotaping” OR MH tap*:ti,ab,kw OR KT:ti,ab OR Rocktap*:ti,ab,kw
OR strap*[tw] OR “adhesive band*”[tw] OR “Bandages and Dressings” OR tape OR bandag*:ti,ab,kw OR wrap*:ti,ab,kw OR
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
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APPENDIX A (CONTINUED)
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APPENDIX B
Inclusion Criteria
We included articles reporting on lateral elbow tendinopathy that reported information relating to pertinent physical therapist practice
on the following topics.
• Epidemiology of the diagnosis, including prevalence and incidence, clinical course, classification, risk factors, and prognosis
• Classification, functional anatomy, and pathophysiology
• Tests and measures for diagnosis and/or differential diagnosis of lateral elbow tendinopathy, including but not limited to “specific
tests and measures” and imaging
• Measurement properties of instruments and tests specific to measuring outcomes (including but not limited to symptoms, functions,
activity, and participation) that are either specific to the diagnosis of lateral elbow tendinopathy or that measure general UE function-
al outcomes
• Articles published in peer-reviewed journals that include studies of the following types:
◦ Meta-analyses and systematic reviews
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◦ For time frames not covered in the meta-analyses or systematic reviews, acceptable quality experimental and quasi-experimental,
cohort, case series including fewer than 30 participants, and cross-sectional studies were included based on last dates searched in
the secondary analyses.
Exclusion Criteria
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1. Self-report Measures
APPENDIX C
FLOWCHART OF ARTICLES
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APPENDIX C (CONTINUED)
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3. Exercise
APPENDIX C (CONTINUED)
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4. Manual Therapy: Joint Mobilizations
APPENDIX C (CONTINUED)
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6. Dry Needling
APPENDIX C (CONTINUED)
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7. Orthoses
APPENDIX C (CONTINUED)
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8. Taping
APPENDIX C (CONTINUED)
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9. Thermal Modalities
APPENDIX C (CONTINUED)
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10. Ultrasound
APPENDIX C (CONTINUED)
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11. Phonophoresis
APPENDIX C (CONTINUED)
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12. Iontophoresis
APPENDIX C (CONTINUED)
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13. TENS
APPENDIX C (CONTINUED)
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14. Laser
APPENDIX C (CONTINUED)
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APPENDIX C (CONTINUED)
15. Ergonomics
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From: Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
BMJ. 2021;372:n71. https://doi.org/10.1136/bmj.n71
For more information, visit http://www.prisma-statement.org/.
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APPENDIX D
Outcomes study or Outcomes study or ecological study Consecutive retrospective cohort prospective cohort
ecological study study
Lower-quality RCTf
III Systematic reviews Lower-quality retrospective cohort study Lower-quality exploratory diagnostic Local nonrandom study High-quality
of case-control High-quality cross-sectional study studies cross-sectional
studies Case-control study Nonconsecutive retrospective study
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b
High quality includes RCTs with greater than 80% follow-up, blinding, and appropriate randomization procedures.
c
High-quality cohort study includes greater than 80% follow-up.
d
High-quality diagnostic study includes consistently applied reference standard and blinding.
e
High-quality prevalence study is a cross-sectional study that uses a local and current random sample or censuses
f
Weaker diagnostic criteria and reference standards, improper randomization, no blinding, and less than 80% follow-up may add bias and threats to validity.
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APPENDIX E
• Level of evidence is assigned based on the study design using the Levels of Evidence table (APPENDIX D), assuming high quality (eg,
for intervention, the randomized clinical trial starts at level I).
• Study quality is assessed using the critical appraisal tool, and the study is assigned 1 of 4 overall quality ratings based on the critical
appraisal results.
• Level of evidence assignment is adjusted based on the overall quality rating:
◦ High quality (high confidence in the estimate/results): the study remains at assigned level of evidence (eg, if the randomized clini-
cal trial is rated high quality, its final assignment is level I). High quality should include the following:
◾ a randomized clinical trial with greater than 80% follow-up, blinding, and appropriate randomization procedures;
◾ a cohort study including greater than 80% follow-up;
◾ a diagnostic study including consistently applied reference standard and blinding; and
◾ a prevalence study that is a cross-sectional study which uses a local and current random sample or censuses.
◦ Acceptable quality: the study does not meet requirements for high quality and weaknesses limit the confidence in the accuracy of
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APPENDIX E (CONTINUED)
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APPENDIX
APPENDIX
E (CONTINUED)
A
Martínez-Beltrán et al (2020) 1 1 0 1 1 0 0 1 1 1 1 7
Mostafaee et al (2020) 1 1 1 1 0 0 1 1 1 1 1 8
Nagrale et al (2009) 1 1 0 1 0 0 1 1 1 1 1 7
Özmen et al (2021) 1 1 0 1 0 0 0 1 1 1 1 6
Reyhan et al (2019) 1 1 1 1 0 0 0 1 1 1 1 7
Rodríguez-Huguet et al (2020) 1 1 1 1 0 1 0 1 1 1 1 8
Sethi and Noohu (2018) 1 1 0 1 0 0 0 0 1 1 1 5
Sevier and Stegink-Jansen (2015) 1 1 0 1 0 0 1 0 1 1 1 6
Tezel et al (2020) 1 1 0 1 0 0 1 0 0 1 1 5
Journal of Orthopaedic & Sports Physical Therapy®
Tran et al (2021) 1 1 1 1 0 0 0 1 1 1 1 7
Uygur et al (2021) 1 1 1 1 0 0 1 1 1 1 1 8
Vuvan et al (2020) 1 1 1 1 0 0 1 1 1 1 1 8
Yalvaç et al (2018) 1 1 1 1 1 0 0 1 0 1 1 7
Yi et al (2018) 1 1 1 1 0 0 1 0 0 1 0 5
Zunke et al (2020) 1 1 0 1 0 0 0 1 1 0 1 5
a
Scoring: 1 = criteria is present, 0 = criteria not present.
b
Eligibility criteria were specified.
c
Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received.
d
Allocation was concealed.
e
The groups were similar at baseline regarding the most important prognostic indicators. fThere was blinding of all subjects.
g
There was blinding of all therapists who administered the therapy.
h
There was blinding of all assessors who measured at least one key outcome. iMeasures of at least one outcome were obtained from more than 85% of the subjects
initially allocated to groups.
j
All subjects for whom outcomes measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least
one key outcome was analyzed by “intention to treat.”
k
The results of between-group statistical comparisons are reported for at least one key outcome.
l
The study provides both point measures and measures of variability for at least one key outcome. Eligibility criteria item does not contribute to total score.
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APPENDIX
APPENDIX
E (CONTINUED)
A
AMSTAR
AMSTAR Scoresa
Systematic Review 1b
2c
3d
4e
5f
6g 7h 8i 9j 10k 11l Score
Bisset et al (2005) 1 1 1 0 0 1 1 1 1 0 0 7
Bisset et al (2011) 1 1 1 0 0 1 1 1 1 0 0 7
Borkholder et al (2004) 1 1 1 0 0 1 1 1 1 0 0 7
Chang et al (2010) 1 1 1 0 0 1 1 1 0 0 0 6
Chen and Baker (2021) 1 0 1 0 0 1 1 1 1 1 1 8
Cullinane et al (2014) 1 1 1 0 0 1 1 1 0 0 0 6
Dick et al (2011) 1 1 1 0 0 1 1 1 0 0 0 6
Dingemanse et al (2013) 1 1 1 0 0 0 1 1 0 0 0 5
George et al (2019) 1 0 1 1 0 1 1 1 1 1 1 9
Healy et al (2018) 1 1 1 0 0 0 1 1 0 0 0 5
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Heales et al (2020) 1 1 1 0 0 1 1 1 1 1 1 9
Herd and Meserve (2008) 1 0 1 0 0 1 1 1 0 0 0 5
Hoogvliet et al (2013) 1 1 1 0 0 0 1 1 1 0 0 6
Karanasios et al (2021) 1 1 1 1 0 1 1 0 1 1 1 9
Kohia et al (2008) 1 1 1 0 0 1 1 1 0 0 0 6
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Laimi et al (2018) 1 1 1 0 0 1 1 1 0 0 0 6
Lian et al (2019) 1 1 1 0 0 1 0 1 1 1 0 7
Loew et al (2014) 1 1 1 0 1 1 1 1 1 1 0 9
Lucado et al (2018) 1 0 1 0 1 1 1 1 1 1 0 8
Navarro-Santana et al (2020) 1 1 1 1 0 0 1 1 1 1 0 8
Olaussen et al (2013) 1 1 1 1 1 1 1 1 1 1 0 10
Raman et al (2012) 1 1 1 0 0 1 1 1 0 0 0 6
Shahabi et al (2020) 1 1 1 1 0 1 1 1 1 0 0 8
Sims et al (2014) 1 1 1 0 0 1 1 1 0 0 0 6
Journal of Orthopaedic & Sports Physical Therapy®
Tumilty et al (2010) 1 1 1 0 0 1 1 1 1 0 0 7
Yoon et al (2021) 1 1 1 1 1 0 1 1 1 1 1 10
Zhong et al (2020) 0 1 1 0 0 1 1 1 1 1 0 7
a
Scoring: 1 = criteria is present, 0 = criteria not present.
b
Was an a priori design provided?
c
Was there duplicate study selection and data extraction?
d
Was a comprehensive literature search performed?
e
Was the status of publication (ie, grey literature) used as an inclusion criterion?
f
Was the list of included and excluded studies provided?
g
Were the characteristics of the included studies provided?
h
Was the scientific quality of the included studies assessed and documented?
i
Was the scientific quality of the included studies used appropriately in formulating conclusions?
j
Were the methods used to combine study findings appropriate?
k
Was the likelihood of publication bias assessed?
l
Was the conflict of interest stated?
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APPENDIX
APPENDIX
E (CONTINUED)
A
EVIDENCE TABLE
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APPENDIX
APPENDIX
E (CONTINUED)
A
Evidence Rating
and Critical
Study Type of Study Appraisal Score Conditions Sample Characteristics Outcome Measures Important Results
Yoon et al Study review/ Level of evidence: Six studies qualified for inclu- All included studies were Pain, muscle strength, A significant improvement in
(2021) meta-anal- II sion: (1) patient allocation determined to have high function the VAS score after eccen-
ysis AMSTAR score: was randomized, (2) the risk of bias as assessed by tric exercise (SMD, −0.63;
10/11 sample was composed of the Cochrane Risk to Bias 95% CI: −0.90, −0.36)
patients with LET, (3) the Tool. All studies examined relative to the VAS score in
intervention was eccentric eccentric exercise alone to the comparison group was
exercise, and (4) the study passive treatment (heat, observed in the 4 studies
outcome was pain inten- ice, US, cross-friction that looked at VAS.
sity, strength, or function. massage), stretching, Four studies reported
Studies were only included or concentric exercises. outcomes of muscle
that evaluated effects of Treatment frequencies strength: 3 studies with
eccentric exercise (eccen- varied among studies. grip strength and 1 study
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APPENDIX
APPENDIX
E (CONTINUED)
A
Evidence Rating
and Critical
Study Type of Study Appraisal Score Conditions Sample Characteristics Outcome Measures Important Results
Chen and Bak- Meta-analysis Level of evidence: Eight moderate quality (av- Adult patients with lateral Pain (VAS), grip strength, When comparing eccentric
er (2021) II erage PEDro = 6) articles elbow tendinopathy symp- function (studies used strengthening of the wrist
AMSTAR : 8/11 RCT and quasi-experi- toms longer than 3 weeks. various questionnaires to extensors to other forms of
mental trials published measure function) strengthening and pain-re-
through December 2018 lieving modalities, there
with a total of 504 patients were significant large effect
that included eccentric size in reducing pain and
strengthening of the improving function in the
wrist extensors as part short term. A significant
of treatment protocol improvement in the VAS
or compared eccentric score after eccentric exer-
strengthening with other cise (SMD, −0.63; 95% CI:
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APPENDIX
APPENDIX
E (CONTINUED)
A
Evidence Rating
and Critical
Study Type of Study Appraisal Score Conditions Sample Characteristics Outcome Measures Important Results
Karanasios et Meta-analysis Level of evidence: Thirty low- to very low-quality Two thousand one hundred PRTEE, Tennis Elbow Function In the long term, exercise was
al (2020) II RCTs published through twenty-three participants Scale, Nirschl/Pettrone better than corticosteroid
AMSTAR score: November 2019 assessing from 30 RCTs with LET pain score, DASH, Pain- injection in improving
9/11 the effectiveness of wrist tendinopathy free function question- PFGS (MD, 12.15 kg;
exercise alone or as an naire, GROC, pain, PFGS 95% CI: 1.69, 22.6), pain
additive intervention reduction (SMD, −0.56;
compared with passive 95% CI: −0.78, –0.34), and
interventions, wait and see, disability (SMD, −0.64;
or injections inpatients 95% CI: −0.86, –0.42).
with LET. Similar observations
were noted for the short
term and the midterm,
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APPENDIX
APPENDIX
E (CONTINUED)
A
Evidence Rating
and Critical
Study Type of Study Appraisal Score Conditions Sample Characteristics Outcome Measures Important Results
Raman et al Systematic Level of evidence: Adults who were diagnosed Eleven articles (12 studies) VAS, DASH, Modified Patients with LET who per-
(2012) review II with lateral epicondylitis from Jan 1990 to Decem- Nirschl/Pettrone score form isotonic, eccentric,
AMSTAR score: and received one of the ber 2010 met inclusion (16%), Mayo Elbow concentric, isometric,
6/11 following exercise interven- criteria. Of the 12 studies, Performance score (8%), or isokinetic exercises of
tions of the wrist: isotonic 9 addressed the effects of Patient-rated Forearm the wrist show positive
exercises, exercises com- isotonic (eccentric/concen- Evaluation changes in pain, strength,
bined with conventional tric) exercises, two studied (16%), Short Form-36 and disability over time.
therapy, eccentric exercise the effect of isometric (8%), and the
alone, isometric exercises, exercises, and one studied Global measure of
or isokinetic exercises. isokinetic exercises. The improvement (8%). Range
exercise programs ranged of motion and pain-free
over a period of 4 to 52 grip strength (no pooling of
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AMSTAR score: following inclusion criteria; (eccentric, isotonic, patient satisfaction scale use of wrist exercises as
7/11 published systematic isometric) (no pooling of results an effective intervention
reviews of RCTs and conducted). for LET.
RCTs in any language, at
least single blinded, and
containing >20 individuals
of whom >80% were
followed up.
Day et al Clinical com- Level of evidence: N/A N/A N/A This commentary describes
(2019) mentary V an evidence-based region-
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randomized control had more than one improvement, provement compared with
trial design, used 1 vali- treatment group, so pain, and grip control with RR and 95% CI
dated patient-centered the 11 included stud- strength at 4-12, of 2.27 (1.04, 4.97) and 2.75
outcome, scored a 5 or ies investigated 15 26, and 52 weeks (2.09, 3.62), respectively.
greater on the PEDro, treatment groups rel- of follow-up However, for the intermediate
included patients with evant for this review. term (3-6 months), outcomes
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(6 reps, 30–45-s
hold), and a progres-
sive eccentric wrist
extension strength-
ening program using
resistance bands.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Coombes et al RTC stratified by Level of evidence: II Participants were ran- Eligibility criteria Quality-Adjusted Physical therapy had greater
(2016) high and low PEDro score: domly allocated into included patients who Life Years (QA- initial costs but was the only
pain scores 6/10 1 of 4 groups: saline were 18 years and LYs), a measure intervention that resulted in
injection, corticoste- older, pain more than of quality of life significantly greater quali-
roid injection, physical 6 weeks, greater than and a “1 year ty-of-life scores after 1 year.
therapy plus saline, 30 on the VAS, and 2 cost to society, The probability of being more
and physical therapy clinical signs of lateral incremental cost effective than placebo
plus corticosteroid. All epicondylalgia. A total costs, and cost was 81% for physical therapy,
participants received of 154 participants to the individual 53% for corticosteroid, and
1 injection and were included in the analysis.” Cost 24% for the combination of
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(2008) review AMSTAR score: 5/11 following: exper- were deemed as having frequently used the use of MWM in providing
imental design, met inclusion outcome mea- immediate and long-term
comparison between criteria. Specific sures were PFGS benefits. Good short-term re-
at least 2 treatment mobilizations that and patient-re- sults were demonstrated with
conditions, subjects are used included ported rating of cervical manipulative therapy.
with clinical diagnosis mobilization with or change or global No specific summary data
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
verse friction massage Patients with pain mean and SD 1.93 ± 0.74 and
and Mill’s manipulation intensity >7 on the 1.70 ± 0.79 respectively (P
(n = 30), whereas NPRS and/or having value = 0.2). Grip strength
group B received history of acute results (lbs) at posttreatment
MWM technique (n trauma, fractures, level for both groups were
= 30) for 12 sessions surgery and/or having 53.5 ± 2.13 and 42.3 ±
over 4 weeks any neurological or 1.97, respectively (P<.01).
systemic disease were After 8 weeks of treatment,
excluded. Cyriax manual therapy and
MWM both were equally
effective in improving pain;
however, because there
was no control group, the
improvements made in both
groups could have been
due to the passage of time.
The Cyriax approach was
better for pain management,
whereas Mulligan techniques
improved the functional
status better in patients with
lateral epicondylitis.
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treatment ended.
Zunke et al (2020) RCT Level of evidence: II A grade III mobilization Women and men aged Pain-free grip, skin Mobilization at the thoracic
PEDro score: 5/10 of the ribs at T5 was between 18 and 55 conductance and spine resulted in significantly
performed at 2 Hz years with unilateral, peripheral skin increased strength of pain-
(120 impulses per acute and subacute temperature free grip and a decrease in
minute) for 2 minutes. (pain duration did peripheral skin temperature
For the control group, not exceed 6 month) within the treatment group.
a sham US therapy lateral epicondylalgia
was performed on the were included.
Journal of Orthopaedic & Sports Physical Therapy®
same segment as in
the treatment group
for 2 minutes.
Abbreviations: LET, lateral elbow tendinopathy; MD, mean difference; MWM, mobilization with movement; NPRS, numeric pain-rating scale; PFGS, pain-
free grip strength; PRTEE, Patient-Rated Tennis Elbow Evaluation; RCT, randomized clinical trial; SMD, standardized mean difference; US, ultrasound; VAS,
visual analog scale.
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Yi et al (2018) RCT Level of evidence: Patients were included if they had Three treatments: Visual analog scale There was a statistically significant
II signs and symptoms consis- group 1 (n = 11): (VAS) pain rat- greater effect on VAS, DASH, and
PEDro score: 5/10 tent with lateral epicondylitis splinting and ings, Disabilities grip strength (P<.05) for the DFM
for at least 6 weeks and were stretching; group 2 of the Arm, plus lidocaine injection group at 6
greater than 18 years of age. (n = 11): a cortisone Shoulder and months compared with the other 2
injection; or group 3 Hand (DASH) groups (ANOVA). No between-group
(n = 12): a lidocaine scores, and grip comparison data were given. Deep
injection with deep strength friction massage plus lidocaine
friction massage. injection is an effective treatment for
Outcomes were lateral epicondylitis and can be used
measured at in patients who have failed other
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Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Blanchette and Clinical trial Level of evidence: Participants were randomly Eligibility criteria PRTEE, PFGS, pain There was not a statistically significant
Normand II assigned to an experimental included being difference in outcomes between the
(2011) PEDro score: 7/10 (n = 15) or a control group 18 years of age or group receiving instrument-assisted
(n = 15). The experimental older, having lateral soft tissue mobilization and the
group received 2 treatments epicondylitis (any control group. No between-group
of instrument-assisted soft duration) confirmed data were reported other than
tissue mobilization per week by a positive Mill’s P values. Within-group means,
for 5 weeks. The control group and Cozen’s test. A standard deviations, and 95% CIs
received education about the total of 30 partici- were reported.
natural history of LET, advice pants were included
about ergonomics, stretching in the study.
exercises, and the first level of
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analgesics.
Abbreviations: ANOVA, analysis of variance; ES, effect size; LET, lateral elbow tendinopathy; PFGS, pain-free grip strength; PRTEE, Patient-Rated Tennis
Elbow Evaluation; RCT, randomized clinical trial; US, ultrasound.
Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Uygur et al (2021) RCT Level of evidence: I Patients in the DN group received One hundred eight Patient-Rated DN and CS injection afforded
PEDro score: 8/10 15 0.25 × 25-mm stainless patients with lateral Tennis Elbow significant improvements during
steel needles that were insert- epicondylitis whose Evaluation the 6 months of follow-up. However,
ed at the lateral epicondyle pain was not re- compared with CS injection, DN
region and throughout the lieved by 3 weeks of was more effective. (P<.01). Four
course of the extensor carpi first-line treatment patients treated with injection (7.6%)
radialis brevis tendon. DN was (NSAID and forearm developed skin complications.
repeated twice weekly. For CS brace) One patient treated with DN (2.04%)
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Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Navarro-Santana Meta-analysis Level of evidence: Included RCTs where at least one Seven trials were Pain, related-dis- Low to moderate evidence suggests
et al (2020) II group received any type of dry included in the ability, function, a positive effect of dry needling for
AMSTAR score: needling (muscular or tendon) analyses. Six stud- pressure pain pain, pain-related disability, pressure
8/11 for the management of lateral ies targeted active threshold, pain sensitivity, and strength at the
epicondylalgia of musculo- trigger points with strength short term in patients with lateral
skeletal origin. Included the the needle, whereas epicondylalgia of musculoskeletal
following diagnostic terms the seventh study origin. Dry needling facilitated a de-
in the meta-analysis: lateral targeted the tendon. crease in pain (SMD, –1.13; 95% CI:
epicondylalgia, epicondylitis, The methodological –1.64, –0.62), decrease in disability
tennis elbow, or lateral elbow quality scores (SMD, –2.17; 95% CI: –3.34, –1.01),
tendinopathy ranged from increase in pressure pain threshold
6 to 8 (mean = 6.6, (SMD, 0.98; 95% CI: 0.30, 1.67)
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Abbreviations: CS, corticosteroid; DN, dry needling; NSAID, nonsteroidal anti-inflammatory drug; PE, percutaneous electrolysis; PPT, pressure pain thresh-
old; RCT, randomized clinical trial; SMD, standardized mean difference.
8/11 subjects (greater than 18 were included in the and function on pain compared with other
years old); (3) reported pain qualitative analysis (different physical therapy interventions for
scores in both intervention and 16 studies were measurement all patients (short term). In younger
and comparison groups; and included in the me- tools). patients (<45 years), there was no
(4) studies in which subjects ta-analysis. All the statistically significant effect on pain
treated with a counterforce included trials were (SMD, −0.86; 95% CI: −2.45, 0.72).
brace were compared to other parallel design. Four In the long term, other physical
interventions (physical therapy studies were rated therapy interventions seemed to
interventions, other orthoses, as “good,” 5 studies have a greater positive effect than
laser therapy, or sham). were rated as “fair,” the counterforce brace (SMD, 1.17;
and 8 studies were 95% CI: 0.00, 2.34).
rated as “poor.”
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Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Heales et al Systematic Level of evidence: Studies were included if they met Seven randomized Pain intensity Low-quality evidence is available to
(2020) review II the following criteria: (1) par- crossover studies during wrist support a significant decrease in
AMSTAR score: ticipants with a clinical diag- extensor muscle pain during contraction (SMD range:
9/11 nosis of LET; (2) the use of an contraction, −0.83 to −0.65) and improvements
isolated wrist and/or forearm passive stretch in PFGS (SMD range: 0.24-0.38)
orthosis; (3) a randomized force prior to with forearm orthoses compared to
controlled trial or randomized pain, pain inten- a control or placebo. The difference
crossover controlled trial; (4) sity following the in pain decrease during extensor
a control condition without an entire testing muscle contraction was greater in
orthosis, or a placebo condi- condition, individuals wearing a wrist support
tion; (5) an outcome measure PFGS, maximal than a placebo orthosis (MD, −0.48
related to pain (eg, VAS, PPT, grip strength, cm; 95% CI: −0.96, −0.01). There is
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PFGS), function (eg, strength) wrist extensor low-quality evidence that forearm
or sensorimotor measures strength, orthoses can immediately reduce
(eg, proprioception); and (6) sensorimotor pain during contraction and improve
examined immediate effects outcomes. PFGS but not maximal grip strength
(ie, within session). in individuals with lateral elbow
tendinopathy.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Healy et al (2018) Systematic Level of evidence: Systematic review of RCTs assess- Effect size or odds Pain intensity One study found greater reduction in
review II ing clinical and cost effective- ratios were possible pain with laser when compared to
AMSTAR score: ness of prosthetic and orthotic to calculate from a lateral counterforce brace (ES,
5/11 interventions. Eight studies pain outcome data 1.04 (95% CI: 0.35, 1.73), whereas
that examined individuals with provided. another reported that a lateral coun-
LET were included. terforce brace reduced pain more
than sham laser therapy (ES, −0.8;
95% CI: −1.45, −0.15). Success rates
were slightly higher for the physical
therapy–plus–lateral counterforce
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Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Bisset et al (2011) Systematic Level of evidence: Clinical trial or systematic review Eighty systematic Pain, global Conflicting evidence for or against
review II regarding any type of interven- reviews, RCTs, improvement, the use of orthoses. Corticosteroid
AMSTAR score: tion approach or observational and functional injections were more effective in
7/11 studies that met the improvement the short term (RR, 2.9; 95% CI:
inclusion criteria (1 1.8, 5.7), on global improvement
systematic review scores compared with orthosis, but
and 1 RCT regarding not at the intermediate term (RR,
orthoses). 0.70; 95% CI: 0.46, 1.05) or long
term (RR, 0.90; 95% CI: 0.60, 1.03).
Low- to medium-quality studies
have reported that the use of a wrist
orthosis or elbow strap does not ap-
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individuals on electromyographic
(EMG) signal intensity in the wrist
extensors and grip strength. All
styles of wrist orthoses resulted
in similar decreased grip strength
compared with no orthosis; the
semicircular wrist support orthotic
design resulted in reduced EMG sig-
nal intensity in the wrist extensors
compared with the dorsal and volar
designs.
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Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
MacDermid et al Survey study Level of evidence: N/A Six hundred and The survey Respondents were predominantly
(2010) V ninety-three consisted of female (85%) and their average
members of the structured ques- time in practice was 18.7 years;
American Society tions related 81% were certified hand therapists.
of Hand Therapists to respondent Respondents were asked about
or individuals who demographics, 49 treatments often used in the
were certified hand as well as ques- management of individuals with
therapists identified tions regarding LET. Ranks of how frequent the
through the Hand the examination, interventions were used and their
Therapy Certifica- prognostic perceived effectiveness were listed.
tion Commission factors, and Eighty-one percent of respondents
(estimated 37% interventions reported using either a forearm
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Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Zhong et al Meta-analysis Level of evidence: I Inclusion criteria: RCTs that Five RCTs with a total Visual analog Kinesiology tape yielded statistically
(2020) AMSTAR score: included participants with of 168 patients scale (VAS), superior pain scores, grip strength,
7/11 diagnosis of LET who had were included in grip strength; Modified Mayo Performance Index,
received kinesiology tape, the MA, all with Modified Mayo and DASH score. Improvements in
sham taping, or physical low risk of bias. Performance pain (WMD, −0.46; 95% CI: −0.90,
therapy, and at least one of the Index; Disabili- −0.02), grip strength (WMD, 1.63;
following outcome measures ties of the Arm, 95% CI: 0.27, 3.00), function as
was reported: pain score, Shoulder and measured by the Modified Mayo
functional outcome, PFGS, and Hand (DASH) Performance Index (WMD, 4.23;
adverse events. score, and 95% CI: 2.80, 5.65), and function as
adverse events measured by the DASH score (WMD,
−5.25; 95% CI: −9.10, −1.39) in the
kinesiology taping group over the
control groups. The most common
adverse effect reported was skin
irritation from the tape.
Kinesiology tape is effective in relieving
pain, restoring grip strength, and
improving function in LET.
Table continues on next page.
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Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Bisset et al (2005) Meta-analysis Level of evidence RCTs that included participants One high-quality PFGS, pressure PFGS improved 24% from baseline, and
=I with diagnosis of lateral study was includ- pain threshold pressure pain threshold improved
AMSTAR = 7/11 epicondylitis treated with a ed that assessed when measured immediately and 30
relevant physical intervention the immediate minutes postintervention compared
measured by at least one effects of a with the placebo rigid tape and no-
clinically relevant outcome specific taping tape groups.
measure. technique (rigid
diamond-deload-
ing taping) in par-
ticipants whose
mean duration of
symptoms was
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kinesiology tape) with no taping techniques outcomes, and included studies, application of
other concurrent treatment; on the immediate participant-rated rigid tape using a diamond deloading
an untaped comparator or short-term function (DASH, technique is likely to immediately
condition provided either as effects on PRTEE). For improve pain and function in individ-
a baseline measurement (ie, outcomes. Several the immediate uals with LET. It is unclear whether
before application), a separate studies demon- effects of tape, kinesiology tape influences pain and
experimental condition, or an strated high risk outcomes were function immediately or in the short
unaffected limb; an outcome of bias. measured at term. Data are unable to be pooled;
related to pain or function 0 min, or at 0 most reported percent change in
and a full-text, peer-reviewed, and 30 minutes, outcomes. No adverse effects are
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Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Martínez-Beltrán RCT Level of evidence: Individuals clinically diagnosed One hundred four Isometric wrist No significant differences (P<.05) in any
et al (2021) II with LET with symptoms of participants were extensor, grip, other variables between the 2 groups.
PEDro score: 7/10 unknown duration randomized to 2 and isokinetic No statistically significant intergroup
groups. Group 1: pronation and differences were found regarding
kinesiology tape supination maximum strength variables or
using “I” muscle strength by regarding the time for reaching
toning technique Baltimore maximal strengthening of any of the
applied from Therapeutic movements studied. No adverse
lateral epicondyle Equipment effects or harms were reported.
to wrist (n = 52). (BTE) isokinetic
Group 2: kinesiology dynamometer.
placebo taping
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using a 5-cm-wide
white athletic
bandage with no
tension applied (n
= 52). Participants
received a 1×
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
taping application
with outcomes
measured imme-
diately prior to
and after taping.
Mansiz-Kaplan et RCT Level of evidence: Individuals with LET >3 months Eighty-seven Clinical (VAS, Improvement in VAS, PRTEE-pain,
al (2021) II duration participants: 44 PRTEE) and ul- and PRTEE-function in the second
PEDro score: 6/11 randomized into trasonographical and sixth weeks were statistically
the control group evaluations (CET significant in all groups (P<.001).
and 43 into the thickness, radial In the kinesiology tape group, the
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Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Tezel et al (2020) RCT Level of evidence: Forty-eight patients with chronic Inclusion criteria Pain intensity with Pain and functional levels of patients
II LET were as follows: VAS, arm pain with chronic LE were significantly
PEDro score: 5/10 (1) age between and function improved both with kinesiology tape
18 to 65 years, with PRTEE (pain, P = .001; function, P = .001)
(2) pain and questionnaire, and sham groups (pain, P = .001;
tenderness on the grip strength function, P = .001), but no significant
lateral epicondyle with hand dyna- difference was observed between the
for at least 3 mometer, and groups.
months, and (3) wrist extensor
provocation of strength by
the lateral elbow an isokinetic
pain with at least device.
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wrist extensors).
These patients
were randomly
assigned to either
the kinesiology
tape group or the
sham group.
Abbreviations: ADL, activities of daily living; CET, common extensor tendon; CSA, cross-sectional area; DASH, Disabilities of the Arm, Shoulder and Hand;
ESWT, extracorporeal shock wave therapy; LET, lateral elbow tendinopathy; PFGS, pain-free grip strength; PRTEE, Patient-Rated Tennis Elbow Evaluation;
RCT, randomized clinical trial; US, ultrasound; VAS, visual analog scale; WMD, weighted mean difference.
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ulated at 4 Hz, duration: 200 μs, using analgesic TENS with or without cryotherapy.
and motor level amp) medications. The burst TENS plus cryotherapy
(5) Cryotherapy (ice pack applied A total of 112 group showed significantly superior
to lateral elbow) females pain tolerances (MD, 4.9; 95% CI: 4.8,
(6) Cryotherapy and burst TENS participated in 5.0) compared with all other groups.
(combination of groups 4 and 5) the study (16 per
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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
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Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Agostinucci et al RCT: the par- Level of evidence: Participants were selected via Of the 70 VAS scores and All 4 groups showed significant changes
(2013) ticipants III convenience sampling. Baseline participants DASH in all 3 measures demonstrating
chose PEDro score: 4/10 measures of grip strength, VAS who started the no significant difference between
their group scores on single-arm chair study only 49 exercise and cryotherapy or a com-
number pick-up, and DASH scores were completed the bination of the two for treating lateral
at random recorded. Participants were study. epicondylalgia.
from 1 randomly assigned to groups: Inclusion criteria All 4 treatment groups showed improved
to 4 Group 1: exercise only, Group 2: included indi- DASH scores (average of 47.6%),
exercise and standard gel pack, viduals over which meets the minimal important
Group 3: CryoMAX and exercise, 18 years, pain change requirement. All groups also
Group 4: CryoMAX only. localized to the had decreased VAS scores (average
All groups were given the same lateral elbow, of 37.5%) and increased grip strength
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1 W/cm2 power
was applied with
a 5-cm diameter
applicator. The
second group
received US
with same
parameters
using pulsed-
wave (1:4) US.
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Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Yalvac et al (2018) Prospective, Level of evidence: Fifty adults with at least 3 months Group 1 received VAS, algometer, grip ESWT and therapeutic US are equally
random- II duration of symptoms, diag- therapeutic US dynamometer, effective in treating LET. ESWT is an
ized, single PEDro score: 7/10 nosed as chronic LET. (n = 24; 5 males quick-disabil- alternative therapeutic intervention
blind, and 15 females; ity of the arm, and is as effective as US. No differenc-
clinical mean age: 43.75 shoulder and es in improvement in outcomes were
trial ± 4.52). Group 2 hand (Quick- demonstrated in either group. Both
received ESWT DASH), PRTEE, ESWT and therapeutic US were equally
(n = 20; 8 males and Short effective in treating LET in the short
and 16 females; Form-36 (SF-36) term especially with improving VAS
mean age: 46.04 health survey pain scores (MDs >22/100 for both
± 9.24). Thera- questionnaire. treatments) and QuickDASH scores
peutic US was Outcomes (MDs >15/100 for both treatments).
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administered at collected
1.5 W/cm2, 1-MHz at baseline,
frequency, con- after treatment,
tinuous mode to and 1 month
the painful area, after treatment
5 minutes once concluded.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
a day, 5 days
a week, for 10
sessions in total.
Lizis (2015) RCT Level of evidence Fifty individuals with chronic LET (1) US: received Pain (VAS) levels Both groups had a significant decrease
= II (symptoms persisting past 12 continuous US were tested at in pain levels throughout the study;
PEDro score: 6/10 months) were randomly allo- (intensity: .8 W/ baseline, imme- however, the ESWT group experienced
cated by a blinded statistician cm2; frequency: diately following a significantly greater analgesic
to 2 groups 1 MHz) 3 times completion of effect (88% reporting good or
a week for 10 intervention, excellent pain reduction immediately
treatments (tx) and 3 months postintervention and 96% 3 months
Journal of Orthopaedic & Sports Physical Therapy®
cpg102 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
APPENDIX
APPENDIX
E (CONTINUED)
A
Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Hoogvliet et al Systematic Level of evidence: Studies that included the eval- A total of 12 RCTS Pain, function, No evidence was found to support US as
(2013) review II uation of several therapeutic and 1 review grip strength a treatment method compared with
AMSTAR score: interventions: stretching, were included; (no pooling of re- an exercise and stretching program for
6/11 strengthening, concentric/ 1 review and sults conducted) the treatment of LET. Even when US
eccentric exercises, and 1 recent RCT was combined with friction massage,
manipulation of the cervical or discussed US as an exercise and stretching program
thoracic spine, elbow, or wrist an intervention. showed better short-term improve-
for the treatment of lateral or ments. US plus friction massage was
medial elbow tendinopathy. less effective in reducing pain than
exercise in the short term (8 weeks)
(SMD, 0.95; 95% CI: 0.26, 1.64) and
long-term (36 months) follow-up (MD,
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included. Modalities examined review; US outcome tools moderate evidence to support that US
were US, ESWT, TENS, and was included used in each in combination with friction massage
laser therapy. in nine of the study varied is more effective than laser therapy. US
included articles. was more effective at reducing pain
Search included and improving global function than a
articles that were placebo treatment at 13 weeks based
published up to on moderate evidence. Pooled data
August 2012. showed a significant improvement
on pain (SMD, −0.98; 95% CI: −1.64,
−0.33) in the US group compared to
a placebo or no treatment in the mid-
term. However, there was conflicting
evidence regarding the benefit of US in
the short term. In addition, the combi-
nation of US with friction massage was
more effective in reducing pain than
laser therapy (SMD, −0.84; 95% CI:
−1.58, −0.09) at 6 weeks.
Table continues on next page.
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg103
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
APPENDIX
APPENDIX
E (CONTINUED)
A
Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Bisset et al (2005) Systematic Level of evidence: The review included studies The review included Pain scores (PVAS Insufficient evidence to support or
review and II that had participants with 28 RCTs; 5 or ordinal scale), refute US as a unimodal treatment
meta-anal- AMSTAR score: confirmed diagnosis of lateral studies looked at grip strength, for lateral epicondylitis. Even though
ysis 7/11 epicondylitis, included at the effectiveness improvement some studies showed an improvement
least one physical agent for of US. (data was in outcome measures in short-term
therapeutic intervention, were pooled for some follow-ups (up to 3 months), all studies
randomized, compared at interventions but showed no difference between groups.
least 2 groups, and included not all data for One high-quality study (Smidt et al)
at least one relevant outcome US was pooled) found the combination of US, friction
measure. massage, and exercise was more
effective in the management of LET in
the long term than corticosteroid injec-
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Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Baktir et al (2019) Randomized Level of evidence: Adults with LET Twelve participants were The visual analog Within-group mean change in scores
parallel II randomized to each scale (VAS), were reported for each outcome.
group trial PEDro score: 7/10 group. pressure There were no significant differences
LLLT group (wavelength algometer, the between groups improvements in
of 904 nm, 50 Hz, and Patient-Rat- pain at rest (P = .07), pressure pain
maximum peak power ed Tennis threshold (P = .89), grip in elbow
of 0.12 mW, applied Elbow Evaluation extension (P = .06), or function (P =
Journal of Orthopaedic & Sports Physical Therapy®
cpg104 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
APPENDIX
APPENDIX
E (CONTINUED)
A
Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Nagrale et al RCT Level of evidence: Sixty patients with LET Randomly assigned to Pain, PFGS, and Both groups demonstrated improvement
(2009) II receive either 10 min- PRTEE in pain, PFGS, and function as mea-
PEDro score: 7/10 utes of deep transverse sured by the PTREE at 4 and 8 weeks.
friction massage plus The group receiving transverse friction
a single application of massage and manipulation demon-
Mill’s manipulation or strated significantly better outcomes
phonophoresis using a than the group receiving phonopho-
1% diclofenac sodium resis plus supervised exercise at the
gel plus supervised 8-week follow-up. The calculated
exercise effect size of this group at the 8-week
follow-up was 0.74 for PFGS, −0.74 for
function, and −0.81 for VAS.
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Bisset et al (2011) Systematic Level of evidence: Adults who were diagnosed Two systematic reviews Pain, grip strength, One study found that there was no signif-
review II with tennis elbow with that included 2 RCTs PFGS icant difference between US and pho-
AMSTAR score: the following inclusion that compared US to nophoresis in grip strength, pain, or
7/11 criteria; published sys- phonophoresis (with PFGS. The addition of friction massage
temic reviews, RCTs (in corticosteroid agent); to the 2 treatment groups also did not
any language), at least one “low-quality significantly impact moderate-term (5
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
single blinded, including RCT” examined the weeks) outcome measures. The other
>20 individuals of whom difference between study examined short-term results (5
>80% were followed up. iontophoresis and days) of bracing, activity modifica-
phonophoresis tions, and ice massage combined with
US or phonophoresis. No significant
difference was found between groups.
More high-quality evidence is needed to
determine if iontophoresis or phono-
phoresis is better at reducing pain and
increase function.
Journal of Orthopaedic & Sports Physical Therapy®
Abbreviations: LET, lateral elbow tendinopathy; LLLT, low-level laser treatment; PFGS, pain-free grip strength; RCT, randomized clinical trial.
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg105
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
APPENDIX
APPENDIX
E (CONTINUED)
A
Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Baktir et al (2019) Randomized Level of evidence: Adults with LET Twelve participants were VAS, pressure al- Along with improvements in pain (ES =
parallel II randomized to the LLLT gometer, PRTEE, 1.22), function and grip strength were
group trial PEDro score: 7/10 group, 12 to the pho- and grip strength associated with the iontophoresis
nophoresis group, and dynamometer group (PRTEE, P = .006; ES = 0.78;
13 to the iontophoresis grip strength with elbow extension, P
group = .011; ES = 1.03; with elbow flexion, P
= .003; ES = 0.52) Of the 3 modalities
(iontophoresis, laser, and phonopho-
resis), iontophoresis was the only
modality shown to be beneficial for
improving pain and function on the
PRTEE.
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Sims et al (2014) Systematic Level of evidence: Review of RCT to assess the Fifty-eight RCTs of level Pain levels, func- All studies found significant short-term
review II conservative treatment I or II quality (double tional status, pain relief with the use of iontophore-
AMSTAR score: options for lateral or single blinded) grip strength sis when compared to a placebo using
6/11 epicondylitis. Article were included within either sodium diclofenac, sodium
inclusion criteria were the review; 4 RCTs salicylate, or dexamethasone; howev-
patients with lateral specifically examined er, pain scores were not significantly
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
cpg106 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
APPENDIX
APPENDIX
E (CONTINUED)
A
Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Kohia et al (2008) Systematic Level of evidence: Review examined RCTs to Twelve RCTs were included Pain scores (VAS), When naproxen iontophoresis was
review II discover the most appro- within the results; 7 grip strength compared with naproxen phonopho-
AMSTAR score: priate treatment protocol studies were classified resis, both groups showed a decrease
6/11 for lateral epicondylitis. as level I evidence, and in VAS scores and an increase in
Interventions in the 9 studies were clas- grip strength; however, no significant
study included iontopho- sified as level II. Four difference was found between the 2
resis, phonophoresis, studies were evaluated interventions. When iontophoresis
US, bracing, Cyriax phys- but not included in the was coupled with infrared treatment,
iotherapy, shockwave results due to “lack of the group that received iontophoresis
therapy, Bioptron light scientific rigor” (unsure with sodium diclofenac demonstrated
therapy, glyceryl trini- of which level of a greater reduction in pain than the
trate transdermal patch, evidence the dropped group that received iontophoresis with
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and standard physical studies were); 2 level II sodium salicylate (both groups saw
therapy protocols. studies included ionto- pain reduction).
Articles were assessed phoresis as a chosen
and included based on intervention.
the Megens and Harris
evaluation tool.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Abbreviations: ES, effect size; LET, lateral elbow tendinopathy; PFGS, pain-free grip strength; PRTEE, Patient-Rated Tennis Elbow Evaluation; RCT, random-
ized clinical trial; VAS, visual analog scale.
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg107
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
APPENDIX
APPENDIX
E (CONTINUED)
A
Evidence Rating
and Critical Ap- Sample Outcome
Study Type of Study praisal Score Conditions Characteristics Measures Important Results
Chesterton et al RCT Level of evidence Participants were randomly Eligibility criteria were Intensity of pain No additional benefit of supplementing
(2013) = II assigned to a TENS + patients aged over over the last primary care management with
PEDro score: 7/10 primary care manage- 18 years with a new 24-hour period self-administered TENS for 6 weeks.
ment or primary care clinical diagnosis of at 6 weeks, 6 At final examination (6 weeks), the
management alone. LET, which was defined months, and 12 between-group MD in pain was −0.33
Primary care man- as pain and tenderness months; global (95% CI: −0.96, 0.31).
agement participants over the region of the change in elbow
were given advice on common extensor pain, function,
activity, self-manage- tendon origin that number of
ment, and progressive increased on resisted sick days due
exercises. The TENS extension of the wrist to symptoms,
group received the same or on grip. Two hundred general health,
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occurred.
Abbreviations: BMI, body mass index; LET, lateral elbow tendinopathy; MD, mean difference; RCT, randomized clinical trial; VAS, visual analog scale; TENS,
transcutaneous electrical nerve stimulation.
cpg108 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
APPENDIX
APPENDIX
E (CONTINUED)
A
Evidence Rating
and Critical Ap- Sample Outcome
Study Type of Study praisal Score Conditions Characteristics Measures Important Results
Lian et al (2019) Systematic Level of evidence: Inclusion criteria were Thirty-six randomized Studies using the At short-term follow-up, only local
review II (1) randomized place- placebo-controlled VAS for pain corticosteroid injection improved
AMSTAR score: bo-controlled trials of a trials, evaluating 11 scores and/or pain; however, it was associated with
7/11 nonoperative treatment different treatment grip strength pain worse than placebo at long-term
for ECRB, (2) at least modalities, with a total follow-up. At midterm follow-up, laser
10 adult participants, of 2746 patients were therapy and local botulinum toxin
(3) follow-up >1 week, included. injection improved pain. At long-term
(4) full-text availabil- follow-up, extracorporeal shock wave
ity, and (5) outcome therapy provided pain relief. With
measurements of pain regards to grip strength, only laser
intensity (as measured therapy showed better outcomes
by the VAS) and/or grip in comparison with placebo. The
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journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg109
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
APPENDIX
APPENDIX
E (CONTINUED)
A
Evidence Rating
and Critical Ap- Sample Outcome
Study Type of Study praisal Score Conditions Characteristics Measures Important Results
Sims et al (2014) Systematic Level of evidence Randomized controlled Eight studies (both RCTs Pain, grip strength, Four early studies found that there
review = II trials examining nonsur- and double-blind RCTs) functional was no statistically significant
AMSTAR = 6/11 gical treatment of lateral examined the effect of assessment improvement in symptoms. Four later
epicondylitis low-intensity laser ther- studies found statistically significant
apy versus placebo. differences between the low-intensity
laser therapy groups and placebo
groups. Results are inconclusive.
Chang et al (2014) Systematic Level of evidence = Randomized controlled tri- Three studies (RCTs) Pain, strength, Three studies used laser acupuncture
review II als that examined man- examined the effect self-report while 6 used manual acupuncture.
AMSTAR = 9/11 ual or laser acupuncture of laser acupuncture measures Low-quality evidence demonstrated
as an intervention for versus sham acu- that manual acupuncture may be
lateral epicondylalgia puncture on the same effective in short-term pain relief (OR
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were unclear.
Bisset et al (2011) Systematic Level of evidence Systematic reviews of Two systematic reviews Pain, global Conflicting data and heterogeneity
review = II RCTs and RCTs in any and 6 RCTs comparing improvement, between studies suggests caution
AMSTAR = 7/11 language on the effects different intensity functional when drawing conclusions; however, a
of treatments for tennis laser therapy regimens improvement 904-nm wavelength over the tendon
elbow versus placebo area may be effective in reducing pain
and improving functional outcomes in
the short term.
Tumilty et al Systematic Level of evidence Randomized controlled Twenty-five trials were Grip strength, pain Six studies yielded a positive effect of
(2010) review = II trials and controlled included in the review, low-intensity laser on pain reduction
Journal of Orthopaedic & Sports Physical Therapy®
AMSTAR = 7/11 clinical trials of low-in- and 22 were random- and 7 studies reported no effect or
tensity laser treatment ized controlled trials. inconclusive evidence related to pain
administered to patients reduction with the use of low-level
diagnosed with tendi- laser treatment for LET. The authors
nopathy and assessing were able to pool data related to grip
pain or functional strength using higher-quality studies
outcomes. (≥6 on PEDro scale; n = 4). Overall,
the grip strength of the participants
receiving low-intensity laser therapy
demonstrated a final grip strength
that was 9.59 kg (95% CI: 5.90,
13.27) greater than the control group
participants. Of those studies that
demonstrated a positive effect (12
out of the 13), the parameters used
included a 904-nm wavelength
and between 2-100 mW/cm2 power
density. Low-intensity laser treatment
was potentially effective in treating
tendinopathy using recommended
doses, but the overall evidence was
inconclusive.
Table continues on next page.
cpg110 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines
APPENDIX
APPENDIX
E (CONTINUED)
A
Evidence Rating
and Critical Ap- Sample Outcome
Study Type of Study praisal Score Conditions Characteristics Measures Important Results
Bisset et al (2005) Systematic Level of evidence Randomized controlled tri- Twenty-eight trials were Pain, grip strength, When comparing laser to a place-
review = II als that had participants included in the review, global improve- bo treatment, change in global
AMSTAR = 7/11 diagnosed with lateral and 6 included a laser ment improvement was not statistically
epicondylitis, which was intervention. significant (RR, 1.09; 95% CI: 0.77,
defined as lateral elbow 1.53) at 3-month follow-up. At 1-year
pain that increased on follow-up, global improvement score
palpation and/or during change was approaching but did not
resisted wrist extension, reach statistical significance (RR,
where at least one 1.52; 95% CI: 0.97, 2.38). Pooled data
intervention included showed a null summated treatment
a relevant physical effect on pain, grip strength, or global
intervention. improvement in the treatment of
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lateral epicondylitis.
Abbreviations: ECRB, extensor carpi radialis brevis; ES, effect size; LET, lateral elbow tendinopathy; LLLT, low-level laser treatment; PCS, physical component
summary; PRTEE, Patient-Rated Tennis Elbow Evaluation; RR, relative risk; SMD, standardized mean difference; US, ultrasound; VAS, visual analog scale.
Evidence Rating
and Critical Ap- Sample Outcome
Study Type of Study praisal Score Conditions Characteristics Measures Important Results
Tran et al (2021) RCT Level of evidence: Injured workers with a diag- Forty-nine workers were Pain (NPRS), PFGS There were no statistically significant
II nosis of acute or chronic randomized into either with elbow flexed differences in improvement between
PEDro score: 7/10 unilateral LET who a standardized hand and extended, groups for pain, PFGS, or function
had a current worker’s therapy group (n = and function (P>.05) The investigators used an in-
compensation claim. 25) or an interven- (PRTEE). tension to treat analysis that included
tion group (n = 24) 6 individuals who did not receive the
who received hand allocated education intervention.
therapy plus a work-
Journal of Orthopaedic & Sports Physical Therapy®
place-based education
intervention. Hand
therapy consisted of
10 sessions over 12
weeks. The education
intervention consisted
of 2 additional sessions
consisting of educa-
tion, assessment, and
work modifications
according to the
identified occupational
risk factors.
Dick et al (2011) Systematic Level of evidence: Looking at workplace Twenty-eight papers were Employment out- Limited evidence that computer
review II interventions effective reviewed but only four comes- absence keyboards with altered force
AMSTAR score: at preventing/reducing were used for guideline rates, rate of displacement or altered geometry
6/11 sickness/absence. Only recommendations: return to work help nonspecific arm pain. Limited
4 pathologies looked at carpal tunnel (9 papers evidence on the usefulness of modi-
carpal tunnel syndrome, reviewed), fied keyboards.
nonspecific arm pain, nonspecific arm pain LET: not enough quality evidence on
tenosynovitis, and lateral (15 papers reviewed), workplace management. Multidisci-
epicondylitis tenosynovitis (1 paper plinary approach is beneficial.
reviewed),
lateral epicondylitis (1
paper reviewed)
Abbreviations: LET, lateral elbow tendinopathy; NPRS, numeric pain-rating scale; PFGS, pain-free grip strength; PRTEE, Patient-Rated Tennis Elbow Evalu-
ation; RCT, randomized clinical trial; VAS, visual analog scale.
journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg111
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