Jospt 2022 0302

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Clinical Practice Guidelines

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

Lateral Elbow Pain and Muscle


Function Impairments
Clinical Practice Guidelines Linked to the International Classification
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of Functioning, Disability and Health from the Academy of Hand and


Upper Extremity Physical Therapy and the Academy of Orthopaedic
Physical Therapy of the American Physical Therapy Association
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

J Orthop Sports Phys Ther. 2022;52(12):CPG1-CPG111. doi:10.2519/jospt.2022.0302

SUMMARY OF RECOMMENDATIONS................................. CPG2


INTRODUCTION.................................................................. CPG4
METHODS........................................................................... CPG5
CLINICAL PRACTICE GUIDELINES:
Journal of Orthopaedic & Sports Physical Therapy®

Impairment/Function-Based Diagnosis............................. CPG8


Pathoanatomical Features................................................... CPG8
Risk Factors.......................................................................... CPG9
Clinical Course....................................................................CPG10
Prognosis............................................................................. CPG11
Diagnosis/Classification..................................................... CPG12
Examination......................................................................... CPG15
Interventions....................................................................... CPG25
DECISION TREE................................................................ CPG43
AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS.... CPG45
REFERENCES....................................................................CPG46
APPENDICES.................................................................... CPG53

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.

INTERVENTIONS: THERAPEUTIC EXERCISE


INTERVENTIONS: DRY NEEDLING
B Clinicians should use isometric, concentric, and/or eccen-
Journal of Orthopaedic & Sports Physical Therapy®

B Clinicians should use either tendon or trigger point dry


tric therapeutic resisted exercises of the wrist extensors in
needling for the treatment of pain and functional deficits
the treatment of individuals with subacute or chronic LET.
associated with LET.
F Clinicians may use a phased approach to reintroduce stress,
increase strength, improve endurance, and restore optimal INTERVENTIONS: ORTHOSES
motor control in individuals who have LET symptoms with high-de-
D Based on conflicting evidence, a recommendation cannot
mand occupations, hobbies, performing arts, or athletic interests.
be made regarding the use of a forearm counterforce or
wrist support orthosis to alleviate intermediate or long-term
MULTIMODAL INTERVENTIONS: INCLUDING symptoms in individuals with LET.
THERAPEUTIC EXERCISE
Clinicians should use therapeutic resisted wrist extension F Clinicians may use a forearm counterforce or wrist sup-
B
strengthening exercises in combination with other thera- port orthosis to be worn during activity for immediate im-
peutic interventions, including manual therapy, in the treatment provement of pain and strength in those with LET whose
of patients with subacute or chronic LET. symptoms are aggravated with activity.

C Clinicians may include shoulder and scapular stabilizer INTERVENTIONS: TAPING


muscle training exercises, when impairments are identi-
fied, in conjunction with other forms of wrist extensor strengthen- B Clinicians should use rigid taping techniques for immedi-
ing exercise in individuals with LET. ate/short-term pain relief and improvement in pain-free
muscle function in those with irritable LET.
INTERVENTIONS: MANUAL THERAPY JOINT Clinicians may use kinesiology tape application as part of
MOBILIZATIONS/MANIPULATIONS C
a multimodal treatment program for immediate and
B Clinicians should use local elbow joint manipulation or short-term management of pain and muscle function in individu-
mobilization techniques to reduce pain and increase pain- als 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: CRYOTHERAPY 2-4 weeks from onset or aggravation of symptoms), in individuals


Clinicians may use cryotherapy combined with burst presenting with highly irritable symptoms of LET.
C
transcutaneous electrical nerve stimulation (TENS) to re-
duce pain in the short term in individuals with symptoms of LET INTERVENTIONS: TENS
for greater than 30 days.
C Clinicians may use burst TENS applied to the painful re-
Clinicians may use cryotherapy to reduce pain in individu- gion or high- or low-frequency TENS applied to acupunc-
E
als with irritable symptoms of LET. ture points, for short-term pain relief in individuals with LET.

INTERVENTIONS: THERAPEUTIC ULTRASOUND INTERVENTIONS: LASER


D Based on conflicting evidence, a recommendation cannot C Clinicians may use laser therapy for improvements in pain
be made for the use of ultrasound as a stand-alone and grip strength, seen in follow-up periods >4 weeks to
treatment. 6 months, for individuals with LET.
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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.

equipment, and workstation adjustments is moderately support-


INTERVENTIONS: IONTOPHORESIS ed by best practice/standard of care.
C Clinicians may use iontophoresis with an anti-inflamma- *These recommendations and clinical practice guidelines are based on the scien-
tory drug, early in the rehabilitation phase (no later than tific literature published prior to November 2021.

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

ROM: range of motion TENS: transcutaneous electrical nerve stimulation


RR: relative risk UE: upper extremity
SD: standard deviation US: ultrasound
SEM: standard error of measurement VAS: visual analog scale
SMD: standardized mean difference WMD: weighted mean difference
SRM: standardized response mean W/cm2: Watts per centimeter squared
TDN: trigger point dry needling

Introduction
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AIM OF THE GUIDELINES STATEMENT OF INTENT


The Academy of Hand and Upper Extremity Physical Thera- These guidelines are not intended to be construed or to serve
py (AHUEPT) and Academy of Orthopaedic Physical Ther- as a standard of medical care. Standards of care are deter-
apy (AOPT) of the American Physical Therapy Association mined on the basis of all clinical data available for an individ-
(APTA) have an ongoing effort to create evidence-based ual patient and are subject to change as scientific knowledge
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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®

LET. Briefly, the following databases were searched between


January 2001 to November 2021: PubMed including Med- This guideline was issued in 2022, based on the published
line, CINAHL, and the Cochrane Library (see APPENDIX A for literature from January 2001 to November 30, 2021, and
full search strategies, dates, and results, available at www. will be considered for review in 2027, or sooner if import-
jospt.org and www.handpt.org). ant evidence becomes available. Any updates to the guide-
line in the interim period will be noted on the AOPT and
The authors declared relationships and developed a con- AHUEPT of the APTA websites: www.orthopt.org and
flict management plan, which included submitting a con- www.handpt.org.
flict-of-interest form to the AOPT. Articles authored by
members of the CPG team were assigned to an alternate LEVELS OF EVIDENCE
reviewer. The AOPT and AHUEPT funded the CPG devel- Individual clinical research articles were graded according to
opment team for travel and CPG development training. The criteria adapted from the Centre for Evidence-Based Med-
CPG development team maintained editorial independence icine, Oxford, UK (http://www.cebm.net)25 for diagnostic,
with regards to the funding agencies. prospective, and therapeutic studies. In teams of 2, each re-
viewer independently assigned a level of evidence and evalu-
Articles contributing to recommendations were reviewed ated the quality of each article using a critical appraisal tool.
based on prespecified inclusion and exclusion criteria with If the 2 reviewers did not agree on levels of evidence for a
the goal of identifying evidence relevant to physical therapist particular article, a third content expert was used to resolve
clinical decision-making for adults with LET. Two members the issue. (See APPENDICES D and E for Levels of Evidence table
of the CPG development team independently screened the ti- and details on procedures used for assigning levels of evi-
tle and abstract prior to full text review to obtain the final set dence, available at www.jospt.org and www.handpt.org.) The
of articles used to make the recommendations. (See APPEN- evidence was organized from the highest to lowest level of
DIX B for inclusion and exclusion criteria, available at www. evidence. An abbreviated version of the grading system is
jospt.org and www.handpt.org.) The team leader (A.M.L.) provided in TABLE 1.

journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg5
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

TABLE 1 Levels of Evidence TABLE 2 Grades of Recommendation

I Evidence obtained from high-quality diagnostic studies, prospective Grades of Level of


studies, systematic reviews, or randomized controlled trials Recommendation Strength of Evidence Obligation
II Evidence obtained from lesser-quality diagnostic studies, systematic A Strong evidence A preponderance of level I and/or level Must or
reviews, prospective studies, or randomized controlled trials (eg, weaker II studies support the recommen- should
diagnostic criteria and reference standards, improper randomization, no dation. This must include at least 1
blinding, <80% follow-up) level I study
B Moderate evidence A single high-quality randomized Should
III Case-controlled studies or retrospective studies
controlled trial or a preponderance
IV Case series of level II studies support the recom-
V Expert opinion mendation
C Weak evidence A single level II study or a prepon- May
derance of level III and IV studies,
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including statements of consensus


GRADES OF EVIDENCE by content experts, support the
The overall strength of the evidence supporting recommenda- recommendation
tions made in these guidelines was graded according to guide- D Conflicting Higher-quality studies conducted on this
lines described by Guyatt et al,66 as modified by MacDermid114 evidence topic disagree with respect to their
and adopted by the coordinator and reviewers of this project. conclusions. The recommendation is
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

based on these conflicting studies


In this modified system, the typical A, B, C, and D grades of
E Theoretical/ A preponderance of evidence from May
evidence have been modified to include the role of consensus
foundational animal or cadaver studies, from
expert opinion and basic science research to demonstrate bi- evidence conceptual models/principles or
ological or biomechanical plausibility (TABLE 2). In developing from basic sciences/bench research,
their recommendations, the authors considered the strengths supports this conclusion
and limitations of the body of evidence and the health bene- F Expert opinion Best practice based on the clinical May
fits, side effects, and risks of tests and interventions. experience of the guideline develop-
ment team

GUIDELINE REVIEW PROCESS AND VALIDATION


Journal of Orthopaedic & Sports Physical Therapy®

Identified reviewers who are experts in UE injury manage-


ment and rehabilitation reviewed a prepublication draft of revisions. These guidelines were also posted for public com-
this CPG content and methods for integrity, accuracy, and ment on the AOPT website (www.orthopt.org), and a notifi-
that it fully represents the condition. Any comments, sugges- cation of this posting was sent to the members of the AOPT
tions, or feedback from the expert reviewers were delivered and AHUEPT. Any comments, suggestions, and feedback
to the author and editors for consideration and appropriate gathered from public commentary were sent to the authors

Planned Strategies and Tools to Support the Dissemination


TABLE 3
and Implementation of This CPG

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

and editors to consider and make appropriate revisions in


the guideline. In addition, a panel of consumer/patient rep- ICD and ICF Codes
resentatives and external interested parties, such as claims TABLE 4 Associated With Lateral
reviewers, medical coding experts, academic educators, Elbow Pain
clinical educators, physician specialists, and researchers,
also reviewed the guideline and provided feedback and rec- International Statistical Classification of Diseases and Related Health Problems
(ICD-10) 2015
ommendations that were given to the authors and editors
ICD-10 M77.1 Lateral epicondylitis
for further consideration and revisions. The AOPT Clinical
Practice Guideline Advisory Panel reviews guideline devel-
opment methods, policies, and implementation processes on International Classification of Functioning, Disability and Health (ICF)
a yearly basis. ICF Codes Description
Muscle Function Impairments
DISSEMINATION AND IMPLEMENTATION TOOLS b730-b74 Muscle functions
In addition to publishing these guidelines in the Journal of b730 Muscle power functions
b7300 Power of isolated muscles and muscle groups
Orthopaedic & Sports Physical Therapy (JOSPT), these guide-
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b7301 Power of muscles of one limb


lines will be posted on CPG (free access) areas of the JOSPT, b740 Muscle endurance functions
AOPT, and AHUEPT websites and submitted to be available b7400 Endurance of isolated muscles
for free access on the ECRI Guidelines Trust (guidelines.ecri. b7401 Endurance of muscle groups
org) and the Physiotherapy Evidence Database (www.PEDro. Pain
org.au). The planned implementation tools for patients, clini- b280 Sensation of pain
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

b28014 Pain in upper limb


cians, educators, payers, policy makers, and researchers, and
Motor Control Impairments
the associated implementation strategies are listed in TABLE 3.
b1471 Quality of psychomotor functions
b760 Control of voluntary movement functions
ORGANIZATION OF THE GUIDELINE b7602 Coordination of voluntary movements
When systematic reviews were conducted to support specific b7603 Supportive functions of arm or leg
actionable recommendations, summaries of studies with the Activity Limitations
corresponding evidence levels were followed by evidence syn- d445 Hand and arm use
thesis and rationale for the recommendation(s) with harms d4453 Turning or twisting the hands or arms
and benefits statements and gaps in knowledge. Topics for d430 Lifting and carrying objects
Journal of Orthopaedic & Sports Physical Therapy®

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.

journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg7
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

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.

age = 47 years; 71 women, 106 men) in an RCT, age, sex,


The authors of a multicenter prospective trial with 83 sub- and duration of symptoms not to be significant (P>.05) in
jects (mean age = 44.2 years; 47 women, 36 men) under- predicting treatment success, as defined by a report of be-
going physical therapy, consisting of 10 visits over 8 weeks ing much better or completely recovered, at 26- or 52-week
with ultrasound (US), soft tissue massage, stretching, follow-up.
and strengthening components, determined predictors of
8-week outcomes.201 Predictors for greater disability (r2 = A prospective international study followed 349 subjects
0.61, P = .0001) included higher baseline Disabilities of the (mean age = 48 years, 171 females, 178 males) from 2 RCTs
Arm, Shoulder and Hand (DASH) scores (β = .50; 95% CI: investigating conservative interventions for LET in a primary
Journal of Orthopaedic & Sports Physical Therapy®

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®

Abbreviations: ICF, International Classification of Functioning, Dis-


ability and Health; LET, lateral elbow tendinopathy.
(Maudsley’s Test) 117

ICF Category Measurement of Impairment of Body Function


Description Special test to assist with the diagnosis of LET
to interventions. MacDermid and Silbernagel113 proposed a
Measurement method Patient position: descriptive classification (TABLE 8) that considers 6 classifi-
The patient can be in sitting or standing with the elbow cation axes, including irritability and distribution of symp-
in full extension, forearm pronation, and fingers in toms while including descriptive information on the context
extension. (general population, sports, worker’s compensation, etc), the
Test:
acuity, the likely underlying pathology (usually determined
The examiner supports the distal end of the forearm and
applies resistance to the dorsum of the distal phalanx by imaging), and the course (recurrent vs isolated episode or
of the third digit of the hand, indirectly stressing the persistent symptoms). This, when used appropriately, would
ECRB muscle and tendon. provide the clinician with a holistic picture of patients with
Positive test: LET and can be effective in tracking progress and guiding
Reproduction of pain at the lateral epicondyle of the hu-
treatment. For example, when determining the stage of irri-
merus or within 2 cm distal to the common extensor
tendon insertion site. tability, self-reported pain scores (NRPS) help quantify pain
Nature of variable Nominal/dichotomous intensity as either mild intensity (≤3/10), moderate intensity
Units of measurement None (4-6/10), or severe intensity ≥7/10). Distribution of symptoms
Measurement properties Maudsley’s test showed little association with pressure can be classified as unilateral and localized to the lateral epi-
pain threshold (β = .293).145 condyle (type 1), bilateral and localized to the lateral epicon-
Sensitivity = 88%159 dyles (type 2), or diffuse symptoms at the elbow along with
Sensitivity = 66%; 95% CI: 53%, 76%51 cervical or diffuse UE pain or neuropathic pain (type 3).
Abbreviations: ECRB, extensor carpi radialis brevis; ICF, International
Classification of Functioning, Disability and Health; LET, lateral elbow
tendinopathy.
An assessment of how symptom irritability affects function
using PTREE scores can indicate mild disability (score of

cpg12 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

al other pathologies result in a similar distribution of pain;


Mill’s Stretch Test or therefore, a thorough physical examination based on the ex-
TABLE 7
Long Extensor Stretch 124 clusion of other disorders as the cause of lateral elbow pain is
especially important for a more confident diagnosis of LET.
ICF Category Measurement of impairment of body function The classification system that is presented here can be uti-
Description Special test to assist with the diagnosis of LET lized. However, research is required to validate classification
Measurement method Patient position: systems and to assess their effectiveness on outcomes. Scien-
The patient can be in sitting or standing beginning with the tific inquiry into the value of subclassifying individuals into
elbow flexed to 90°, with the forearm pronated, and the
groups to allow for intervention-matching is needed.
wrist fully flexed.
Test:
The examiner extends the elbow slowly while palpating the The CPG team feels that the classification of patients with
lateral epicondyle. LET based on level of irritability can be useful to direct treat-
Positive test: ment. Self-reported pain, distribution of symptoms, and level
Reproduction of pain at the lateral epicondyle of the
of disability should all be considered in the stage of irrita-
humerus or within 2 cm distal to the common extensor
bility. For those who have severe pain, type 3 distribution,
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tendon insertion site.


Nature of variable Nominal/dichotomous
and high disability, the focus of treatment can be on symp-
Units of measurement None
tom modulation. Joint and soft-tissue mobility is the focus
Measurement Mill’s test showed little association with pressure pain of treatment for those with moderate pain, type 3 distribu-
properties threshold (β = .267).145 tion, and moderate disability. When mild pain with type 1-2
Sensitivity = 53%; Specificity = 100%159 distribution and low disability is achieved, loading the wrist
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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®

clinical presentation of LET and promptly refer patients to


As systems for subclassifying LET evolve and become validat- other health care professionals for further evaluation and
ed, it may be possible to direct treatment to more effectively management, if appropriate. The steps in developing a differ-
manage symptoms in specific subpopulations of individuals ential diagnosis include history taking, physical examination
with LET. Physical therapists may document the classifica- (including proper examination of special tests), and possibly,
tion of LET considering context, acuity, pathology, course, imaging. The conditions to consider with a differential diag-
distribution of symptoms, and irritability, and consider these nosis of lateral elbow pain, although not all-inclusive, include
factors in treatment planning. Empirical validation of clas- the following:
sification systems is needed to better guide treatment and • Cervical radiculopathy103
future research initiatives. • Radial tunnel syndrome54,154
• Posterior interosseous syndrome69
SUMMARY • Plica syndrome156,176
An accurate clinical diagnosis of LET is very important to • Radio-capitellar chondromalacia,104
plan treatment and to prevent recurrence. The ICD diagnosis • Posterolateral rotatory instability90
of LET and the associated ICF diagnosis of pain and muscle • Myofascial trigger points in the wrist extensors71
function impairments are typically made when, on clinical History and physical exam findings are considered the gold
examination, the patient presents with reports of pain local standard used to confirm the diagnosis. Imaging, however,
to the lateral epicondyle reproduced with palpation, resist- can be useful in evaluating the extent of disease, identifying
ed wrist and/or digit extension, and stretch/elongation of associated pathology, and excluding other sources of elbow
the long wrist extensors. There are 3 common special tests pain; particularly in cases where initial nonsurgical treat-
(Maudsley’s, Cozen’s, and Mill’s stretch) that are used to ment is unsuccessful. For refractory cases of LET, initial im-
arrive at a clinical diagnosis of LET. These tests have weak aging should include radiographs. Radiographs are usually
evidence supporting their diagnostic usefulness.188,211 More negative but may demonstrate calcium deposition adjacent
problematic in the clinical diagnosis of LET is that sever- to the lateral epicondyle and can be used to exclude other

journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg13
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

TABLE 8 Descriptive Classification of Lateral Elbow Tendinopathy a

Axis I Axis II Axis IV


Context Acuity Course
◽ General Population (screening/prevention) ◽ Acute (0-6 wk) ◽ Isolated episode
◽ Mixed Clinical Setting (Treatment) ◽ Subacute (<3 mo) ◽ Recurrent
◽ Special Population ◽ Chronic (>3 mo) ◽ Persistent
◽ Athlete _____ Axis III ◽ predictable
◽ Work _______ Pathology ◽ unpredictable
◽ Claim (Workers’ Compensation) ◽ Tendinosis
◽ Other _____________ ◽ Paratenonitis
◽ Mixed
Axis V Axis VI^
Distribution Irritability
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◽ 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.

work that persists after activity, but does not limit


activity
◽ Level IV: Mild* to moderate** pain that occurs Moderate
during exercise/work activity, persists >6 hours
and limits activity
◽ Level V: Moderate** overall pain ratings; severe
pain with heavy activities of daily living
◽ Level VI: Moderate** to severe*** overall pain Severe
ratings; severe pain with light activity; intermittent
pain at rest
Journal of Orthopaedic & Sports Physical Therapy®

◽ Level VII: Constant pain at rest, severe*** pain


with activity, pain disturbs sleep
VAS Pain Score ______ PRTEE Pain Score ______ PRTEE Total score ______
^The highest stage the person is most aligned with preferably defined by validated pain and disability measures
*Mild pain: ≤3/10 on VAS; 20/50 on PRTEE pain scale and 40/100 on PRTEE full scale
**Moderate Pain: 4-6/10 VAS; 21-34/50 on PRTEE pain scale and 41-69/100 on PRTEE full scale
***Severe Pain: >7/10 VAS; >36/50 on PRTEE pain scale and >70/100 on PRTEE full scale
a
Table adapted with permission from Joy MacDermid.

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

PATIENT-REPORTED OUTCOME MEASURES

TABLE 9 Patient-Rated Tennis Elbow Evaluation Questionnaire (PRTEE)

ICF Category Activity Limitations and Participation Restrictions


Description The PRTEE112 is a 15-item self-reported questionnaire to measure patients’ perceived pain and disability. It has 5 items on pain, 6 items on
the difficulty in performing usual activities, and 4 items on the difficulty in performing specific activities. Each of the items is scored on a
0-10 scale. The total score ranges from 0 to 100 where 100 indicates greater disability. It takes approximately 5 minutes to complete.138
Clinical measurement properties Test-retest reliability: Intraclass correlation coefficient (ICC) = 0.96131
Work-related LET ICC (2,1) = 0.89138
Mixed group-work and nonwork-related LET r2 = 0.87157
LET in tennis players ICC = 0.7632
LET in the general population
Internal consistency: 0.85-0.94 across the subscales155
0.96119
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Standard error of measurement (SEM) 0.6138


Construct validity: r = 0.72 to 0.884,119,131,155,166
With DASH r = 0.894
With Patient Rated Wrist Evaluation (PRWE) r = 0.614
With Hospital Anxiety & Depression Scale (HADS) (depres- r = −0.45131
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

sion subscale) r = 0.66131


With Pain-Free Grip Strength (PFGS) r = −0.61131
With VAS for pain r = −0.65131
With Short Form-36 (Physical function)
With Short Form-36 (bodily pain)
Sensitivity to change: Standardized response mean (SRM) = 0.84 : effect size (ES) = 1.0632
SRM =1.9 : ES = 1.6131
SRM = 2.0155
Minimal clinically important difference (MCID) Seven points for participants who rated themselves as “a little better” and
11 points for participants who rated themselves as “much better” or
“completely recovered” on the global change scale (GCS).148
Journal of Orthopaedic & Sports Physical Therapy®

Translation and cross-cultural adaptations: Greek175


All versions were comparable to the original English version Canadian French18
and have demonstrated acceptable psychometric Turkish5
properties. Dutch189
French93
Italian24
Swedish132
Hong Kong Chinese106
Persian119
Korean97
German120
Persian86
Persian166
Instrument variations The PRTEE was initially called the Patient Rated Forearm Evaluation Questionnaire (PRFEQ).112,138
Abbreviations: ICF, International Classification of Functioning, Disability and Health; LET, lateral elbow tendinopathy; PRTEE, Patient-Rated Tennis
Elbow Evaluation.

cpg16 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

TABLE 10 Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH)

ICF Category Activity Limitations and Participation Restrictions


Description The DASH is a region-specific self-report questionnaire to measure impairments and functional limitations due to disorders in the upper
limb. There is an optional component containing questions covering sports and performing arts, and work. The total DASH score ranges
from 0 (no disability) to 100 (severe disability). The DASH has been extensively used in efficacy studies on the management of LET.11
Clinical measurement properties Test-retest reliability: ICC = 0.91-0.96 (UE musculoskeletal disorders)11,160
SEM SEM = 4.6-5.22 (UE musculoskeletal disorders)11,160
Construct validity: r = 0.72-0.884,119,131,155,166
With PRTEE r = 0.67-0.71160
With Global Disability Rating
Sensitivity to change: SRM = 1.6 (tennis players)155
SRM = 0.9 (general population)131
Minimal detectable change (MDC90) = 12.2 (UE musculoskeletal disorders)160
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MDC90 = 10.7 (UE musculoskeletal disorders)11


MCID MCID = 10.2 (UE musculoskeletal disorders)160
Instrument variations The DASH has a shorter version called the QuickDASH, which has 11 items from the DASH.11 No studies are available on the psychometric
properties of the QuickDASH in an LET sample.
Abbreviations: ICC, intraclass correlation coefficient; ICF, International Classification of Functioning, Disability and Health; LET, lateral elbow tendi-
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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.

TABLE 11 Patient-Specific Functional Scale (PSFS)


Journal of Orthopaedic & Sports Physical Therapy®

ICF Category Activity Limitations and Participation Restrictions


Description The PSFS is a self-report outcome measure that is used to quantify patient-identified activity limitations related to any musculoskeletal
disorder. Patients self-select activities to rate on an 11-point scale. The anchor “0” represents being “unable to perform” the task, and “10”
represents being “able to perform at prior level.” Measurement properties have been established for adults with general UE musculoskele-
tal conditions75 but have not been specifically tested for adults with LET.
Clinical measurement properties Test-retest reliability: ICC = 0.97 (chronic pain)177
Interrater reliability: ICC (2,1) = 0.71 (UE musculoskeletal disorders)75
SEM: SEM = 0.41 (chronic pain)177
Criterion Validity (Concurrent Validity) r = −0.67 (chronic pain)177 with Roland-Morris
Minimal DetecTABLE Change (MDC) MDC = 2 points (chronic pain)177
MCID MCID = 1.2 points (UE musculoskeletal disorders)75
Abbreviations: ICC, intraclass correlation coefficient; ICF, International Classification of Functioning, Disability and Health; LET, lateral elbow tendi-
nopathy; MCID: minimal clinically important difference; MDC, minimal detectable change; SEM, standard error of measurement; UE, upper extremity.

journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg17
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

TABLE 12 The Numeric Pain-Rating Scale (NPRS)

ICF Category Self-report of Impairment of Body Function: Pain Levels


Description To measure or evaluate the levels of pain, clinicians use a variety of self-report tools in their practice such as VAS, NPRS, and verbal rating
scale. A systematic review80 conducted to compare different scales used to measure pain intensity in adults concluded NPRS to be the
ideal measure. Patients rate their level of pain on a scale of 0-10 (“0” = no pain and “10” = worst imaginable pain).61,80 It has been shown
to have acceptable psychometric properties. In a study looking into the validity of 4 pain rating scales, the NPRS was reported to be more
responsive and sensitive to change than other scales.61
Clinical measurement properties Test-retest reliability: ICC (2,1) = 0.74 (95% CI: 0.55, 0.86) (UE musculoskeletal disorders, including
elbow disorders)75
Construct validity: r = 0.84 (patients with LET)155
PRTEE r = 0.51 (95% CI: 0.39, 0.61) (UE musculoskeletal disorders, including elbow
PSFS disorders)75
MDC 5.7 (95% CI: 3.8, 7.2) (UE musculoskeletal disorders, including elbow
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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.

CLINICIAN-BASED OUTCOME MEASURES

TABLE 13 Roles and Maudsley (RM) Score


Journal of Orthopaedic & Sports Physical Therapy®

ICF Category Activity Limitations and Participation Restrictions


Description The RM Score was first described by Roles and Maudsley to classify the outcome after surgery for persistent LET cases.154 Since then, it has
been used in classifying outcomes in nonsurgical management. This score is provided by the clinician based on their observations and
outcomes and is classified into 4 levels: Excellent – no pain, full movement, full activity; Good – occasional discomfort, full movement, full
activity; Fair – some discomfort after prolonged activity; Poor – pain limiting activities.154 However, the RM score has not been validated
extensively in the LET population.
Clinical measurement properties Construct validity: r = 0.78132
With PRTEE (Swedish version)
Sensitivity to change: SRM of 1.52 (tennis players)155
Abbreviations: ICF, International Classification of Functioning, Disability and Health; LET, lateral elbow tendinopathy; PRTEE, Patient-Rated Tennis
Elbow Evaluation; SRM, standardized response mean; 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

TABLE 14 Mayo Elbow Performance Index (MEPI)

ICF Category Activity Limitations and Participation Restrictions


Description The MEPI is another clinician-based outcome measure that has been used in studies looking into the efficacy of treatment for LET. This
index comprises 4 parts: pain (45 points), elbow range of motion (ROM) (20 points), stability (10 points), and the ability to do functional
tasks (25 points). The maximum total score possible is 100. A higher score indicates better function. The interpretation for the MEPI
scores is: 90 to 100 points – excellent; 75 to 89 points – good; 60 to 74 points – fair; less than 60 points – poor. In general, the MEPI has
demonstrated acceptable levels of clinical measurement properties.126 However, the MEPI has not been validated extensively in the LET
population.
Clinical measurement properties Construct validity r = 0.83 to 0.89186
with other similar scoring systems of the elbow r = −0.56186
With DASH r = 0.64186
With M-ASES-e
Instrument variations There are at least 3 variants of the MEPI, each focusing on various aspects of the actual MEPI in different proportions.192
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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®

TABLE 15 Elbow Range of Motion

ICF Category Measurement of Impairment of Body Function: Mobility of Joints


Description The amount of active elbow flexion/extension ROM is measured using a universal goniometer. Flexion/extension of the elbow can be measured
from the lateral side. The forearm is in supination, and the hand is held with the palm upward. The goniometer arms are positioned parallel
to the midline of the arm and forearm. The value “0” is described as full neutral extension/flexion. Hyperextension is indicated by positive
values, whereas a loss in extension is indicated by negative values.
Measurement properties Intrarater reliability:
Flexion ICC = 0.95 (UE musculoskeletal disorders)6; 0.76 (95% CI: 0.47, 0.90) SEM 3° (Normal subjects)212
Extension ICC = 0.92 (UE musculoskeletal disorders)6; 0.92 (95% CI: 0.80, 0.97) SEM 2°(Normal subjects)212
Interrater reliability:
Flexion ICC = 0.58-0.62(UE musculoskeletal disorders)6; 0.86 (95% CI: 0.53, 0.96) SEM 2°(Normal subjects)212
Extension ICC = 0.58-0.87 (UE musculoskeletal disorders)6; 0.89 (95% CI: 0.63, 0.97) SEM 1° (Normal subjects)212
The precision of measurement (Standard deviation of random error): (LET)174
Flexion = 2°
Extension = 2°
Concurrent validity:
With fluid-based goniometer r = 0.83 (Normal subjects)143
MDC95:
Flexion 10°(UE musculoskeletal disorders)6
Extension 10°(UE musculoskeletal disorders) 6
Instrument variations Fluid goniometer,143 JTECH goniometer,9 and NK goniometer6
Abbreviations: ICC, intraclass correlation coefficient; ICF, International Classification of Functioning, Disability and Health; LET, lateral elbow tendi-
nopathy; MDC, minimal detectable change; ROM, range of motion; SEM, standard error of measurement; UE, upper extremity.

journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg19
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

TABLE 16 Forearm Range of Motion

ICF Category Measurement of Impairment of Body Function: Mobility of Joints


Description The amount of active forearm supination/pronation ROM is measured using a universal goniometer. The elbow is flexed to 90° and kept by the
side of the trunk adjacent to the body and with the forearm unsupported in a neutral position (thumb up). To measure pronation, the stable
arm of the goniometer is placed parallel to the humerus, and the movable arm is in contact with the dorsal aspect of the wrist near the
ulnar styloid process; the patient is asked to actively rotate the forearm inward (palm down) as far as possible. To measure supination, the
stable arm of the goniometer is placed parallel to the humerus and the moveable arm is in contact with the volar aspect of the wrist near
the ulnar styloid process; the patient is asked to actively rotate the forearm outward (palm up) as far as possible.
Measurement properties Intratester reliability:
Pronation
ICC (3,1) = 0.86 to 0.98 (SEM 1.4° to 2.8°) (UE musculoskeletal disorders and normal subjects)91
ICC (2,1) = 0.89 (95% CI: 0.80, 0.94) (SEM 2.10°) NK goniometer (UE musculoskeletal disorders)9
ICC (2,1)= 0.86 (95% CI: 0.77, 0.92) (SEM 2.24°) JTECH goniometer (UE musculoskeletal disorders)9
ICC = 0.90 (95% CI: 0.77, 0.96) SEM 8° (Normal subjects)212
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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

TABLE 17 Wrist Range of Motion

ICF Category Measurement of Impairment of Body Function: Mobility of Joints


Description The amount of active wrist flexion/extension ROM is measured using a universal goniometer. The elbow is held flexed to approximately 90°, the
forearm in pronation, and the wrist in neutral flexion/extension. The distal arm of the goniometer is placed along the lateral aspect of the fifth
metacarpal, and the proximal goniometer arm is placed along the lateral aspect of the forearm triquetrum. The flexion/extension angles are
measured from a lateral view.
Measurement properties Intratester reliability:
Flexion:
ICC(1,1) = 0.95 (lower limit of 95% CI: 0.93) (SEM 4.52°) (UE musculoskeletal disorders)83
ICC (3,l) = 0.86 to 0.92 (SEM 5.74° to 7.22°) (UE musculoskeletal disorders)102
ICC (2,1) = 0.97 (95% CI: 0.95, 0.98) (SEM 1.98°) NK goniometer (UE musculoskeletal disorders)9
ICC (2,1) = 0.95 (95% CI: 0.91, 0.97) (SEM 2.59°) JTECH goniometer (UE musculoskeletal disorders)9
MDC90:
4.62° (NK goniometer); 6.04° (JTECH goniometer) (UE musculoskeletal disorders)9
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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

ICF Category Measurement of Impairment of Body Function: Mobility of Joints


Description The amount of active wrist radial and ulnar deviation ROM is measured using a universal goniometer. The elbow is flexed to 90°, the
forearm is pronated, the wrist is in neutral, fingers are extended and adducted, and the palm is flat on the table. One arm of the
goniometer is aligned with the third metacarpal and the other is in line with the radius with the axis at the capitate bone. For radial
deviation, the hand is actively deviated to the radial side as far as possible, and for ulnar deviation, the hand is actively deviated
towards the ulnar side as far as possible.
Measurement properties Intrarater reliability:
Radial deviation
ICC (1,1 ) = 0.90 (lower limit of 95% CI: 0.86) (SEM 2.55°) (UE musculoskeletal disorders)83
ICC (2,1) = 0.96 (95% CI: 0.92, 0.98) (SEM 0.96°) NK goniometer (UE musculoskeletal disorders)9
ICC (2,1) = 0.93 (95% CI: 0.88, 0.96) (SEM 1.26°) JTECH goniometer (UE musculoskeletal disorders)9
MDC90:
2.24° (NK goniometer); 3.04° (JTECH goniometer) (UE musculoskeletal disorders)9
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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

TABLE 19 Pressure Pain Threshold (PPT)

ICF Category Measurement of Impairment of Body Function: Pain Sensitivity


Description The minimum pressure that produces pain or discomfort when the head of the algometer is applied perpendicular to the common
extensor tendon at the lateral epicondyle of the humerus. The PPT is measured in kg/cm2; the value is often reported as a force given
an instrument with a set surface area.
Measurement properties Individuals with LET:
Interobserver 95% limits of agreement: −2.82, 1.50 kg/cm2173
Interobserver reliability: ICC = 0.77; 95% CI: 0.62, 0.86173
Intratester reliability: ICC (3,1) = 0.95193
Between-session reliability: ICC (2,3) = 0.93; 95% CI: 0.85, 0.9772
Within-session reliability: ICC (2,3) = 0.93; 95% CI: 0.85, 0.9772
SMD (similar to MDC95) 1.5 kg/cm2173
MDC:
Between-session MDC 1.79 kg/cm272
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Within-session MDC 1.64 kg/cm275


Abbreviations: ICC, intraclass correlation coefficient; ICF, International Classification of Functioning, Disability and Health; LET, lateral elbow tendi-
nopathy; MDC, minimal detectable change; SMD, standardized mean difference.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Evidence Synthesis symptoms overexert the wrist extensors during assessment


Physical impairment measures of wrist ROM, elbow ROM, causing symptom aggravation.
pressure pain threshold (PPT), PFGS, and maximum grip
strength have all demonstrated excellent interrater and intra- Gaps in Knowledge
rater reliability in those with LET. The MDC values are avail- Except for the wrist and elbow ROM measures, all the other
able for all the described impairment measures. The PFGS measures had a limited number of studies looking into their
was the only impairment measure that had any information clinical measurement properties in the LET population. Mea-
on diagnostic accuracy in an LET sample. A recent inter- surement of wrist extension strength needs more research in
Journal of Orthopaedic & Sports Physical Therapy®

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

TABLE 20 Pain-Free Grip Strength (PFGS)

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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ICC (2,3) = 0.93; 95% CI: 0.84, 0.9772


ICC (2,1) = 0.94; 95% CI: 0.85, 0.9779
Within-session reliability:
Elbow flexed
ICC (2,3) = 0.96; 95% CI: 0.92, 0.9872
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ICC (2,1) = 0.96; 95% CI: 0.92, 0.9979


Elbow extended
ICC (2,3) = 0.97; 95% CI: 0.93, 0.9872
ICC (2,1) = 0.98; 95% CI: 0.93, 0.9979
SMD 1.4 kg-force173
MDC-Between session
Elbow flexed: 9.2 kg-force79
Elbow extended: 9.4 kg-force79
MDC-Within Sessions
Elbow flexed: 5.3 kg-force79
Elbow extended: 4.7 kg-force79
Journal of Orthopaedic & Sports Physical Therapy®

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.

TABLE 21 Maximum Grip Strength

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
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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.

of symptoms. No adverse effects of any type of exercise were


A comprehensive exercise progression algorithm reported in these studies.
V has been proposed for individuals with LET.43,44
The program is designed to provide exercise dosing Published research studies provide little information regard-
guidelines for musculature along the UE kinetic chain in ing specific rehabilitation guidelines that optimize return to
those with LET. Specific criteria are recommended for exer- function while minimizing risk of recurrent symptoms in
cise advancement between 3 phases of the exercise program. individuals with LET. Based on expert opinion, a phased ap-
Phases 1 and 2 focus on controlled muscle recruitment proach to reintroducing stress, increasing strength, improv-
through a loading progression of isometric, isotonic, and ec- ing endurance, and restoring optimal motor control may be
Journal of Orthopaedic & Sports Physical Therapy®

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
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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.
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into 1 of 4 groups: saline injection (n = 39), corticosteroid


injection (n = 40), exercise + saline (n = 39), and exercise RECOMMENDATION
+corticosteroid (n = 36). All participants received 1 injec- Clinicians should use therapeutic resisted wrist ex-
tion and standardized advice on resting for 10 days followed B tension strengthening exercises in combination
with other therapeutic interventions, including
by a gradual return to activity. The participants allocated to
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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
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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®

II ported MWM of the elbow for improving PFGS


immediately compared with a sham mobilization
PRTEE.151

(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

In an RCT, Akbar et al3 compared Cyriax manual Evidence Synthesis


II therapy to Mulligan’s MWM intervention measur-
ing both pain and grip strength. Sixty-six partici-
A preponderance of level 2 evidence demonstrates that lat-
eral glide MWM technique to the elbow, Mill’s manipulation
pants between the ages of 20-50 years old diagnosed with technique, or regional mobilization techniques all demon-
LET from an orthopaedic physician were included in the strate a positive effect compared with a placebo or control
study. Pain (0-10) after 8 weeks of treatment was found to be group on pain, PFGS, and function in the short term. The

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
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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-
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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®

and improve function in individuals with chronic LET. There


seems to be a benefit when instrument-assisted soft tissue Rodríguez-Huguet et al152 completed an RCT that
mobilization is added to exercise, but not as a stand-alone
treatment to improve pain and functional status for patients
I compared adding trigger point dry needling (TDN)
or percutaneous electrolysis (PE) to eccentric exer-
with LET. Deep friction massage does not appear to be an cises in the treatment of LET. Thirty-two participants were
effective intervention as a stand-alone treatment to improve randomly allocated to either group 1 (n = 16) that received 4
symptoms in individuals with LET, but it may be beneficial sessions of PE or group 2 (n = 16) that received 4 sessions of
when included with a lidocaine injection. Deep transverse TDN. The PE treatment consisted of the delivery of contin-
tendon cross-friction massage does not appear to improve uous galvanic current with intensity of 350 microamps to the
pain and function when compared to other treatments. While common extensor tendon (guided by US) at the elbow using
the potential benefits include improvement in pain and func- an acupuncture needle for 1.2 minutes. Pain (NPRS), PPT,
tion, harms include temporary bruising following treatment. quality of life, and ROM were measured at baseline, at the
No study related to soft tissue mobilization reported serious end of treatment, and at 1- and 3-month follow-ups. The ef-
adverse effects. fect (eta-squared) on pain reduction (n2 = 0.46) was moder-
ate, and improved PPT (n2 = 0.11) was small in all 3 follow-ups
Gaps in Knowledge in favor of the PE groups (P<.05). Percutaneous electrolysis
Given the variety of soft tissue techniques available to physical could be superior to TDN when added to an eccentric exer-
therapists to use for treatment of tendinopathy, there is a need cise program in the management of LET after a 3-month
for high-quality RCTs comparing specific, clearly operation- follow-up. Complications and adverse effects were not re-
alized, manual therapy soft tissue techniques against a true ported or discussed.
control group while using homogenous outcome measures.
The characteristics of those individuals who would benefit Navarro-Santana et al129 completed a meta-analysis
most from soft tissue techniques also need to be determined.
Insufficient evidence is available regarding the dosage of soft
II to evaluate the effect of any type of DN alone or
combined with other treatment interventions on

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-
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the shorter term. These results were similar to the findings


of a 2015 systematic review examining tendon DN.100
II uate the immediate effect of forearm counterforce
and wrist support orthoses on pain and strength in
individuals with LET. They included 7 randomized crossover
Evidence Synthesis trials in their review. Low-quality evidence is available to
There is moderate evidence to suggest that a variety of DN support a significant decrease in pain during contraction
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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,
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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.

V 693) revealed that 81% of respondents utilized ei-


ther a forearm counterforce or wrist support ortho-
designs and outcomes will facilitate statistical pooling of the
data to enable more definitive recommendations. While CPG
sis for immediate pain relief in individuals with LET whose team members recommend the short-term (2-4 weeks) use
pain was aggravated with activities.115 It is the opinion of the of either a forearm counterforce or a wrist support orthosis
CPG team that clinicians may incorporate the use of either a for individuals who have highly irritable symptoms of LET,
forearm counterforce or wrist support orthosis for individu- further research studies are needed that include that sub-
als who have LET symptoms with high irritability and diffi- group of participants.
culty performing functional activities while they are active;
as long as it is comfortable, it diminishes their pain and it RECOMMENDATION
Journal of Orthopaedic & Sports Physical Therapy®

improves their function. Based on conflicting evidence, a recommendation

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
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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.

in a single-blinded placebo-controlled randomized crossover


design.194 Sixteen individuals (mean duration of symptoms >1 Martínez-Beltrán et al121 investigated the applica-
year) were randomly allocated to 1 of 3 rigid taping condi- II tion of kinesiology tape on wrist extensor isometric
muscle strength and grip, isokinetic pronation and
tions, rigid diamond-deloading taping, placebo rigid tape,
and no tape. Pain-free grip strength and PPT were measured supination strength, and the time it took to reach that
before, immediately after, and 30 minutes after each taping strength in patients with at least 3 months duration of LET
technique. Pain-free grip strength increased 24% from base- symptoms. This one-time intervention included kinesiology
line in the rigid diamond-deloading taping group, which was tape using “I” muscle toning technique applied from lateral
significant compared with the placebo and no-taping groups. epicondyle to wrist for the experimental group and tape pla-
Journal of Orthopaedic & Sports Physical Therapy®

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.
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wrist extensor strength in LET. This study included 48 pa- RECOMMENDATION


tients who were randomly allocated to either the treatment Clinicians should use rigid taping techniques for
group (n = 27) or the control group (n = 21). The VAS, B immediate/short-term pain relief and improve-
ment in pain-free muscle function in those with
PRTEE, grip strength, and wrist extensor strength measured
by an isokinetic device were recorded before and after the irritable LET.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

treatment. Kinesiology tape was applied for a 5-day duration,


and it was repeated 3 times. No significant differences in im- Clinicians should use kinesiology tape application
provement of pain and function between the kinesiology tape C as a part of a multimodal treatment program for
immediate and short-term management of pain
or control groups were noted.182
and muscle function in individuals with LET.
Evidence Synthesis
Diamond-deloading taping technique with rigid tape at the CRYOTHERAPY
lateral epicondyle appears to have an immediate positive ef- The use of cryotherapy and heat has been anecdotally rec-
fect on PFGS over sham taping and control groups. A recent ommended as an intervention for years; however, very few
Journal of Orthopaedic & Sports Physical Therapy®

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
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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
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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.

elbow flexion, P = .003, ES = 0.52).7 Of the 3 modalities (ion-


Gaps in Knowledge tophoresis [3-5 mA at 40 mA/min], laser [.12 mW], and
Evidence, to this point, is not favorable for the use of pho- phonophoresis [topical prednisolone, 2 mg/d at 1 W/cm2 and
nophoresis to administer anti-inflammatory medications 1 MHz]), iontophoresis was the only modality shown to be
to manage pain and function in LET. Few studies select- beneficial for improving pain and function on the PRTEE.
ed individuals who may be more likely to benefit from the Therefore, when both pain and function are significant im-
administration of anti-inflammatory medications based on pairments related to LET, iontophoresis may be a good mo-
acuity and irritability of symptoms. It is also possible that al- dality choice in the short term. No notation of adverse effects
ternative medications administered through the mechanism for any of the modalities was made.
Journal of Orthopaedic & Sports Physical Therapy®

of phonophoresis could be effective, but no high-quality ev-


idence exists to support this assertion. Because the parame- Sims et al172 conducted a large-scale systematic re-
ters of the US used to drive the medications into the tissues
varied or were not clearly delineated in studies, the optimal
II view of level 1 or 2 RCTs assessing nonsurgical in-
terventions in the management of LET. Specifically,
frequency, intensity, duty cycle, and optimal treatment area for iontophoresis, 4 RCTs were located and assessed. In gen-
are not known for phonophoresis in the management of eral, regardless of the drug, iontophoresis provided a signif-
LET. icant improvement (P<.05) in self-reported pain in the short
term when compared to a placebo; however, pain scores were
RECOMMENDATION not significantly different at moderate- to long-term fol-
Clinicians should not use phonophoresis with 10% low-ups. No pooling of data was conducted. No moderate or
C hydrocortisone gel, topical prednisolone (2 mg/d), or
1% diclofenac sodium gel for the treatment of LET.
severe adverse effects were reported.172

Bisset et al16 evaluated 4 systematic reviews that


IONTOPHORESIS
Da Luz41 et al conducted a double-blind RCT with
II compared the effects of iontophoresis with a place-
bo or other interventions. The RCTs included in all
II 24 adults with LET, of unknown symptom duration
or irritability, assigned to either an iontophoresis
the reviews were of very low quality according to the GRADE
evaluation of evidence. Iontophoresis coupled with an active
group (with 4 mg/mL dexamethasone and 4% lidocaine gel) anti-inflammatory drug may be effective for 2 weeks but not
using 5 mA for 15 minutes or a galvanic electrical current at 4 weeks for reducing pain. It was unclear whether ionto-
group. Both groups received treatment 3 times a week for 4 phoresis improved a patient’s self-reported global improve-
weeks while single-session treatment duration was 15-20 ment.16 As part of this review, Bisset also included a previous
minutes. At final measurements, the iontophoresis group systematic review performed in 2005.17 Three studies exam-
demonstrated significantly lower pain at rest than the gal- ined the effect of iontophoresis on symptoms of LET in their
vanic current group (P = .002). The mean (±SD) pain level meta-analysis. Pooled data on self-rated global improvement

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®

for delivery of an anti-inflammatory medication (naproxen,


sodium diclofenac, pirprofen, prednisolone) over placebo or
II electrophysical modalities for the treatment of LET
found one low-quality study202 that demonstrated
phonophoresis in the short term (<2 weeks) for managing a positive effect of either high-frequency (5 KHz modulated
pain and improving function in patients with LET. Although by 100 Hz) or low-frequency (5 KHz modulated by 2 Hz)
symptom duration of individual studies is not consistently TENS when applied to acupuncture points over placebo
defined, iontophoresis appears to be beneficial in patients TENS. No statistical difference in the percentage changes of
presenting with acute or highly irritable symptoms of LET. VAS scores between the low- and high-frequency TENS
There appears to be no long-term benefit of iontophoresis. groups was seen; however, a significant difference was
Although minor skin irritations may occur with the use of demonstrated between both TENS groups and the sham
iontophoresis, no study reported any moderate or severe ad- TENS groups (P<.05). These effects were demonstrated over
verse or harmful events. 2 weeks.50

Gaps in Knowledge Chesterton et al30 conducted an RCT that included


It is not clear as to the optimal dosage or type of anti-inflam-
matory medication it takes to improve outcomes in patients
II 241 adults who were randomized into groups receiv-
ing primary care management plus TENS or a group
with LET when using iontophoresis. Care should be taken to receiving primary care management alone. Primary care man-
include only participants in the inflammatory phase of LET agement consisted of instruction in activity modification,
as they most likely benefit from the administration of anti-in- self-management, and exercises. The results demonstrated no
flammatory medication. additional benefit of using continuous high-frequency TENS
with a biphasic waveform applied for 45 minutes once a day
RECOMMENDATION for 6 weeks as an adjunct treatment to a consultation with a
Clinicians may use iontophoresis with an anti-in- general practitioner for education and advice on exercises in
C flammatory drug, early in the rehabilitation phase
(no later than 2-4 weeks from onset or aggravation
patients newly diagnosed with LET. Forty-three percent of all
participants reported symptom duration exceeding 3 months.

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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HILT to LILT and a placebo or control condition on out- interventions.


comes in patients with LET.
In research related to individuals with various musculoskele-
RECOMMENDATION tal disorders of the UE in general,55,64,96,191 weak evidence sup-
Clinicians may use laser therapy for improvements ports the use of computer-prompted work breaks, ergonomic
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

C in pain and grip strength, seen in follow-up periods


>4 weeks to 6 months, for individuals with LET.
training, forearm supports, ergonomic keyboard/mouse, and
frequent breaks from typing for improving UE symptoms.
While ergonomic interventions have the potential to reduce
ERGONOMICS stresses imparted on the common extensor tendon in those
Ergonomic training, forearm supports, ergonomic keyboard/ with LET, no harms were noted for ergonomic interventions.
mouse, and frequent breaks all positively affect symptoms
in the UE of computer users in individuals with cumulative Gaps in Knowledge
trauma disorders.64 However, few studies examining work- High-quality studies are needed to determine the effec-
place interventions focus on individuals specifically with tiveness of education, behavioral modifications, ergonomic
Journal of Orthopaedic & Sports Physical Therapy®

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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function while minimizing chances of re-irritation of the ten-


Individuals who present with or who achieve symptoms that don. Education of the individual on self-care strategies should
are less severe, more predictable, and less irritable (eg, sub- be provided and emphasized throughout the treatment.
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®

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

AFFILIATIONS AND CONTACTS


Jane Fedorczyk, PT, PhD, CHT Medical Center, Jameson Crane Department of Exercise Science
AUTHORS Professor Sports Medicine Institute Arnold School of Public Health
Director, Center of Hand and Upper Assistant Clinical Professor, School of University of South Carolina
Ann M. Lucado, PT, PhD, CHT Limb Rehabilitation Health and Rehabilitation Sciences,
Associate Professor Fellow, American Physical Therapy
Jefferson College of Rehabilitation Physical Therapy Division
Department of Physical Therapy Sciences The Ohio State University Association
Mercer University Thomas Jefferson University Columbus, OH Wilderness EMT
Atlanta, GA Philadelphia, PA John.dewitt@osumc.edu Columbia, SC
lucado_am@mercer.edu Jane.Fedorczyk@jefferson.edu PBEATTIE@mailbox.sc.edu
Steve Paulseth, PT, DPT, SCS, ATC
Joseph M. Day, PT, PhD, OCS Ruby Grewal, MD, MSc, FRCSC Paulseth & Associates Physical
Associate Professor
Department of Physical Therapy
Associate Professor Therapy, Inc GUIDELINES EDITORS
Roth | McFarlane Hand & Upper Limb Los Angeles, CA
University of Dayton Christopher Carcia, PT, PhD
Centre, St. Joseph’s Health Care Paulsethpt@yahoo.com
Dayton, OH Physical Therapy Program Director and
The University of Western Ontario
jday01@udayton.edu London, Canada James A. Dauber, DPT, DSc Associate Professor
Associate Professor Department of Kinesiology
Joshua I. Vincent, PT, PhD School of Physical Therapy, Marshall
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RobRoy L. Martin, PT, PhD Colorado Mesa University


Adjunct Assistant Clinical Professor Professor University
McMaster University Grand Junction, CO
Department of Physical Therapy Huntington, WV
Hamilton, Canada dauber@marshall.edu ccarcia@coloradomesa.edu
Duquesne University
vincenj@mcmaster.ca Pittsburgh, PA
Mike Szekeres, PhD, OT Reg (Ontario), Guy Simoneau, PT, PhD, FAPTA
Joy C. MacDermid, BSc, BScPT, MSc, Staff Physical Therapist CHT Editor
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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

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Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®

cpg52 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

APPENDIX A

SEARCH STRATEGIES AND SEARCH RESULTS (JANUARY 1, 2001, THROUGH NOVEMBER 30, 2021)

Outcome Measures Search Results (March 17, 2022)


Cochrane Library Total Results from Total Duplicates Articles Remaining to
Outcome Measures PubMed Results CINAHL Results Results Databases Removed Screen
Self-report measures 1301 71 64 1436 325 1111
Clinician-based and 1595 109 76 1780 415 1365
impairment measures

Intervention Search Results (March 17, 2022)


Cochrane Library Total Results from Total Duplicates Articles Remaining to
Intervention PubMed Results CINAHL Results Results Databases Removed Screen
Exercise 329 289 435 1053 511 542
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Manual therapy 103 121 138 362 247 115


Soft tissue 30 44 60 134 77 57
Dry needling 25 16 49 90 52 38
Orthotics 166 153 200 519 254 265
Taping 70 68 122 260 191 69
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Thermal modalities 58 60 111 229 124 105


Ultrasound 63 61 43 167 96 71
Phonophoresis 8 12 12 32 12 20
Iontophoresis 17 16 19 52 34 18
TENS 17 132 44 193 75 118
Low-level laser 58 42 84 184 111 73
Acupuncture 54 48 88 190 110 80
Ergonomics 532 420 314 1266 617 649
Abbreviations: CINAHL, Cumulative Index to Nursing and Allied Health Literature; TENS, transcutaneous electrical nerve stimulation.
Journal of Orthopaedic & Sports Physical Therapy®

Outcome Measures and Prognosis


Search Topic Terms PubMed Terms CINAHL Terms Cochrane Library
Lateral elbow tendinopathy “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 epicondy- “lateral elbow tendinitis” OR “lateral “lateral elbow tendinitis”:ti,ab,kw OR (“lateral”
lit*”[tw] OR “lateral epicondylos*”[tw] OR epicondylit*” OR “lateral epicondy- NEXT epicondylit*):ti,ab,kw OR (“lateral” NEXT
“lateral epicondylalgia”[tw] OR “lateralis los*” OR “lateral epicondylalgia” OR epicondylos*):ti,ab,kw OR “lateral epicon-
epicondylitis humeri”[tw] OR “lateralis epi- “lateralis epicondylitis humeri” OR dylalgia”:ti,ab,kw OR “lateralis epicondylitis
condylalgia humeri”[tw] OR “lateral humeral “lateralis epicondylalgia humeri” humeri”:ti,ab,kw OR “lateralis epicondylalgia
epicondylit*”[tw] OR “lateral elbow tendinop- OR “lateral humeral epicondylit*” humeri”:ti,ab,kw OR (“lateral humeral” NEXT epi-
athy”[tw] OR ((“Elbow Tendinopathy”[Mesh] OR “lateral elbow tendinopathy” OR condylit*):ti,ab,kw OR “lateral elbow tendinop-
OR epicondyl*[tw] OR “Tendinopathy”[Mesh] ((MH “Elbow Injuries” OR epicondyl* athy”:ti,ab,kw OR (([mh “Elbow Tendinopathy”]
OR tendinitis[tw] OR tendonitis[tw] OR OR MH “Tendinopathy” OR tendinitis OR epicondyl*:ti,ab,kw OR [mh Tendinopathy]
tendinopathy[tw] OR tendinosis[tw] OR OR tendonitis OR tendinopathy OR tendinitis:ti,ab,kw OR tendonitis:ti,ab,kw OR
tendinalgia[tw] OR peritendinitis[tw] OR OR tendinosis OR tendinalgia OR tendinopathy:ti,ab,kw OR tendinosis:ti,ab,kw OR
enthesopathy[tw]) AND lateral[tw]) peritendinitis OR enthesopathy) AND tendinalgia:ti,ab,kw OR peritendinitis:ti,ab,kw OR
lateral) enthesopathy:ti,ab,kw) AND lateral:ti,ab,kw)
Table continues on next page.

journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg53
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

APPENDIX A (CONTINUED)

Search Topic Terms PubMed Terms CINAHL Terms Cochrane Library


Clinical measurement properties SRM OR “Standardized response means”[tw] “SRM” OR “Standardized response SRM OR Standardized response means OR ES OR
OR ES OR “effect sizes” OR “Standard error of means” OR “ES” OR “effect sizes” OR effect sizes OR standard error of measurement
measurement” OR SEM OR MDC OR “Minimal “Standard error of measurement” OR SEM OR MDC OR Minimal Detectable
Detectable Change”[tw] OR MCID OR “Min- OR “SEM” OR “MDC” OR “Minimal Change OR MCID OR Minimally Clinical
imally Clinical Important difference”[tw] OR Detectable Change” OR “MCID” OR Important difference OR Sensitivity to change
“Sensitivity to change”[tw] OR responsive- “Minimally Clinical Important dif- OR responsiveness OR reliability OR Validity OR
ness[tw] OR reliability[tw] OR Validity[tw] ference” OR “Sensitivity to change” validation OR precision OR ROC OR Receiver
OR validation[tw] OR precision[tw] OR ROC OR “responsiveness” OR “reliability” operating curve OR Floor and ceiling effects OR
OR “Receiver operating curve”[tw] OR Floor OR “Validity” OR “validation” OR sensitivity OR specificity OR likelihood ratio OR
and ceiling effects[tw]) OR sensitivity[tw] OR “precision” OR “ROC” OR “Receiver reproducibility
specificity[tw] OR “likelihood ratio”[tw] OR operating curve” OR “Floor and
reproducibility[tw] ceiling effects” OR “sensitivity” OR
“specificity” OR “likelihood ratio” OR
“reproducibility”
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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.

cpg54 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

APPENDIX A (CONTINUED)

Search Topic Terms PubMed Terms CINAHL Terms Cochrane Library


(“2001”[Date - Publication] : “3000”[Date - Publi- DT 2001-2022 AND LA English Limits: Cochrane Library Publication Date from
cation]) AND English[language] January 2001 to present
(“clinical trials as topic”[Mesh] OR “clinical tri- ((MH “Clinical Trials”) OR (MH n/a
al”[pt] OR “randomized controlled trial”[pt] OR “Randomized Controlled Trials”)
“controlled clinical trial”[pt] OR randomized[- OR (MH “Control Group”) OR (MH
tiab] OR randomization[tiab] OR random-allo- “Double-Blind Studies”) OR (MH
cation[tiab] OR randomly[tiab] OR trial[tiab] “Random Assignment”) OR TI RCT)
OR groups[tiab] OR “Control Groups”[Mesh] OR ((TI randomized OR AB random-
OR “Matched-Pair Analysis”[Mesh] OR ized) OR (TI randomization OR AB
case-control[tiab] OR case-comparison[tiab] randomization) OR (TI random-allo-
OR case-series[tiab] OR case-study[tiab] OR cation OR AB random-allocation) OR
case-studies[tiab] OR control-group[tiab] OR (TI randomly OR AB randomly) OR
prospective[tiab] OR “Prospective Stud- (TI trial OR AB trial) OR (TI groups
ies”[Mesh] OR cohort[tiab] or groups[tiab] OR OR AB groups) OR (TI case-con-
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longitudinal[tiab] OR meta analysis[Publication trol OR AB case-control) OR (TI


Type] OR systematic review[Publication Type] case-comparison OR AB case-com-
OR systematic-review[ti] OR “systematic parison) OR (TI case-series OR AB
literature review”[ti] OR meta-analysis[ti] OR case-series) OR (TI case-study OR
meta-analyses[ti] OR scoping-review[ti]) AB case-study) OR (TI case-studies
OR AB case-studies) OR (TI con-
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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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APPENDIX A (CONTINUED)

Search Topic Terms PubMed Terms CINAHL Terms Cochrane Library


Dry Needling “Dry Needling”[Mesh] OR needling[tw] OR “dry MH “Dry Needling” OR needling OR [mh “Dry Needling”] OR needling:ti,ab,kw OR
needle*”[tw] OR “intramuscular stimulation”[tw] “dry needle*” OR “intramuscular (“dry needle*”):ti,ab,kw OR “intramuscular
stimulation” stimulation”:ti,ab,kw
Orthotics (“Orthotic Devices”[Mesh] OR “Splints”[Mesh] OR MH “Orthoses” OR MH “Orthoses ([mh “Orthotic Devices”] OR [mh Splints] OR
orthoses[tw] OR orthotic*[tw] OR orthosis[tw] Design” OR MH “Orthoses Fitting” orthoses:ti,ab,kw OR orthotic*:ti,ab,kw
OR device*[tw] OR brace*[tw] OR bracing[tw] OR MH “Slings” OR MH “Taping and OR orthosis:ti,ab,kw OR device*:ti,ab,kw
OR splint*[tw] OR sleeve*[tw] OR binder*[tw] Strapping” OR orthoses OR orthotic* OR brace*:ti,ab,kw OR bracing:ti,ab,kw
OR fixator*[tw] OR cast*[tw] OR counter- OR orthosis OR device* OR brace* OR splint*:ti,ab,kw OR sleeve*:ti,ab,kw OR
force[tw] OR band[tw] OR bands[tw] OR OR bracing OR splint* OR strap* binder*:ti,ab,kw OR fixator*:ti,ab,kw OR
armband*[tw] OR “elbow support*”[tw] OR OR sleeve* OR binder* OR fixator* cast*:ti,ab,kw OR counterforce:ti,ab,kw OR
“wrist support*”[tw] OR “external support*”[tw] OR cast* OR counterforce OR band band:ti,ab,kw OR bands:ti,ab,kw OR arm-
OR immobilis*[tw] OR immobiliz*[tw]) OR bands OR armband* OR “elbow band*:ti,ab,kw OR (“elbow support*”):ti,ab,kw
support*” OR “wrist support*” OR OR (“wrist support*”):ti,ab,kw OR (“external
“external support*” OR immobilis* support*”):ti,ab,kw OR immobilis*:ti,ab,kw OR
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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.

stabiliz*[tw] OR stabilis*[tw]) OR tapes OR taping OR kinesiotap* strap*:ti,ab,kw OR (“adhesive band*”):ti,ab,kw


OR Rocktap* OR bandag* OR wrap* OR stabiliz*:ti,ab,kw OR stabilis*:ti,ab,kw)
OR strap* OR “adhesive band*” OR
stabiliz* OR stabilis* OR TI(KT) OR
AB(KT)
Thermal modalities (“Cryotherapy”[Mesh] OR “Cold Tempera- MH “Cryotherapy” OR MH “Heat-Cold ([mh Cryotherapy] OR [mh “Cold Temperature”] OR
ture”[Mesh] OR “Hot Temperature”[Mesh] OR Application” OR MH “Heat Thera- [mh “Hot Temperature”] OR [mh Temperature]
Temperature[Mesh] OR cryotherap*[tw] OR peutic Use” OR MH “Temperature” OR cryotherap*:ti,ab,kw OR hypotherm*:ti,ab,kw
hypotherm*[tw] OR cold*[tw] OR cool*[tw] OR OR cryotherap* OR hypotherm* OR OR cold*:ti,ab,kw OR cool*:ti,ab,kw OR
ice[tw] OR iced[tw] OR icing[tw] OR freez*[tw] cold* OR cool* OR ice OR iced OR ice:ti,ab,kw OR iced:ti,ab,kw OR icing:ti,ab,kw
OR frozen[tw] OR warm[tw] OR hot[tw] OR icing OR freez* OR frozen OR warm OR freez*:ti,ab,kw OR frozen:ti,ab,kw OR
Journal of Orthopaedic & Sports Physical Therapy®

heat*[tw] OR hypertherm*[tw] OR therm*[tw] OR hot OR heat* OR hypertherm* warm:ti,ab,kw OR hot:ti,ab,kw OR heat*:ti,ab,kw


OR temperature*[tw] OR fahrenheit[tw] OR OR therm* OR temperature* OR OR hypertherm*:ti,ab,kw OR therm*:ti,ab,kw OR
celsius[tw] OR kelvin[tw]) fahrenheit OR celsius OR kelvin temperature*:ti,ab,kw OR fahrenheit:ti,ab,kw OR
celsius:ti,ab,kw OR kelvin:ti,ab,kw)
Ultrasound (((“Ultrasonic Therapy”[Mesh] OR “ultrasound (MH “Ultrasonic Therapy” OR MH ((([mh “Ultrasonic Therapy”] OR “ultrasound ther-
therap*”[tw] OR “ultrasonic therap*”[tw] OR “in- “Ultrasonics” OR “ultrasound ap*”:ti,ab,kw OR “ultrasonic therap*”:ti,ab,kw
terventional ultrasound”[tw] OR “interventional therap*” OR “ultrasonic therap*” OR “interventional ultrasound”:ti,ab,kw OR “in-
ultrasonic”[tw] OR “therapeutic ultrasound”[tw] OR “interventional ultrasound” terventional ultrasonic”:ti,ab,kw OR “therapeutic
OR “therapeutic ultrasonic”[tw] OR “ultrasound OR “interventional ultrasonic” ultrasound”:ti,ab,kw OR “therapeutic ultrason-
treatment*”[tw] OR “ultrasonic treatment*”[tw]) OR “therapeutic ultrasound” OR ic”:ti,ab,kw OR “ultrasound treatment*”:ti,ab,kw
OR ((ultrasound[tiab] OR ultrasonic[tiab]) AND “therapeutic ultrasonic” OR “ultra- OR “ultrasonic treatment*”:ti,ab,kw) OR
(Physical Therapy Modalities”[Mesh]))) NOT sound treatment*” OR “ultrasonic ((ultrasound:ti,ab OR ultrasonic:ti,ab) AND
((sonograph[tiab] OR sonography[tiab] OR treatment*”) OR (((TI ultrasound ([mh “Physical Therapy Modalities”]))) NOT
imaging[tiab] OR diagnos*[tiab] OR percuta- OR AB ultrasound) OR (TI ultrasonic ((sonograph:ti,ab OR sonography:ti,ab OR
neous[tiab] OR injection[tiab] OR “extracorpo- OR AB ultrasonic)) AND ((MH imaging:ti,ab OR diagnos*:ti,ab OR percutane-
real shockwave”[tiab]) NOT (therap*[tiab] OR “Physical Therapy”+)))) NOT (((TI ous:ti,ab OR injection:ti,ab OR “extracorporeal
intervention*[tiab] OR treat*[tiab])) sonograph OR AB sonograph) OR shockwave”:ti,ab) NOT (therap*:ti,ab OR inter-
(TI sonography OR AB sonography) vention*:ti,ab OR treat*:ti,ab)))
OR (TI imaging OR AB imaging)
OR (TI diagnos* OR AB diagnos*)
OR (TI percutaneous OR AB
percutaneous) OR (TI injection OR
AB injection) OR (TI “extracorporeal
shockwave” OR AB “extracorporeal
shockwave”)) NOT ((TI therap* OR
AB therap*) OR (TI intervention* OR
AB intervention*) OR (TI treat* OR
AB treat*))))
Table continues on next page.

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APPENDIX A (CONTINUED)

Search Topic Terms PubMed Terms CINAHL Terms Cochrane Library


Phonophoresis “Phonophoresis”[Mesh] OR phonophor*[tw] OR MH “Phonophoresis” OR phonophor* [mh Phonophoresis] OR phonophor*:ti,ab,kw OR
sonophor*[tw] OR sonophor* sonophor*:ti,ab,kw
Iontophoresis “Iontophoresis”[Mesh] OR iontophor*[tw] OR MH “Iontophoresis” OR iontophor* [mh Iontophoresis] OR iontophor*:ti,ab,kw OR
ionization[tw] OR ionisation[tw] OR “electromo- OR ionization OR ionisation OR ionization:ti,ab,kw OR ionisation:ti,ab,kw OR
tive drug administration”[tw] OR EMDA[tw] OR “electromotive drug administration” “electromotive drug administration”:ti,ab,kw
electrophoresis[tw] OR electroosmosis[tw] OR OR EMDA OR electrophoresis OR EMDA:ti,ab,kw OR electrophoresis:ti,ab,kw
“direct electrical current”[tw] OR “direct current OR electroosmosis OR “direct OR electroosmosis:ti,ab,kw OR “direct electrical
stimulation”[tw] electrical current” OR “direct current current”:ti,ab,kw OR “direct current stimula-
stimulation” tion”:ti,ab,kw
TENS “Transcutaneous Electric Nerve Stimulation”[Mesh] MH “Transcutaneous Electric Nerve [mh “Transcutaneous Electric Nerve Stimulation”]
OR “transcutaneous electrical nerve stim- Stimulation” OR “transcutaneous OR “transcutaneous electrical nerve stimula-
ulation”[tw] OR “transcutaneous electrical electrical nerve stimulation” OR tion”:ti,ab,kw OR “transcutaneous electrical
nerve stimulator*”[tw] OR “transcutaneous “transcutaneous electrical nerve nerve stimulator*”:ti,ab,kw OR “transcutaneous
nerve stimulator*”[tw] OR TENS[tiab] OR stimulator*” OR “transcutaneous nerve stimulator*”:ti,ab,kw OR TENS:ti,ab OR
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“transdermal electrostimulation”[tw] OR nerve stimulator*” OR “trans- “transdermal electrostimulation”:ti,ab,kw OR


“transcutaneous nerve stimulation”[tw] OR dermal electrostimulation” OR “transcutaneous nerve stimulation”:ti,ab,kw OR
“transcutaneous electrical stimulation”[tw] OR “transcutaneous nerve stimulation” “transcutaneous electrical stimulation”:ti,ab,kw
“nerve stimulat*”[tw] OR neurostimulation[tw] OR “transcutaneous electrical OR “nerve stimulat*”:ti,ab,kw OR neurostimu-
OR electroanalgesia[tw] OR “analgesic cutane- stimulation” OR “nerve stimulat*” lation:ti,ab,kw OR electroanalgesia:ti,ab,kw OR
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ous electrostimulation”[tw] OR neurostimulation OR electro- “analgesic cutaneous electrostimulation”:ti,ab,kw


analgesia OR “analgesic cutaneous
electrostimulation” OR TI (TENS) OR
AB (TENS)
Low-level laser “Low-Level Light Therapy”[MeSH] OR “Laser MH “Phototherapy” OR MH “Laser [mh “Low-Level Light Therapy”] OR [mh “Laser
Therapy”[MeSH] OR “low-level light therap*”[tw] Therapy” OR MH “Lasers” OR MH Therapy”] OR “low-level light therap*”:ti,ab,kw
OR “low-level laser therap*”[tw] OR “low-power “Phototherapy” OR “low-level light OR “low-level laser therap*”:ti,ab,kw OR
light therap*”[tw] OR “low-power laser ther- therap*” OR “low-level laser ther- “low-power light therap*”:ti,ab,kw OR “low-power
ap*”[tw] OR “low-power laser irradiation”[tw] OR ap*” OR “low-power light therap*” laser therap*”:ti,ab,kw OR “low-power laser
LLLT[tw] OR photobiomodulation[tw] OR “laser OR “low-power laser therap*” OR irradiation”:ti,ab,kw OR LLLT:ti,ab,kw OR pho-
biostimulation”[tw] OR “laser phototherap*”[tw] “low-power laser irradiation” OR tobiomodulation:ti,ab,kw OR “laser biostimula-
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OR light*[tw] OR laser*[tw] LLLT OR photobiomodulation OR tion”:ti,ab,kw OR “laser phototherap*”:ti,ab,kw


“laser biostimulation” OR “laser OR light*:ti,ab,kw OR laser*:ti,ab,kw
phototherap*” OR light* OR laser*
Acupuncture “Acupuncture Therapy”[Mesh] OR “Acupuncture MH “Acupuncture” OR MH “Electroacu- [mh “Acupuncture Therapy”] OR [mh “Acupunc-
Points”[Mesh] OR “Acupuncture”[Mesh] OR puncture” OR MH “Meridians+” OR ture Points”] OR [mh Acupuncture] OR [mh
“Electroacupuncture”[Mesh] OR acupunc- acupunctur* OR electroacupunctur* Electroacupuncture] OR acupunctur*:ti,ab,kw
tur*[tw] OR electroacupunctur*[tw] OR OR acupoint* OR electroacupunctur*:ti,ab,kw OR acu-
acupoint*[tw] point*:ti,ab,kw
Ergonomics “Ergonomics”[Mesh] OR ergonomic*[tw] MH “Ergonomics+” OR ergonomic* OR [mh Ergonomics] OR ergonomic*:ti,ab,kw OR
OR “human engineering”[tw] OR “human “human engineering” OR “human biomechanic*:ti,ab,kw OR “human engineer-
factors”[tw] OR occupational[tw] OR “functional factors” OR occupational OR “func- ing”:ti,ab,kw OR “human factors”:ti,ab,kw
rehabilitation”[tw] OR “vocational rehabilita- tional rehabilitation” OR “vocational OR occupational:ti,ab,kw OR “functional
tion”[tw] OR workplace[tw] OR workload*[tw] rehabilitation” OR workplace OR rehabilitation”:ti,ab,kw OR “vocational reha-
OR environment*[tw] OR kinematic[tw] OR workload* OR environment* OR bilitation”:ti,ab,kw OR workplace:ti,ab,kw OR
posture[tw] OR lifting[tw] OR motion*[tw] OR kinematic OR posture OR lifting OR workload*:ti,ab,kw OR environment*:ti,ab,kw
“movement therap*”[tw] OR “movement-based “movement therap*” OR “move- OR kinematic:ti,ab,kw OR posture:ti,ab,kw OR
therap*”[tw] OR design[tw] OR layout[tw] OR ment-based therap*” OR design OR lifting:ti,ab,kw OR “movement therap*”:ti,ab,kw
force[tw] OR counterforce[tw] OR geometry[tw] layout OR force OR counterforce OR OR “movement-based therapy”:ti,ab,kw
OR “assistive technolog*”[tw] OR reeduca- geometry OR “assistive technolog*” OR design:ti,ab,kw OR layout:ti,ab,kw OR
tion[tw] OR “re-education”[tw] OR reeducation OR “re-education” force:ti,ab,kw OR counterforce:ti,ab,kw OR geom-
etry:ti,ab,kw OR “assistive technolog*”:ti,ab,kw
OR reeducation:ti,ab,kw OR re-education:ti,ab,kw
Abbreviations: CINAHL, Cumulative Index to Nursing and Allied Health Literature; TENS, transcutaneous electrical nerve stimulation.

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APPENDIX B

ARTICLE INCLUSION AND EXCLUSION CRITERIA

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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We excluded the following types of articles.


• Meeting abstracts, press releases, theses, nonsystematic review articles, articles reporting on studies that are within timeframes
searched within meta-analyses and systematic reviews, and articles that could not be retrieved in English
We excluded articles reporting on the following topics.
• Cervical radiculopathy, primary peripheral nerve entrapment including radial tunnel syndrome and posterior interosseous syndrome,
and joint pathology including plica syndrome, radiocapitellar chondromalacia, and posterolateral rotatory instability as causes of lat-
eral elbow pain
• Topics outside the scope of physical therapist practice including but not limited to pharmacological and surgical interventions unless
directly compared to conservative physical therapy management
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1. Self-report Measures
APPENDIX C

FLOWCHART OF ARTICLES

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APPENDIX C (CONTINUED)

2. Clinician-Based and Performance-Based Measures


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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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5. Manual Therapy: Soft Tissue 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

LEVELS OF EVIDENCE TABLEa

Intervention/ Pathoanatomic/Risk/Clinical Course/ Prevalence of Condition/


Level Prevention Prognosis/Differential Diagnosis Diagnosis/Diagnostic Accuracy Disorder Exam/Outcomes
I Systematic review of Systematic review of prospective cohort Systematic review of high-quality Systematic review, Systematic review of
high-quality RCTs studies diagnostic studies high-quality cross-sec- prospective cohort
High-quality RCTb High-quality prospective cohort studyc High-quality diagnostic studyd with tional studies studies
validation High-quality cross-sectional High-quality prospec-
studye tive cohort study
II Systematic review of Systematic review of retrospective cohort Systematic review of exploratory Systematic review of stud- Systematic review
high-quality cohort study diagnostic studies or consecutive ies that allows relevant of lower-quality
studies Lower-quality prospective cohort study cohort studies estimate prospective cohort
High-quality cohort High-quality retrospective cohort study High-quality exploratory diagnostic Lower-quality cross-sec- studies
studyc Consecutive cohort studies tional study Lower-quality
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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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High-quality case-con- cohort


trol study
Lower-quality cohort
study
IV Case series Case series Case-control study Lower-quality
cross-sectional
study
V Expert opinion Expert opinion Expert opinion Expert opinion Expert opinion
Abbreviation: RCT, randomized clinical trial.
a
Adapted from the Center for Evidence-based Medicine 2009 levels of evidence.216 See also APPENDIX E.
Journal of Orthopaedic & Sports Physical Therapy®

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.

cpg74 | december 2022 | volume 52 | number 12 | journal of orthopaedic & sports physical therapy
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

APPENDIX E

PROCEDURES FOR ASSIGNING LEVELS OF EVIDENCE

• 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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the estimate—downgrade 1 level (based on critical appraisal results).


◦ Low quality: the study has significant limitations that substantially limit confidence in the estimate—downgrade 2 levels (based on
critical appraisal results).
◦ Unacceptable quality: serious limitations—exclude from consideration in the guideline (based on critical appraisal results).
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

APPENDIX E (CONTINUED)

Lateral Elbow Tendinopathy Outcome Measures Quality Appraisals


Quality of studies included in the systematic review of outcome measures
Item Evaluation Score for Each Criterion on the MacDermid Quality Assessment Tool
(Min = 0; Max = 2) Quality Score Level of
Study 1 2 3 4 5 6 7 8 9 10 11 12 Total Score (%) Evidence
Poltawski and Watson (2011) 2 2 2 2 1 2 2 2 2 2 2 2 23 95.83 I
Leung et al (2004) 2 2 1 2 1 2 2 2 2 2 2 1 21 87.50 I
Overend et al (1999) 2 1 1 2 1 2 2 2 2 2 2 2 21 87.50 I
Cacchio et al (2012) 1 2 1 2 1 2 2 2 2 2 2 1 20 83.33 I
Blanchette and Normand (2010) 2 2 2 2 0 1 2 2 2 2 2 1 20 83.33 I
Rompe et al (2007) 2 2 2 2 1 0 2 2 2 2 1 2 20 83.33 I
Van Ark et al (2014) 2 2 0 2 0 2 2 2 2 2 2 1 19 79.16 I
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Chung and Wiley (2010) 2 2 1 0 0 2 2 2 2 2 2 2 19 79.16 I


Altan et al (2010) 1 2 1 2 1 2 2 2 2 2 1 1 19 79.16 I
Kaux et al (2016) 1 2 1 2 1 2 1 0 2 2 2 2 18 75 I
Stasinopoulos et al (2015) 1 2 0 1 1 2 2 2 2 2 2 1 18 75 I
Nilsson et al (2008) 1 1 0 2 1 2 2 2 2 2 1 1 17 70.83 I
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Newcomer et al (2005) 1 2 2 2 0 2 2 2 2 2 1 1 17 70.83 I


Alizadehkhaiyat et al (2007) 2 2 0 0 0 n/a 2 2 2 2 0 1 13 54.16 II
Journal of Orthopaedic & Sports Physical Therapy®

cpg76 | 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

Lateral Elbow Tendinopathy Appraisal Grid Interventions


PEDro
PEDro Scoresa
Study 1b 2c 3d 4e 5f 6g 7h 8i 9j 10k 11l Total
Agostinucci et al (2012) 1 1 0 0 0 0 0 1 1 1 0 4
Akbar et al (2021) 1 1 1 1 0 0 0 1 0 1 1 6
Baktir et al (2019) 1 1 1 0 0 1 1 0 1 1 1 7
Blanchett and Normand (2011) 1 1 1 1 0 0 0 1 1 1 1 7
Chesterton et al (2013) 1 1 1 1 0 0 1 0 1 1 1 7
Coombes et al (2016) 1 1 1 0 0 0 1 0 1 1 1 6
da Luz et al (2019) 1 1 1 0 1 0 1 1 0 1 1 7
Day et al (2021) 0 1 0 1 1 0 0 1 0 1 1 6
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Hüseyin Ünver et al (2021) 1 1 1 1 1 0 1 0 0 1 1 7


Kaydok et al (2020) 1 1 1 1 1 0 1 1 0 1 1 8
Lizis (2015) 1 1 0 1 0 0 0 1 1 1 1 6
Macedo (2015) 1 1 0 0 0 0 0 1 1 1 1 5
Mansiz-Kaplan et al (2021) 0 1 0 1 0 0 1 1 0 1 1 6
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

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
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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?

cpg78 | 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 TABLE

Evidence Table: Exercise


Evidence Rating
and Critical
Study Type of Study Appraisal Score Conditions Sample Characteristics Outcome Measures Important Results
Vuvan et al RCT Level of evidence: Exercise group received Forty patients meeting the PRTEE, GROC, PFGS, pain The unsupervised exercise
(2020) I advice to complete an following inclusion criteria: (NPRS), and pressure group reported a decrease
PEDro score: unsupervised program aged 18 to 70 years; unilat- thresholds in worst pain (standardized
8/10 of isometric exercise eral lateral elbow pain, ≥6- mean difference (SMD,
of the wrist extensors wk duration; average pain −0.80; 95% CI: −1.45,
at home for 8 wk. The severity during the past −0.14) and disability
program consisted of daily week, ≥2 on an 11-point (SMD, −0.92; 95% CI:
isometric wrist extension numerical rating scale (0 −1.58, −0.26), but not in
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exercise, performed using = no pain; 10 = worst pain perceived rating of change


a container of water with a imaginable); provoked by or PFGS when compared
handle as resistance. at least 2 of the following: with wait and see at 8
gripping, palpation of the wk. No serious adverse
lateral epicondyle, stretch- effects were reported.
ing of forearm extensor Unsupervised isometric
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

muscles, resisted wrist wrist extensor exercise


extension, resisted second was effective in improving
or third finger extension, pain and disability, but not
and reduced PFGS perceived rating of change
and PFGS when compared
with wait and see at 8 wk.
Table continues on next page.
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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

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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tric exercise + adjuvant with eccentric muscle


therapy vs same adjuvant strength. A significant
therapy) or (eccentric exer- improvement in muscle
cise vs other strengthening strength in the eccentric
exercises. Exclusion: (1) exercise group (SMD, 1.05;
The trial did not have an 95% CI: 0.78, 1.33) relative
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

appropriate comparison to the comparison group


group; (2) eccentric was observed. Sensitivity
exercise was performed analysis, conducted by
with other nonsurgical individually excluding the
treatments and the effects studies, also showed ben-
of eccentric exercise could eficial effects of eccentric
not be isolated; or (3) data exercise in pain reduction
on pain intensity, strength, and muscle strength
or function were not improvement in patients
sufficiently reported. with LET. Three studies
compared the effects of
Journal of Orthopaedic & Sports Physical Therapy®

eccentric exercises with


those of other strengthen-
ing exercises, such as con-
centric or isotonic exercise.
There was a significant
improvement in pain
intensity after eccentric
exercise (SMD, −0.30; 95%
CI: −0.58, −0.02) relative
to other exercises. Two of
the studies that looked
at eccentric, concentric,
or isotonic exercise also
evaluated muscle strength
and there was no signifi-
cant difference in muscle
strength between the 2
groups (SMD, −0.09; 95%
CI: −0.38, 0.20). Function
was evaluated using the
DASH results in 3 studies
and the meta-analysis did
not reveal any significant
difference in functional
improvement (SMD, −0.08;
95% CI: −0.35, 0.20)
between the 2 groups.
Table continues on next page.

cpg80 | 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
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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forms of strengthening. −0.90, −0.36) relative to


the comparison group was
observed in the 4 studies
that looked at VAS. Four
studies reported outcomes
of muscle strength: 3 stud-
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ies with grip strength and


1 study with eccentric mus-
cle strength. A significant
improvement in muscle
strength in the eccentric
exercise group (SMD, 1.05;
95% CI: 0.78, 1.33) relative
to the comparison group
was observed. Eccentric
exercise combined with
adjuvant therapy showed
Journal of Orthopaedic & Sports Physical Therapy®

beneficial effects regarding


pain reduction and muscle
strength improvement.
Comparison between
eccentric exercise and
other exercises showed
positive effects of eccentric
exercise regarding pain
reduction; however, the
differences in muscle
strength and function
between the groups were
not significant.
Table continues on next page.

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

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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except for short-term pain


reduction. When exercise
was compared to a wait-
and-see approach, only
short-term pain reduction
(SMD, −0.33; 95% CI:
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

−0.60, –0.05) and long-


term elbow disability (SMD,
−0.27; 95% CI: −0.47,
–0.06) were statistically
significant, in favor of
exercise. Low to very low
evidence suggests exercise
of the wrist musculature
is effective compared
with passive interventions
with or without invasive
Journal of Orthopaedic & Sports Physical Therapy®

treatment in LET, but the


effect is small.
Hoogvliet et al Systematic Level of evidence: Studies published through A total of 12 RCTs and 1 review Pain (VAS), function (DASH), Moderate evidence for the
(2013) review II February 2010 that up to February 2010 were grip strength. Data were short-term effectiveness of
AMSTAR score: included the evaluation included. Follow-up time not pooled due to the stretching plus strength-
6/11 of several therapeutic frames of the included heterogeneity of the ening exercises of the
interventions: stretching, studies were up to 3 years. included studies; however, wrist over US plus friction
strengthening, concentric/ when available, authors massage; for short- and
eccentric exercises of the reported percent change or midterm effectiveness of
wrist, and manipulation mean differences between concentric and eccentric
of the cervical or thoracic groups for individual exercises as an adjunct to
spine, elbow or, wrist. studies in the systematic manipulation of the cervi-
review. cal and thoracic spine.
Table continues on next page.

cpg82 | 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
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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weeks. Seven RCTs, 4 results conducted).


non-RCTs, and 1 cohort
study were assessed as
moderate to high quality.
Bisset et al Systematic Level of evidence: Adults who were diagnosed 2 systematic reviews, 1 RCT Pain, grip strength, function, Low-quality evidence neither
(2011) review II with tennis elbow with the evaluating wrist exercise global improvement, or supports nor refutes the
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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-
Journal of Orthopaedic & Sports Physical Therapy®

al treatment algorithm for


individuals with LET that
was designed for an RCT
protocol. The Dual Rehabil-
itation Program describes
2 matrices for exercise
prescription and dosing
for both the shoulder
and distal arm. Exercise
progression parameters
are delineated into 3
phases. Phase 1 = Neu-
romuscular re-education;
Phase 2 = Resistive with
light to moderate loads/
short lever arms; and
Phase 3 = Resistive with
moderate to heavy loads/
long lever arms. Exercise
progression is based off of
individual symptoms and
% MVIC. Time to progress
varies among individuals
with LET based on their
symptom presentation.
Abbreviations: DASH, Disabilities of the Arm, Shoulder and Hand; GROC, Global Rating of Change; LET, lateral elbow tendinopathy; MD, mean difference;
MVIC, maximum voluntary isometric contraction; 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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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

APPENDIX
APPENDIX
E (CONTINUED)
A

Evidence Table: Multimodal Interventions


Evidence Rating and Sample
Study Type of Study Critical Appraisal Score Conditions Characteristics Outcome Measures Important Results
Mostafaee et al RCT Level of evidence: I Patients with LET were Forty-eight patients Pain, PFGS, func- The program that combined
(2020) PEDro score: 8/10 randomly allocated meeting the following tional status multimodal physical therapy
into 2 groups: shoulder inclusion criteria: with shoulder and scapular
and scapula muscle between the ages muscle training was more
training plus conven- 18 and 65, pain over effective in improving pain
tional physical therapy, the lateral humeral (MD, 2.20; 95% CI: 1.32,
and conventional epicondyle with pain 3.09) and function using the
physical therapy severity of at least PRTEE (MD, 21.25; 95% CI:
4 on a VAS for a 11.07, 31.43); and QuickDASH
minimum of 6 weeks, (MD, 15.36; 95% CI: 5.94,
ability to complete 24.78) when compared with
questionnaires in Per- multimodal physical therapy
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sian, and confirmed at 4-month follow-up, but


diagnosis. there were no significant
differences in PFGS.
Day et al (2021) RCT Level of evidence: II Thirty-five adults clinically The SMS group received PRTEE, GROC, Significant main effect for time
PEDro score: 6/10 diagnosed with LET education and grip strength, for the PRTEE measures
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

were randomly treatment as the LT periscapular of both pain and function.


allocated into 2 group treatment, muscle strength Both groups changed at
groups: 19 randomized plus SMS. The LT measured at the same rate, as there was
to local treatment (LT) treatment algorithm baseline and no significant difference
group, 15 randomized included education, discharge from between groups. The initial
to LT plus scapular counterforce bracing, PT (4-6 weeks), change from evaluation to
muscular strengthen- cryotherapy if needed 6- and 12-month discharge was significant
ing (SMS) group for pain control, follow-up (mean = −10.96, SD = 8.7,
manual therapy, and P<.05). Following discharge,
therapeutic exercise pain and functional gains
local to the wrist, were maintained, suggesting
Journal of Orthopaedic & Sports Physical Therapy®

whereas the SMS that the intervention had


treatment algorithm positive long-term effects in
included LT and SMS. both groups. Significant main
effect for time for the strength
outcome measures. Although
the mean differences in scap-
ular muscle strength were
greater in the LT+SMS group,
there were no significant
between-group differences
for all 4 secondary outcome
measures of strength. The
average GROC for all partici-
pants improved at discharge
(mean = 9.33, SD = 1.06),
the 6-month follow-up (mean
= 9.92, SD = 0.93), and the
1-year follow-up (mean =
10.15, SD = 1.00). There were
no statistical differences
between groups for any of the
follow-ups (P>.103).
Table continues on next page.

cpg84 | 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 Sample


Study Type of Study Critical Appraisal Score Conditions Characteristics Outcome Measures Important Results
Cullinane et al Systematic Level of evidence: II RCTs or controlled clinical The 12 low-quality stud- Pain, function, grip Eccentric exercises are most
(2014) review AMSTAR score: 6/11 trials that included ies involved 616 par- strength (no effective as part of a multi-
an eccentric exercise ticipants consisting pooling of results modal intervention program.
therapy group, either of 336 females and conducted)
exclusively or as a 280 males. A total
part of a multimodal of 326 participants
treatment. The search underwent eccentric
included studies up to exercise as part of
February 2013. their rehabilitation.
Olaussen et al Systematic Level of evidence: II The authors included The included studies Relative risk (RR) Corticosteroid injection and
(2013) review AMSTAR score: 10/11 studies published represented a total or standardized manipulation with exercise
between 2009 and population of 1161 pa- mean difference gave a short-term benefit
2012, utilizing a tients. Several studies (SMD) for overall (4-12 weeks) in overall im-
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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
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

a clinical diagnosis of Most participants for individuals treated with


lateral epicondylalgia, had a duration of LET corticosteroid injections were
and reported corti- of several weeks to worse (0.66; 0.53, 0.81) while
costeroid injections, months and only one manipulation with exercise
exercise, education, or stated a short dura- was not different from control
manual therapy as an tion. Studies utilizing (0.99; 0.75, 1.30). In the
intervention. electrotherapeutic long term (greater than 6
modalities or splinting months), both treatments
were excluded. showed no benefit over
control. One study showed
Journal of Orthopaedic & Sports Physical Therapy®

a short-term positive effect


on pain (SMD, 4.45; 95% CI:
3.51, 5.40) and grip strength
(SMD, 3.16; 95% CI: 2.40,
3.92) for eccentric exercises
and stretching. Long-term
follow-up also showed a
positive effect on pain (SMD,
4.65; 95% CI: 3.68, 5.63)
and grip strength (SMD,
3.65; 95% CI: 2.82, 4.47). At
intermediate follow-up, the
authors found an increase
in pain and reduction in grip
strength for the corticosteroid
group. Manipulation and
exercise versus no interven-
tion showed beneficial effect
at short-term follow-up.
Moderate evidence was found
for short-term and long-term
effects of eccentric exercise
and stretching versus no
intervention.
Table continues on next page.

journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg85
Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

APPENDIX
APPENDIX
E (CONTINUED)
A

Evidence Rating and Sample


Study Type of Study Critical Appraisal Score Conditions Characteristics Outcome Measures Important Results
Sethi and Noohu RCT Level of evidence: II Chronic lateral epicon- Twenty-six patients: Pain (VAS), PFGS, There was a statistically
(2018) PEDro score: 5/10 dylalgia Group 1 received functional out- significant difference for time
SMS along with come (PRTEE), effect for all the outcome
conventional physical scapular muscle measures. The scapular
therapy and Group strength, scap- muscle strengthening should
2 received only ular positioning be used along with the
conventional physical (LSST), and conventional physical therapy
therapy. Conventional EMG activity in individuals with chronic
physical therapy were collected at LE to improve pain, PFGS,
consisted of pulsed baseline and 6 functional outcome, muscle
US (20% duty cycle, weeks strength, scapular position,
7.5 min, 1 MHz, 2 W/ and muscle activity.
cm2), ECRB stretching
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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
Journal of Orthopaedic & Sports Physical Therapy®

standardized advice study. effectiveness corticosteroid and physical


on resting for 10 days (measure by therapy.
followed by a gradual the incremental
return to activity. The cost/QALY ratio)
participants allocated
to physical therapy
received a standard
protocol of manual
therapy at the elbow
with gripping, con-
centric and eccentric
wrist exercises, motor
control retraining, and
global upper extremity
exercises.
Abbreviations: DASH, Disabilities of the Arm, Shoulder and Hand; ECRB, extensor carpi radialis brevis; EMG, electromyography; GROC, Global Rating
of Change; LET: lateral elbow tendinopathy; LSST, lateral scapular slide test; MD, mean difference; PRTEE, Patient-Rated Tennis Elbow Evaluation; RCT,
randomized clinical trial; US, ultrasound; VAS, visual analog scale.

cpg86 | 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 Table: Manual Therapy Joint Mobilizations/Manipulations


Evidence Rating and
Study Type of Study Critical Appraisal Score Conditions Sample Characteristics Outcome Measures Important Results
Lucado et al (2019) Systematic Level of evidence: II Studies examining individ- Twenty studies included; Pain, grip strength, There is compelling evidence
review and AMSTAR score: 8/11 uals 18 years and older seven were appropri- and functional that joint mobilizations have
meta-analysis clinically diagnosed ate for meta-analysis. outcomes a positive effect on both
with LET treated with pain and/or functional grip
joint mobilizations/ scores across all time frames
manipulations to the compared to control groups
elbow or related areas in the management of LET.
in the upper quarter. Only 7 trials were appropriate
for the meta-analysis. The
MWM technique to the elbow
demonstrated a moderate
positive mean effect (SMD,
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0.43; 95% CI: 0.15, 0.71) on


pain and a moderate positive
effect on PFGS (SMD, 0.31;
95% CI: 0.11, 0.51). One study
reported a moderate positive
effect (SMD, 0.77; 95% CI:
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

0.81, 1.37) of MWM on pain


and disability compared to
groups receiving placebo
and/or other nonsurgical
interventions as measured by
the PRTEE in the short term.
Mill’s manipulation technique
to the elbow demonstrated
a moderate positive effect
(SMD, 0.47; 95% CI: 0.11,
Journal of Orthopaedic & Sports Physical Therapy®

0.82) on pain (VAS), but no


appreciable effect (SMD,
0.01; 95% CI: −0.27, 0.26) on
PFGS. Regional mobilization
demonstrated effectiveness
over control groups in all
outcomes.
Hoogvliet et al Systematic Level of evidence: II Studies that included A total of 12 RCTS and 1 Pain, function, grip Moderate evidence for short-
(2013) review AMSTAR score: 6/11 the evaluation of review were included. strength with and midterm effectiveness on
several therapeutic not enough PFGS of manipulation of the
interventions: stretch- homogeneity to cervical and thoracic spine
ing, strengthening, pool data as an adjunct therapy to
concentric/eccentric exercise at 6 weeks (MD, 14.6
exercises, and manipu- kg; 95% CI: 9.3, 19.9) and at
lation of the cervical or 6 months (MD, 19.6 kg; 95%
thoracic spine, elbow, CI: 1.6, 37.6) compared with
or wrist. local treatment only. Limited
evidence suggests that the
use of a 2.5 N force while
performing MWM technique
is more effective in increasing
PFGS immediately when
compared to using a force of
1.2 or 1.9 N.
Table continues on next page.

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

APPENDIX
APPENDIX
E (CONTINUED)
A

Evidence Rating and


Study Type of Study Critical Appraisal Score Conditions Sample Characteristics Outcome Measures Important Results
Bisset (2011) Systematic Level of evidence: II Adults who were Two survey reviews, 1 Pain, grip strength, Low-quality evidence supports
review AMSTAR score: 7/11 diagnosed with tennis RCT evaluating joint function, global manipulation of the elbow for
elbow with the follow- mobilizations or improvement, improving PFGS immediately
ing inclusion criteria; manipulations or patient satis- compared with a sham ma-
published systematic faction scale (no nipulation (SMD, 1.28; 95%
reviews of RCTs and pooling of results CI: 0.84, 1.73). Low-quality
RCTs in any language, conducted) evidence also supports elbow
at least single blinded, manipulation when com-
and containing >20 bined with US for reducing
individuals of whom pain at 3 weeks (P<.01) and
>80% were followed at 12 weeks (P<.05).
up.
Herd and Meserve Systematic Level of evidence: II Studies exhibited the Thirteen studies The 2 most Results of this review support
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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.

of LE, use of at least without movement improvement. were provided.


one patient-centered at the elbow, cervical
outcome, and inclu- spine mobilizations,
sion of manipulative Cyriax therapy, and
treatment in at least neural glides.
one group.
Akbar et al (2021) RCT Level of evidence: II Patients, with mean age Patients with LET of Patient-rated tennis Pain (PRTEE) after 8 weeks of
PEDro score: 6/10 of 35.27, were divided either sex aged 20-50 elbow evaluation treatment was found to be
into 2 groups: group A years, having symp- (PRTEE) significantly decreased in
received deep trans- toms for >2 weeks. both Cyriax and MWM groups
Journal of Orthopaedic & Sports Physical Therapy®

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.
Table continues on next page.

cpg88 | 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


Study Type of Study Critical Appraisal Score Conditions Sample Characteristics Outcome Measures Important Results
Reyhan et al RCT Level of evidence: II Forty adults diagnosed Randomized into 2 Pain (VAS), PFGS, MWM lateral glide in addition
(2020) PEDro score: 7/10 with chronic LET (>6 groups; either MWM PRTEE, and glob- to exercise and cryotherapy
weeks duration). lateral glide technique al assessment. appears to have a small posi-
plus exercise (for 3 tive effect on pain, PFGS, and
sets of 10 repetitions function in the short term.
and instructions in
a self-mobilization
technique to perform
for 10 repetitions
every 2 hours) and
cryotherapy or exer-
cise and cryotherapy
alone. Both groups
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were treated 5 times


a week for 2 weeks.
Outcomes measured
at baseline, after
treatment, 4 weeks,
and 3 months after
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

APPENDIX
APPENDIX
E (CONTINUED)
A

Evidence Table: Manual Therapy Soft Tissue Mobilizations


Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Laimi et al (2018) Systematic Level of evidence: Examined the effectiveness of Two trials focused on PRTEE First study: Myofascial release was
review II myofascial release therapy to lateral epicondylitis more effective than conventional
AMSTAR score: relieve chronic musculoskel- physical therapy alone for pain,
6/11 etal pain and to improve joint functional performance, and grip
mobility, functioning level, and strength. Mean PRTEE difference in
quality of life in individuals PRTEE improvement between the
with pain. control and LET group was (−47
points; 95% CI: −44.64, −49.36).
Second study: Myofascial release is
more effective than sham US for
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lateral epicondylitis in computer


professionals. Mean PRTEE
difference in PRTEE improvement
between the control and the LET
group was (−19.3 points; 95% CI:
–22.92, –15.68).
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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
Journal of Orthopaedic & Sports Physical Therapy®

early follow-up nonoperative treatments, including


(6-12 weeks) and at cortisone injection.
6-month follow-up.
Sevier and RCT Level of evidence: The instrument-assisted soft Males and females DASH and VAS Subjects treated with instrument-as-
Stegink-Jansen II tissue mobilization group aged 18-65 years (0-100) sisted soft tissue mobilization
(2015) PEDro score: 6/10 received deep pressure old, diagnosed with demonstrated greater gains in the
with assistive tools from the lateral epicondylitis DASH (standardized ES, 0.40; 95%
wrist to the deltoid followed (2 or more positive CI: 0.00, 0.84) and grip strength
by stretching and eccentric findings with (standardized ES, 0.62; 95% CI:
exercises. The eccentric group Cozen’s, Mill’s, and 0.16, 1.07) compared to the eccen-
received the same exercises, pain upon palpation tric strengthening group. However,
and the patients were also of the wrist extensor there were no differences between
instructed to perform the muscle mass or the groups at 6- and 12-month
exercises at home. The tendon). Symptom follow-up.
instrument-assisted soft tissue duration of at least
mobilization group did not per- 12 weeks. One
form the exercises at home. hundred thirteen
patients were
randomized into 2
groups.
Loew et al (2014) Systematic Level of evidence: RCTs and controlled clinical trials Two RCTs were PFGS, pain, func- Insufficient evidence to demonstrate a
review II comparing deep transverse included. tion (no pooling clinically important benefit of deep
AMSTAR score: friction massage versus no of results transverse friction massage when
9/11 therapy or active treatments conducted) combined with other modalities
(US, phonophoresis, other for treatment of common extensor
therapeutic exercise). tendinopathy.
Table continues on next page.

cpg90 | 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
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 Table: Dry Needling


Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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%)
Journal of Orthopaedic & Sports Physical Therapy®

group methylprednisolone withdrew from the study due to


acetate injections were given. complaints of pain with the DN
procedure.
Rodríguez-Huguet RCT Level of evidence: I Adults diagnosed with lateral A total of 32 subjects Pain pressure Ultrasound-guided percutaneous elec-
et al (2020) PEDro score: 8/10 epicondylitis were included in threshold, pain trolysis as an adjunct to an eccentric
the study inclusion intensity, elbow exercise program is more effective
criteria, which were joint range of for pain and range of movement
patients of both sex- motion, quality than trigger point dry needling as
es, aged between 18 of life an adjunct to the same exercise
and 60 years and program in patients with lateral epi-
diagnosed with LE condylalgia. The effect (eta-squared)
with a poor evolu- on pain reduction (n2 = 0.46) was
tion after 1 month moderate and improved PPT (n2 =
of passive physical 0.11) was small in all 3 follow-ups
therapy, TENS, and in favor of the PE groups (P<.05).
stretching exercise PE could be superior to tendon DN
and pharmacologi- when added to an eccentric exercise
cal treatment. program in the management of LET
after a 3-month follow-up. Compli-
cations and adverse effects were not
reported or discussed.
Table continues on next page.

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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
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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SD = 0.8) out of a with larger ESs mainly in the short


maximum of term when compared to the control
10 points on the PEDro group. Grip strength improved when
scale. compared to the control group but
with a small effect (SMD, 0.48; 95%
CI: 0.16, 0.81).
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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.

Evidence Table: Orthoses


Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Shahabi et al Systematic Level of evidence: Studies were included if (1) Search dates through Pain (different mea- The counterforce brace did not have
(2020) review II RCTs (either crossover or June 2019. surement tools), a statistically significant effect
AMSTAR score: parallel designs); (2) adult Seventeen studies grip strength, (SMD, 0.02; 95% CI: −0.85, 0.80)
Journal of Orthopaedic & Sports Physical Therapy®

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.”
Table continues on next page.

cpg92 | 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
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
Journal of Orthopaedic & Sports Physical Therapy®

bracing (88%) group compared to


the brace-only group (85% success
rate). The odds of success (OR =
1.44; 95% CI: 0.49, 4.23) was not
statistically different between the
groups. No conclusive evidence
from the RCTs included in the data
extraction was found regarding
the effectiveness of the use of an
orthosis or a lateral counterforce
brace compared with a nonorthotic
condition on pain, due to conflicting
evidence.
Sims et al (2014) Systematic Level of evidence: 1. Signs and symptoms of lateral Fifty-eight RCTs with Patient reported Conflicting evidence exists regarding
review II epicondylitis. a variety of non- pain, function, the diagnostic utility of a coun-
AMSTAR score: 2. Evaluated a nonsurgical surgical treatment and disability terforce brace or wrist orthosis.
6/11 intervention. approaches prior to was often Orthoses did not provide conclusive
3. Randomized control trial February 2013. Five reported for evidence of improvement in regards
design. studies examined each study; to pain and function.
4. Level 1 or 2 evidence. the effect of either no pooling of
lateral counterforce results was
bracing or a wrist possible.
support orthosis
on outcomes in
patients with LET.
Table continues on next page.

journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg93
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 (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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pear to have a positive effect when


compared to cortisone injection at 2
weeks and 6 or 12 months. However,
the use of a lateral counterforce
strap appears to be more effective
in enabling individuals with LET to
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

perform daily activities in the short


term (6 weeks) when compared to
pulsed US plus friction massage
plus exercise.
Borkholder et al Systematic Level of evidence: I RCTs that examined the Eleven RCTS met Pain and other A lateral counterforce brace, regardless
(2004) review AMSTAR score: effectiveness of an orthosis for the criteria. Ten of objective find- of style, resulted in increased grip
7/11 the treatment of lateral elbow the studies were ings such as and wrist extensor strength in
tendinopathy rated at a 2b quality, wrist strength symptomatic individuals. One study
whereas 1 study and handheld evaluated the effect of 3 types of
was rated at 1b. dynamometry wrist support orthoses in normal
Journal of Orthopaedic & Sports Physical Therapy®

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.
Table continues on next page.

cpg94 | 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
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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response rate) used in the counterforce or wrist support


responded to the management of orthosis for immediate pain relief
survey. individuals with in individuals with LET whose pain
LET. was aggravated with activities.
Respondents ranked orthoses the
4th most effective intervention in
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

alleviating symptoms of LET behind


rest/activity modification (first), a
home exercise program (second),
and stretching (third).
Abbreviations: ES, effect size; LET, lateral elbow tendinopathy; MD, mean difference; PFGS, pain-free grip strength; PPT, pressure pain threshold; RCT, ran-
domized clinical trial; RR, relative risk; SMD, standardized mean difference; US, ultrasound; VAS, visual analog scale.

Evidence Table: Taping


Evidence Rating
and Critical Sample Outcome
Journal of Orthopaedic & Sports Physical Therapy®

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.

journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg95
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) 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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more than 1 year.


George et al Systematic Level of evidence: Searched up to March 2018. Eight included Pain intensity, Studies reported improvement in
(2019) review II Studies were eligible for studies examining mechanical outcomes based on percentages and
AMSTAR score: inclusion if they had a pop- either rigid taping pain sensitivity, therefore pooling of data was not
9/11 ulation with LET; a tape-only or kinesiology strength, possible. There is a lack of consistent
“intervention” (eg, rigid tape, tape, and placebo sensorimotor high-quality evidence. Based on the
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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
Journal of Orthopaedic & Sports Physical Therapy®

English-language manuscript. following each reported.


Single-subject case studies, condition. In
conference abstracts, retro- short-term
spective studies, and reviews treatment stud-
were excluded. ies, tape was
applied multiple
times over 1
or 2 weeks,
with or without
measurement of
outcomes.
Özmen et al RCT Level of evidence: Forty patients with lateral elbow Patients were ran- The VAS, grip All treatment interventions had statis-
(2021) II tendinopathy. Inclusion criteria domly assigned strength, and tically significant results in reduced
PEDro score: 6/10 were as follows: (1) pain to 3 treatment the pain intensity during ADL at the end
around the lateral epicondyle groups: (1) US, PRTEE Scale of the treatment and at 6 weeks fol-
during the extension of wrist (2) ESWT, (3) lowing completion of treatment. Grip
and fingers against resistance; kinesiology tape strength significantly increased after
(2) tenderness over the lateral 8 weeks in only the kinesiology tape
epicondyle; and (3) symptoms group (P<.05). The PRTEE scores
lasting for at least 3 months. significantly decreased after 2 weeks
and after 8 weeks in the US group
and ESWT groups, and after 8 weeks
in the kinesiology tape group.
Table continues on next page.

cpg96 | 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
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
Journal of Orthopaedic & Sports Physical Therapy®

kinesiology tape nerve CSA) decrease in VAS, PRTEE-pain, and


experimental were performed PRTEE­function was significant for
group. Both before and the 14th weeks (P<.001 ). However, in
groups took oral after treatment the control group, there were no sig-
naproxen and (second week, nificant differences in terms of VAS,
were instructed sixth week, and PRTEE-pain and PRTEE-function at
in activity modifi- 14th week). the 14th weeks (P>.05). The improve-
cation and a HEP. ment in all parameters was superior
Additionally, the in the kinesiology tape group.
kinesiology tape
group received
kinesiology tape
application 3
times a week for
2 weeks, for a
total of 6 sessions
using the inhibitor
and mechanical
correction taping
techniques.
Table continues on next page.

journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg97
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
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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one of the tests


(ie, resisted wrist
extension, resisted
middle finger
extension, or
passive stretch of
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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.
Journal of Orthopaedic & Sports Physical Therapy®

cpg98 | 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 Table: Cryotherapy


Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Macedo et al RCT Level of evidence: Patients were selected via Inclusion criteria No formal outcome The greatest analgesic effect was found
(2015) II convenience sampling and were for the study measure; pain within group 6 with the combination
PEDro score: 5/10 randomly divided into 7 groups: consisted of threshold of cryotherapy and burst TENS
(1) Control group (25-minute rest) young healthy assessment (P≤.001) demonstrating its useful-
(2) Placebo TENS (turned on- no females between ness with pain relief.
amp) the ages of 18-25 Pain threshold and pain tolerance de-
(3) Conventional TENS (symmet- (BMI < 28 kg/ clined in control and placebo groups,
rical biphasic pulsed current; m2) with no increased in groups that received
frequency: 100 Hz, duration: 100 history of UE in- burst TENS with or without cryo-
μs and motor level amp) jury in the past 6 therapy and cryotherapy alone, and
(4) Burst TENS (100 Hz burst-mod- months and not no change found with conventional
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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
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

(7) Cryotherapy and conventional group)


TENS (combination of groups
3 and 5)
A baseline measure of pain
threshold was taken at the lat-
eral epicondyle with a pressure
algometer before the selected
intervention (group dependent).
All interventions lasted 25
minutes. Another pain threshold
Journal of Orthopaedic & Sports Physical Therapy®

measure was taken immediately


following the intervention.
Table continues on next page.

journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg99
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
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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HEP consisting of 3 exercises: symptoms (average of 15%). However, without


(1) resisted forearm supination present for >3 a control group, it is not possible to
with Theraband (TB) 3×10, (2) months, no pre- know if changes are attributed to
resisted wrist extension with TB vious treatment time, placebo, or the treatment itself.
3×10, and (3) straight arm wrist or surgery in the
extensor stretch (20-s hold 3×). past 3 months,
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Groups 2 and 3 were given the or no history of


appropriate ice pack and told musculoskeletal
to apply after exercise for 20 or neuromuscu-
minutes, 10 minutes off, then 20 lar disorders of
minutes again. Group 4 com- the UE. Physical
pleted 3 cycles of 20 minutes on inclusion exam-
20 minutes off. All groups com- ination included
pleted protocols at least 4 times a minimum
a week for 6 weeks. Daily logs of 3/10 on the
were taken; and participants VAS on 2 out of
were reassessed at 6 weeks with 6 provocation
Journal of Orthopaedic & Sports Physical Therapy®

same 3 screening tests. tests, which


included resisted
wrist extension
(with elbow
extended or with
elbow flexed at
90 degrees), re-
sisted third-digit
extension
with elbow
in extension,
ability to lift chair
with elbows in
extension and
forearms pro-
nated (with both
arms or with
only affected
arm), and pain
with palpation.
Twenty-one partic-
ipants dropped
out of the study
for “various
reasons.”
Abbreviations: BMI, body mass index; DASH, Disabilities of the Arm, Shoulder and Hand; MD, mean difference; TENS, transcutaneous electrical nerve stimu-
lation; RCT, randomized clinical trial; UE, upper extremity; VAS, visual analog scale.

cpg100 | 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 Table: Ultrasound


Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
Hüseyin Ünver et RCT Level of evidence: Adults with LET who presented Fifty-one patients Pain (VAS), PRTEE, At 2 weeks, all outcomes were significant-
al (2021) II with pain on the lateral side were random- (maximum) grip ly improved in all groups (P<.05). Pain
PEDro score: 7/10 of the elbow for less than 6 ized into either strength and function demonstrated greater
months, tenderness over the continuous US improvements in both the continuous
lateral epicondyle, and pain (n = 17), pulsed and pulsed US groups compared
during extension of the wrist US, or placebo with sham US. Each group’s baseline,
and digits US groups. 2-week, and 6-week mean scores with
All received SD were reported; however, values of
10 sessions differences between groups and effect
of treatment sizes were not reported.
for 5 minutes
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once per day


for 2 weeks.
Continuous US
therapy group
received 1.5 MHz
frequency, and
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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.
Journal of Orthopaedic & Sports Physical Therapy®

The third group


received sham
US application.
Özmen et al RCT Level of evidence: Forty patients with LET. Inclusion Group 1: ultrasound The VAS, PRTEE, Only the kinesiology tape groups showed
(2021) II criteria were as follows: (1) (US) therapy, and grip significantly increased grip strength
PEDro score: 6/10 pain around the lateral epi- Group 2: extra- strength were at 8 weeks (P<.05). PRTEE scores
condyle during the extension corporeal shock measured at significantly decreased after 2 weeks
of wrist and fingers against wave therapy baseline, 2 and after 8 weeks in the US group and
resistance, (2) tenderness over (ESWT), Group weeks, and 8 ESWT groups, and after 8 weeks in the
the lateral epicondyle, and (3) 3: kinesiology weeks. kinesiology tape group (P<.05).
symptoms lasting for at least tape
3 months.
Table continues on next page.

journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg101
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
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®

applied directly postintervention. postintervention) than the US group


to the lateral Pain was as- (28% reporting good pain reduction
epicondyle for sessed through immediately following and 3 months
≤10 minutes. palpation, grip postintervention with no individuals
(2) Extracorporeal strength, resting reporting excellent pain relief). This
shock wave levels, during suggests that ESWT is more efficient
therapy (ESWT): Thomsen test at immediate and long-lasting pain
received 1000 (Cozen’s) and management when compared to US.
(first tx), 1500 chair test.
(second tx), and
2000 (third-fifth
txs) pulses
(pressure: 2.5
bar; frequency:
8 Hz; density:
.4 mJ/mm2) 1
time a week for
5 weeks. Tx was
≤10 minutes
and applied to
the most painful
area of the
lateral elbow.
Table continues on next page.

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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−2.3 cm; 95% CI: −4.5, 0.01) support-


ed by moderate and limited evidence
respectively. Limited evidence support-
ed the use of wrist manipulation over
the use of US plus friction massage
and exercises on pain during the day
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

(P = .03) in the short term. Limited


evidence suggested that US was more
effective in providing pain relief and
improving pain-free function than
chiropractic care and exercise in the
short term (6 weeks).
Dingemanse et al Systematic Level of evidence: Reviews and RCTs that focused Two reviews and Pain, grip strength, There was moderate evidence found in
(2014) review II on multiple electrophysical 20 RCTs were and function (no the effectiveness of US in treating
AMSTAR score: modalities to treat lateral and included within overall pooling of lateral epicondylitis. Some evidence
5/11 medial epicondylitis were the systematic results). Specific supporting US vs a placebo and
Journal of Orthopaedic & Sports Physical Therapy®

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.

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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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tions but was not more effective than


the control group of no intervention.
Abbreviations: ESWT, extracorporeal shock wave therapy; LET, lateral elbow tendinopathy; MD, mean difference; PRTEE, Patient-Rated Tennis Elbow Evalu-
ation; PVAS, pain visual analog scale; RCT, randomized clinical trial; VAS, visual analog scale.

Evidence Table: Phonophoresis


Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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®

to lateral epicondyle (PRTEE), and .97). When compared to phonopho-


and 4 painful points grip strength resis, iontophoresis has better effects
surrounding it for un- dynamometer for pain, function, and grip strength.
known amount of time, Overall, phonophoresis does not
the phonophoresis appear to be a viable treatment option
group (Prednisolone for this population of LET.
(2 mg/d) was mixed
with aquasonic US
gel at applied with a 5
cm2 applicator using
1 W/cm2 and 1 Mz for
7 minutes), and to the
iontophoresis group
(using 5 mL of 0.4%
prednisolone to the ac-
tive negative electrode
placed over the lateral
epicondyle for 40 mA
min). All participants
received treatment at
the clinic (5 times a
week), consisting of 15
sessions of approxi-
mately 20 minutes.
Table continues on next page.

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.

Evidence Table: Iontophoresis


Evidence Rating
and Critical Sample Outcome
Study Type of Study Appraisal Score Conditions Characteristics Measures Important Results
da Luz et al (2019) RCT Level of evidence: Adults with LET (unilateral Twenty-four participants Pain (VAS), grip At final measurements, the iontophoresis
II or bilateral who had not randomly assigned to strength group demonstrated significantly
PEDro score: 7/10 received any treatment the iontophoresis (n (maximum), and lower pain at rest than the galvanic
in the past 4 weeks). = 12) or the galvanic function PRTEE current group (P = .002). The mean
current (n = 12) group (SD) pain level in the galvanic current
group reduced from 3.50 (2.11) to
2.50 (1.57) (P = .032) and the ionto-
phoresis group demonstrated pain
reduction from 3.83 (1.80) to 0.58
(0.99) (P<.001). Pain with exertion
and PTREE scores were also less in
the iontophoresis group compared
with the galvanic current group
(P<.001). No significant differences
in grip strength were seen between
groups.
Table continues on next page.

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.

epicondylitis, an RCT, iontophoresis. different at moderate- to long-term


and at least one of the follow-ups. One study reported pain
following conserva- score reduction for up to 18 days. Con-
tive interventions: flicting results were found regarding
corticosteroid injections, iontophoresis impact on functional
iontophoresis, botulinum status; one study found no significant
toxin A injections, change in function compared to a pla-
prolotherapy, plasma or cebo group when another study found
blood injections, bracing, “improved grip strength and higher
physical therapy, return to work without restrictions at
Journal of Orthopaedic & Sports Physical Therapy®

shockwave therapy, or the end of therapy” when compared


laser therapy. to dexamethasone and triamcinolone
injections. The existing literature does
not provide enough evidence that one
method of nonoperative treatment is
preferable over another.
Bisset et al (2011) Systematic Level of evidence: Adults who were diagnosed Four systematic reviews, Pain levels, global When comparing the effects of ionto-
review II with tennis elbow with 2 RCTs improvement, phoresis with a placebo or other in-
AMSTAR score: the following inclusion functional terventions, very low-quality evidence
7/11 criteria; published improvement supports the use of iontophoresis cou-
systematic reviews of pled with an active anti-inflammatory
RCTs and RCTs in any drug at 2 weeks but not at 4 weeks for
language, at least single reducing pain. It was unclear whether
blinded, and containing iontophoresis improved the patient’s
>20 individuals of whom self-reported global improvement at 1
>80% were followed up. to 3 months in those with LET.
Table continues on next page.

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.

Evidence Table: TENS


Evidence Rating
and Critical Ap- Sample Outcome
Study Type of Study praisal Score Conditions Characteristics Measures Important Results
Macedo et al RCT Level of evidence Participants were randomly Subjects eligible were Pain threshold and Cryotherapy and burst TENS are effective
(2015) = II assigned to 7 groups: 120 females between tolerance therapeutic agents for the reduction
PEDro score: 5/10 control, placebo TENS, 18 and 25 years old of pressure-induced pain, especially
Journal of Orthopaedic & Sports Physical Therapy®

conventional TENS, with no history of when used concurrently. However,


burst TENS, cryotherapy, upper limb injury in application of cryotherapy with con-
cryotherapy + burst the last 6 months, BMI ventional TENS was found to reduce
TENS, and cryotherapy < 28 kg/m2, not using the individual effects of either therapy.
+ conventional TENS. analgesics, and no skin
Participants’ arms were or vascular alterations
supported and their or sensitivities.
elbows are flexed to 90
degrees, and pressure
tolerance was measured
with a pressure algome-
ter both before and after
the intervention.
Dingemanse et al Systematic Level of evidence Systematic reviews and/or One study assessed the Pain Low-quality evidence showed that in the
(2013) review = II RCTs that had patients efficacy of low-frequen- short term (at 2-week follow-up) there
AMSTAR score = with medial or lateral cy, high-frequency, and was a significant difference in pain
5/11 epicondylitis not caused sham TENS versus reduction between high-frequency
by acute trauma or placebo on acupunc- TENS and sham TENS, and the
systemic disease and ture points. low-frequency TENS and sham TENS.
examined interventions No significant difference on pain was
for treating epicondylitis found between the high-frequency
and their results on pain, TENS and low-frequency TENS.
function, or recovery.
Table continues on next page.

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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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primary care manage- forty-one subjects were Short Form-12


ment information but included in the study. (SF-12) physical
were also given a TENS and mental
machine and instructed subscales
to use it at least 1 time
a day for 45 minutes
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

on days where pain


persisted. The frequency
was 110 Hz with a pulse
duration of 200 μs and
intensity tolerable to
participants as a “very
strong tingling/buzzing”
sensation. They were
advised to use the
machine for a minimum
of 6 weeks when pain
Journal of Orthopaedic & Sports Physical Therapy®

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.

Evidence Table: Laser


Evidence Rating
and Critical Ap- Sample Outcome
Study Type of Study praisal Score Conditions Characteristics Measures Important Results
Kaydok et al RCT Level of evidence: I Sixty patients with LET To evaluate the short- The outcome Both groups showed significant
(2020) PEDro score: 8/10 were randomized into 2 term effectiveness of measures used within-group improvement. When be-
groups high-intensity laser were VAS, Quick- tween group effects were compared
therapy (HILT) and DASH, Short the HILT group, demonstrated signif-
low-intensity laser Form-36 (SF-36), icant improvements in QuickDASH,
therapy (LILT). Along and handgrip SF-36 (PCS) score, and grip strength
with laser treatments, strength mea- scores (P<.05). Both HILT and LILT
both groups received sured at baseline were safe and effective in the shorter
an epicondylitis and 3 weeks. term for treatment of LET; however,
bandage. HILT was superior to LILT in improving
function and grip strength.
Table continues on next page.

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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strength. combined effects sizes for the studies


resulted in favorable outcomes for
laser therapy versus sham/placebo
in the intermediate term (SMD, 1.313;
95% CI: 0.514, 2.111). In addition, at
midterm follow-up, laser therapy was
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

the sole treatment modality shown to


improve grip strength (SMD, 0.576;
95% CI: 0.286, 0.866).
Baktir et al (2019) Randomized Level of evidence: Adults with LET Twelve participants were VAS, pressure Along with improvements in pain,
parallel II randomized to the LLLT algometer, the improvements in function and grip
group trial PEDro score: 7/10 group, 12 to the pho- PRTEE, and strength were associated with the ion-
nophoresis group, and grip strength tophoresis group (PRTEE, P = .006;
13 to the iontophoresis dynamometer ES = 0.78; grip strength with elbow
group extension, P = .011; ES = 1.03; with
elbow flexion, P = .003; ES = 0.52). Of
Journal of Orthopaedic & Sports Physical Therapy®

the 3 modalities (iontophoresis, laser,


and phonophoresis), iontophoresis
was the only modality shown to be
beneficial for improving pain and
function on the PRTEE.
Dingemanse et al Systematic Level of evidence = Systematic reviews and/or Six studies reported on Pain Laser therapy was found to be inferior to
(2013) review II RCTs that had patients effectiveness of laser US plus friction massage for reducing
AMSTAR = 5/11 with medial or lateral versus placebo. pain (SMD, −0.84; 95% CI: −1.58,
epicondylitis not caused −0.09) in the short term (6 weeks)
by acute trauma or based on moderate evidence; howev-
systemic disease and er, there was no difference in global
examined interventions improvement. When compared to
for treating epicondylitis placebo, the evidence was conflicting
and their results on pain, regarding the effectiveness on pain,
function, or recovery. grip strength, and function; however,
there appeared to be no difference
in effect on midterm (6 weeks-6
months) and long-term (greater than
6 months) pain relief. Laser therapy
resulted in improvements in pain
at rest (P<.05) and grip strength
(P<.01) when compared to plyometric
exercises at 8-week follow-up based
on moderate evidence. Conflicting
evidence or evidence of no significant
effect was found; however, laser is
favored over plyometric exercises.
Table continues on next page.

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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acupuncture points. = 2.20; 95% CI: 1.51, 3.21) but there


is no evidence that laser acupuncture
provides an analgesic effect. Laser
acupuncture did not make a substan-
tial difference in treatment outcomes,
and the exact treatment methods
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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 Table: Ergonomics


Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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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