JSES International 6 (2022) 321e330

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JSES International
journal homepage: www.jsesinternational.org

Nonoperative treatment of lateral epicondylitis: a systematic review

and meta-analysis
Peter Lapner, MD, FRCSCa,*, Ana Alfonso, MDa, Jonah Hebert-Davies, MD, FRCSCb,
J W. Pollock, MD, FRCSCa, Jonathan Marsh, MD, FRCSCc,d,
Graham J.W. King, MD, FRCSCe, On behalf of the Canadian Shoulder and Elbow Society
(CSES)
a
Division of Orthopaedic Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
b
Orthopedic Trauma Surgery Clinic at Harborview, Seattle, WA, USA
c
Pan Am Clinic, Winnipeg, MB, Canada
d
Department of Surgery, Section of Orthopaedic Surgery, University of Manitoba, Winnipeg, MB, Canada
e
RothjMcFarlane Hand and Upper Limb Centre, St. Joseph’s Health Care, Western University, London, ON, Canada

a r t i c l e i n f o Background: There is an ongoing controversy regarding the nonoperative treatment of lateral

epicondylitis. Given that the evidence surrounding the use of various treatment options for lateral
Keywords: epicondylitis has expanded, an overall assessment of nonoperative treatment options is required. The
Lateral epicondylitis purpose of this systematic review and meta-analysis was to compare physiotherapy (strengthening),
Nonoperative treatment corticosteroids (CSIs), platelet-rich plasma (PRP), and autologous blood (AB) with no active treatment or
Physiotherapy
placebo control in patients with lateral epicondylitis.
Corticosteroids
Methods: MEDLINE, Embase, and Cochrane were searched through till March 8, 2021. Additional studies
Platelet-rich plasma
Autologous blood were identified from reviews. All English-language randomized trials comparing nonoperative treatment
Systematic review of patients >18 years of age with lateral epicondylitis were included.
Meta-analysis Results: A total of 5 randomized studies compared physiotherapy (strengthening) with no active
treatment. There were no significant differences in pain (mean difference: 0.07, 95% confidence interval
Level of evidence: Level II; Systematic [CI]: 0.56 to 0.41) or function (standardized mean difference [SMD]: 0.08, 95% CI: 0.46 to 0.30).
Review/Meta-analysis Seven studies compared CSI with a control. The control group had statistically superior pain (mean
difference: 0.70, 95% CI: 0.22 to 1.18) and functional scores (SMD: 0.35, 95% CI: 0.54 to 0.16). Two
studies compared PRP with controls, and no differences were found in pain (SD: 0.15, 95% CI: 1.89 to
1.35) or function (SMD: 0.14, 95% CI: 0.45 to 0.73). Three studies compared AB with controls, and no
differences were observed in pain (0.49, 95% CI: 2.35 to 3.33) or function (0.07, 95% CI: 0.64 to 0.50).
Discussion: The available evidence does not support the use of nonoperative treatment options
including physiotherapy (strengthening), CSI, PRP, or AB in the treatment of lateral epicondylitis.
© 2021 The Authors. Published by Elsevier Inc. on behalf of American Shoulder and Elbow Surgeons.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Lateral epicondylitis is common, affecting 1% to 3% of the platelet-rich plasma (PRP), and autologous blood (AB).11,16,38
population.5 The optimal management of lateral epicondylitis in Surgery may be considered when nonoperative treatment fails.3
the high-functioning patient remains controversial. Despite a lack Although there is consensus that nonoperative management
of high-level evidence to inform clinical decision-making, should represent first-line treatment, guidelines informing the
nonoperative management represents first-line treatment. optimal approach to nonsurgical treatment are not well
Nonoperative treatment may include no active treatment, established.11,12,30 Evidence is lacking regarding the superiority of
physiotherapy, and injections including corticosteroids (CSIs), one nonoperative treatment option over another, and past
systematic reviews have not reached definitive conclusions.7,34 Past
systematic reviews have often concentrated on various injection
Institutional review board approval was not required for this systematic review. treatments without considering other common forms of treatment
*Corresponding author: Peter Lapner, MD, FRCSC, Associate Professor, Division of
Orthopaedic Surgery, The Ottawa Hospital e General Campus, University of Ottawa,
such as physiotherapy.13,16 The study by Houck et al found that AB
501 Smyth Road, Box 502, Ottawa, ON, K1H 8L6, Canada. products such as AB and PRP improved pain and elbow function in
E-mail address: plapner@toh.ca (P. Lapner). the intermediate term, and CSI injections relieved pain and

https://doi.org/10.1016/j.jseint.2021.11.010
2666-6383/© 2021 The Authors. Published by Elsevier Inc. on behalf of American Shoulder and Elbow Surgeons. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
P. Lapner, A. Alfonso, J. Hebert-Davies et al. JSES International 6 (2022) 321e330

improved elbow function in the short term.16 In contrast, a recent Information sources and search strategy
meta-analysis reported that injections did not confer any treatment
benefits compared with placebo, whereas physiotherapy improved The search strategies were developed and tested through an
pain and functional scores.18 A meta-analysis by Weber et al iterative process by an experienced medical information specialist
concluded that there was insufficient evidence to support in consultation with the review team. Using the OVID platform, we
physiotherapy for the treatment of tennis elbow.39 These searched Ovid MEDLINE, including Epub Ahead of Print and
inconsistent findings make interpretation of the literature difficult In-Process & Other Non-Indexed Citations, Embase Classic þ
and cloud clinicians’ ability to counsel patients effectively. Embase, and the Cochrane Library. The latest search was conducted
The uncertainty surrounding the efficacy of various available on March 8, 2021.
nonoperative interventions makes the selection of appropriate Three different search strategies were used for physiotherapy,
treatments difficult. With no consistent consensus in the literature, CSI, and PRP/AB, respectively. We used a combination of
the specific nonoperative management of lateral epicondylitis controlled vocabulary (eg, “lateral epicondylitis”) and keywords
remains highly variable with various options commonly used. The (eg, “randomized controlled trial, physiotherapy”). Results were
aim of this systematic review and meta-analysis was to filtered using headings for systematic reviews, RCTs, and non-RCTs
compare the functional and pain outcomes of physiotherapy as applicable for each database. Vocabulary and syntax were
(strengthening), CSI injections, PRP, and AB with no active adjusted across databases. The search was restricted to
treatment or placebo control. English-language studies with no date restrictions on any of the
searches, but when possible, animal-only and opinion pieces were
Methods removed from the results. The three search strategies can be found
in Supplementary Appendix S1.
Inclusion and exclusion The bibliographies of published systematic reviews were
inspected to confirm that no relevant studies had been missed. No
We identified English-language randomized controlled trials attempt was made to contact content experts to obtain information
(RCTs) in any setting comparing nonoperative treatment with a on unknown or ongoing studies.
control in patients aged 18 years or older with lateral epicondylitis.
Studies with a minimum follow-up duration of 6 months after the Screening and data extraction
first intervention were considered. Screening was performed in two stages via two reviewers
This study adheres to the standards of the Preferred working independently and in duplicate against eligibility criteria
Reporting Items for Systematic Review and Meta-Analysis Protocols established a priori. Stage 1 screening was based on review of the
(PRISMA-P) statement32 and was registered at the PROSPERO abstracts and titles identified from the electronic search, whereas
registry of systematic reviews (CRD42021268775). stage 2 screening considered full-text review of the articles deemed
potentially relevant during stage 1. At stage 1, two reviewers inde-
Study eligibility criteria pendently assessed the titles and abstracts for eligible studies using
the liberal accelerated method17 where only one reviewer was
We established the review eligibility criteria based on the PICOS required to include citations for further assessment at full-text
(Population-Intervention-Comparators-Outcomes-Study design) screening and two reviewers were needed to exclude a citation.
framework. Primary studies were included that met the following At stage 2, full-text articles of potentially relevant citations were
criteria: retrieved for full-text screening and the same two reviewers inde-
pendently assessed the article for relevancy. Disagreements be-
 Population: Studies enrolling adult patients aged 18-75 years tween reviewers were resolved via consensus. The study selection
with lateral epicondylitis receiving nonoperative treatment for process was reported using a PRISMA flow diagram.25 References of
their condition were sought. all included studies were scanned for inclusion by one reviewer
 Interventions: (P.L.). Study authors were consulted where necessary for verifying
1) Physiotherapy (must include strengthening exercises and eligibility and for missing or unclear information on studies (and
passive treatment such as stretching, and other modalities information was included if received in a timely manner). When
including laser therapy, extracorporeal shock wave therapy, multiple reports of the same study cohort were published, we used
massage, and acupuncture were excluded). the most complete set and excluded repeated publications.
2) CSI. A standardized data extraction form in Microsoft Excel
3) PRP (methodology used for included studies involved a (Microsoft Corporation, Seattle, WA, USA) was used for collecting
standard protocol of collecting 15 mL of venous blood key study information that included all prespecified data items.
from the cephalic vein, centrifugation of venous blood for 5 After piloting the data extraction form on a small number of
minutes, use of a kit syringe to collect one-third of studies, two reviewers extracted the data independently and any
the original sample of 4-6 mL, and injection of PRP at the site discrepancies were resolved by discussion or a third person.
of greatest pain at the extensor origin of the lateral Information from each study was recorded that included (but not
epicondyle). be limited to) the following: publication characteristics
4) AB (methodology involved collection of 3 mL of venous blood (eg, authors’ names, publication year, and journal), study design
and injection with a 22-G or 23-G needle to the extensor traits (cited trial design, clinical setting, duration of follow-up,
tendon origin of the lateral epicondyle). number of patients randomized and number analyzed for each
 Comparators: No active treatment or placebo control for outcome, occurrence of dropouts, funding source, authors’ conflict
interventions 2, 3, or 4 above. of interest, etc), study population details (patient inclusion and
 Outcomes: End points of interest included the following with a exclusion criteria, age, sex, and body mass index), comorbidities,
minimum of 6-month follow-up. and prior treatments. Intervention and comparator specifics
1) Postintervention pain (visual analog scale for pain). (type of treatment) and outcome data (including reported outcome
2) Functional outcomes (eg, Patient-Rated Tennis Elbow definitions and summary data related to treatment effects
Evaluation, Disabilities of the Arm, Shoulder and Hand). (eg, mean change and the corresponding standard error for
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Figure 1 Flow diagram of search strategy.

Table I preintervention outcome data compared with the interval

Study characteristics. occurring between baseline and 24 months post-treatment.
Total number of trials 17 However, if insufficient data were reported across primary
Age, yr, mean (range) Aggregate: 48 (43-62) studies, we collected outcome data at various time points such as 6
Physiotherapy vs. control: 46 (43-48) months and 12 months post-treatment if possible.
Corticosteroid vs. control: 49 (46-62);
PRP vs. control: 47 (46-49); AB vs. control:
49 (46-52) Risk of bias assessment
Duration of follow-up, 12 (6-12) We used the Cochrane Risk of Bias Tool for RCTs15 to evaluate the
months, median (range) risk of bias of each included trial. Two reviewers carried out
Outcome measures
assessments independently and resolved disagreements via
Clinical Outcome Scores Global Improvement Scale: 1
DASH: 6 consensus or third-party adjudication. All domains of the Cochrane
PRFE: 1 Risk of Bias tool for RCTs were considered, including selection bias
Roles and Maudsley: 1 (sequence generation and allocation sequence concealment),
PFFQ: 4
performance bias (blinding of participants and personnel),
Tennis Elbow Score: 1
Not reported: 3
detection bias (blinding of outcome assessment), attrition bias
Pain VAS: 16 (incomplete outcome data), and reporting bias (selective
Nirschl/Petrone pain score:1 reporting). Trials were scored as low risk, moderate risk, or
PRP, platelet-rich plasma; AB, autologous blood; VAS, visual analog scale; DASH, high risk based on the study methodology. The Grades of
Disabilities of the Arm, Shoulder and Hand. Recommendation, Assessment, Development and Evaluation
(GRADE) approach was used to evaluate the quality of the included
studies.2,14 The GRADE approach rates RCTs as “high” quality but
continuous outcomes, and number of events, and number of total can be graded down due to risk of bias, imprecision, inconsistency,
patients for dichotomous outcomes), and reported scales for indirectness, or publication bias.14 An overall grade is assigned
evaluating the outcomes). Means and measures of dispersion were (high, moderate, low, or very low) based on the aforementioned
approximated from figures in the primary studies using online considerations and graded as per the population, intervention,
tools. We contacted authors for any missing or additional data of comparator, and outcome framework described above and was
interest. Authors’ defined prespecified outcomes of interest were applied to each outcome.
extracted and grouped accordingly for analyses.
Approaches to evidence syntheses
Outcomes and prioritization Criteria for quantitative synthesis. As noted earlier, separate sets of
We explored the Core Outcome Measures in Effectiveness Trials analyses pertaining to comparisons of interventions were
(COMET) initiative but did not locate a core outcome set for the performed. Initially, we inspected the characteristics of included
lateral epicondylitis.24 As such, the end points of interest for this studies such as patients’ clinical characteristics (age, sex) and
review were selected via consultation with our clinical experts. The methodologic homogeneity (eg, risk of bias, study design), and we
primary outcome of interest was pain, whereas the secondary summarized them accordingly. A pairwise meta-analysis for each
outcome of interest included postintervention function. In terms of intervention comparison was pursued to explore statistical
time of assessment for the end points of interest, we considered heterogeneity (based on the I2 statistic) if data permitted.
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Figure 2 Forest plot of physiotherapy versus no active treatment for pain. Risk of bias legend: red dot ¼ high risk of bias; no color ¼ unclear risk; green dot ¼ low risk of bias.

Figure 3 Forest plot of physiotherapy versus no active treatment for function. Risk of bias legend: red dot ¼ high risk of bias; no color ¼ unclear risk; green dot ¼ low risk of bias.

Figure 4 Forest plot of corticosteroids versus no active treatment for pain. Risk of bias legend: red dot ¼ high risk of bias; no color ¼ unclear risk; green dot ¼ low risk of bias.

Statistical analysis and assessment of heterogeneity. Data for of available data. All pairwise comparisons between interventions
patient-reported pain and function were pooled using Revman 5.4.9 were expressed with 95% credible intervals. Cohen’s effect sizes
Mean visual analog scale for pain and standardized mean difference were used as a guide to interpretation of the SMDs,8 with an SMD
(SMD) were used across related functional scales to maximize usage <0.2 considered as a small effect, 0.2 to 0.8 considered a moderate

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Figure 5 Forest plot of corticosteroids versus no active treatment for function. Risk of bias legend: red dot ¼ high risk of bias; no color ¼ unclear risk; green dot ¼ low risk of bias.

Figure 6 Forest plot of PRP versus no active treatment for pain. Risk of bias legend: red dot ¼ high risk of bias; no color ¼ unclear risk; green dot ¼ low risk of bias.

Figure 7 Forest plot of PRP versus no active treatment for function. Risk of bias legend: red dot ¼ high risk of bias; no color ¼ unclear risk; green dot ¼ low risk of bias.

effect, and >0.8 considered a large effect. An SMD of 0.5 was Results
considered a clinically significant improvement in function.27
In addition to inspection of the forest plots, the I2 statistic was The search for studies of nonoperative treatment of lateral
used to detect the presence of heterogeneity (<40%, low epicondylitis identified 1668 potential articles, and 993 articles
heterogeneity and >75% substantial heterogeneity). Fixed effects after duplicates were removed. These were reviewed as full
models were used in the presence of low or absent heterogeneity, abstracts. Of these, 86 articles were reviewed as full texts and 73
and mixed effects models were used if heterogeneity was detected articles were excluded. Four additional articles were added after
(I2 > 40%). inspection of past systematic reviews. Seventeen trials were
We relied on pairwise meta-analyses of each of the main included in the review that compared nonoperative treatment of
outcomes of interest as outlined in the population, intervention, lateral epicondylitis with a control. The study flow is summarized
comparator, and outcome framework described previously. in Figure 1. The sample sizes of individual studies ranged from 18 to

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Figure 8 Forest plot of AB versus no active treatment for pain. Risk of bias legend: red dot ¼ high risk of bias; no color ¼ unclear risk; green dot ¼ low risk of bias.

Figure 9 Forest plot of AB versus no active treatment for function. Risk of bias legend: red dot ¼ high risk of bias; no color ¼ unclear risk; green dot ¼ low risk of bias.

132 patients. Follow-up time was most commonly 12 months but difference in favor of the control group for pain (mean difference:
ranged from 6 to 12 months. Study characteristics are summarized 0.70, 95% CI: 0.22 to 1.18). Statistically higher functional scores were
in Table I. found in favor of controls (SMD: 0.35, 95% CI: 0.54 to 0.16).
No heterogeneity was detected for function, but significant
Physiotherapy heterogeneity was detected for pain (I2 ¼ 56%).

Physiotherapy (strengthening) versus no active treatment Platelet-rich plasma

was compared with data in 5 studies (447 randomized patients)
(Figs. 2 and 3).4,22,23,35,36 One study was included in which the Two studies compared PRP with controls with a total of 64
control group was treated with a band only.22 One study used a brace randomized patients (Figs. 6 and 7).21,28 The mean age was 47 years
in the control group.36 The brace was approximately 6 cm wide and (range: 46-49 years). No differences between groups were found in
fastened with Velcro around the forearm below the elbow. The mean pain (SD 0.15, 95% CI 1.89 to 1.35) or function (SMD 0.14, 95%
age was 46 years (range: 43-48 years). No differences in pain (0.07, CI 0.45 to 0.73). No heterogeneity was detected across the
95% confidence interval [CI]: 0.56 to 0.41) or function (0.08, 95% included studies.
CI: 0.46 to 0.30) were observed between physiotherapy
(strengthening) and control groups. Heterogeneity (I2) was 61% and Autologous blood
53% for pain and function, respectively.
An additional subgroup analysis was conducted in which trials Three studies compared AB with controls with a total of 134
that allowed stretching, a band, or a brace in the no active treatment randomized patients (Figs. 8 and 9).21,31,40 The mean age was 49
group were omitted from the analysis. We found no differences in years (range: 46-52 years). No differences were observed in pain
patient-reported pain (mean difference: 0.38 [95% CI 1.12, 0.37]) (0.49, 95% CI: 2.35 to 3.33) or function (0.07, 95% CI: 0.64 to
or function (95% CI 0.61 [0.13, 1.36]) between groups. 0.50). Significant heterogeneity was detected for pain (I2 ¼ 89%)
and function (I2 ¼ 56%), respectively.
Corticosteroids
Risk of bias
Seven studies were included in the systematic review of CSI
compared with a placebo control or no active treatment with a total Using the Cochrane Risk of Bias tool, 4 of 5 studies (80%)
of 416 randomized patients (Figs. 4 and 5).4,10,20,29,35,37,40 The mean included in the physiotherapy review were found to have a mod-
age was 50 years (range: 46-62 years). There was a statistical erate or high risk of bias (Figs. 2 and 3). There was complete

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Table II
Physiotherapy compared to no active treatment for tennis elbow.

Certainty assessment Number of patients Effect Certainty

Number of Study Risk of Inconsistency Indirectness Imprecision Other Physiotherapy No active Relative Absolute (95% CI)
studies design bias considerations treatment (95% CI)

Pain (scale from: 0 to 10)

5 randomised serious*,y seriousz not serious not serious None 212 2354 - MD 0.07 VAS lower 44
trials (0.56 lower to Low
0.41 higher)
Function
5 randomised serious*,y not serious not serious not serious None 212 235 - SMD 0.13 SD higher 444
trials (0.06 lower to Moderate
0.32 higher)

CI, confidence interval; MD, mean difference; VAS, visual analog scale; SMD, standardized mean difference.
*
treatment allocation was not concealed.
y
Blinding of participants did not occur in any study.
z 2
I ¼ 61% in this comparison.
327

Table III
Corticosteroids compared to control for health problem and/or population.

Certainty assessment Number of patients Effect Certainty

Number of Study design Risk of bias Inconsistency Indirectness Imprecision Other Corticosteroids Control Relative Absolute (95% CI)
studies considerations (95% CI)

Pain (follow-up: range 2 months to 12 months)

7 randomised serious*,y,z seriousx not serious not serious None 258 258 - MD 0.7 VAS higher 44
trials (0.22 higher to Low
1.18 higher)
Function (follow-up: range 2 months to 12 months)
5 randomised serious*,y,z not serious not serious not serious None 211 208 - SMD 0.19 SD lower 444

JSES International 6 (2022) 321e330

trials (0.4 lower to Moderate
0.22 higher)

CI, confidence interval; MD, mean difference; VAS, visual analog scale; SMD, standardized mean difference.
*
In one study, it was unclear whether treatment allocation was truly random.
y
blinding of participants did not occur in two studies.
z
blinding of outcome assessments not done with two studies.
x 2
I value ¼ 56%.
P. Lapner, A. Alfonso, J. Hebert-Davies et al. JSES International 6 (2022) 321e330

Table IV
PRP compared to no active treatment for tennis elbow.

Certainty assessment Number of Effect Certainty

patients

Number of Study design Risk of bias Inconsistency Indirectness Imprecision Other PRP No active Relative Absolute (95% CI)
studies considerations treatment (95% CI)

Pain
1 randomised not serious not serious not serious not serious none 46 49 - MD 0.3 VAS lower 4444
trials (7.27 lower to 6.67 higher) High
Function
2 randomised not serious not serious not serious not serious none 32 32 - MD 0.31 VAS higher 4444
trials (0.19 lower to 0.8 higher) High

PRP, platelet-rich plasma; CI, confidence interval; MD, mean difference; VAS, visual analog scale.

Table V
Question: Autologous blood compared to control for tennis elbow.

Certainty assessment Number of patients Effect Certainty

Number of Study design Risk of bias Inconsistency Indirectness Imprecision Other Autologous Control Relative Absolute (95% CI)
studies considerations blood (95% CI)

Pain
2 randomised not serious not serious not serious Serious* none 50 48 - MD 0.49 VAS higher 444
trials (2.35 lower to 3.33 higher) Moderate
Function
3 randomised not serious not serious not serious not serious none 68 66 - SMD 0.07 SD lower 4444
trials (0.64 lower to 0.5 higher) High

CI, confidence interval; MD, mean difference; VAS, visual analog scale; SMD, standardized mean difference.
*
Only two studies reported pain. Treatment effect estimate range is large due to small number of patients.

agreement among reviewers (P.L. and A.A.). Tables II-V contain the Lian et al found that injected CSIs resulted in better pain outcomes
GRADE summary of findings, as well as the level of certainty for compared with placebo in patients with lateral epicondylitis.19 The
each comparison. The certainty of the GRADE assessments was inclusion criteria in the latter study were not as restrictive as in the
downgraded in most cases most commonly due to methodological current review because studies were included that allowed
concerns related to lack of blinding and lack of concealment of rehabilitation exercises in the control group,26 whereas in the
allocated treatment. Most studies in the CSI review were graded as current review, we only included studies comparing CSI to placebo.
“moderate” risk of bias mainly due to concerns related to blinding The current review also included a greater number of studies
of participants and outcome assessors (Fig. 3 and Table III). The risk comparing CSI with a control than the review by Lian et al.
of bias was graded as “low” in the PRP review (Fig. 4 and Table IV). In a systematic review of overlapping meta-analyses, Houck et al
There were no serious methodological concerns in the review on reported that most previous systematic reviews found that PRP and
AB (Fig. 5 and Table V). AB were effective treatment options in the short term (12-26
weeks).16 In addition, CSIs were found to be effective in the short
Discussion term (<12 weeks). The results of the current review contrast
sharply with the study by Houck et al and do not demonstrate any
This systematic review and meta-analysis included 17 trials benefit of injectable treatment over placebo with follow-up of
comparing the nonoperative treatment of lateral epicondylitis to no >6 months.
active treatment or a placebo control. This study finds that pain and Few prospective randomized trials have been published
functional scores were similar between groups for nonoperative comparing PRP injections with placebo. The results of the present
treatment including physiotherapy (strengthening), PRP, and AB study are similar to a recently published systematic review and
compared with controls. The comparison of CSI with placebo meta-analysis by Simental-Mendia et al33 which reported
control revealed that both pain scores (0.35, 9% CI: 0.54 comparable results between PRP and placebo in pain and functional
to 0.16) and functional scores (0.7, 95% CI: 0.22 to 1.18) favored scores. The present study found similar outcomes with the addition
controls. of one further study to the meta-analysis.
The findings of the present study are consistent with a recent We provide an updated analysis of the lateral epicondylitis
systematic review and meta-analysis of RCTs by Kim et al that literature. Our findings of no added benefit to the nonoperative
compared nonoperative treatment in lateral epicondylitis.18 The treatments studied provide further confidence in the lack of
latter study found that injections did not improve patient-reported effectiveness in these treatment options.
outcomes. Our findings indicate that both pain and function were A strength of our review of nonoperative treatment of lateral
statistically worse in the CSI group. In contrast to the present study, epicondylitis is that it focused exclusively on RCTs to limit the risk
however, Kim et al reported that both physiotherapy and of bias. A further strength was the strict inclusion criteria. Only
electrophysiotherapy improved pain outcomes. One possible studies that compared physiotherapy with a strengthening
explanation for the difference in results may be related to the program compared with no active treatment were included. All
broader inclusion criteria by Kim et al in which studies were other physiotherapy modalities were excluded from the review,
included comparing extracorporeal shock wave therapy6 and which allows a clear interpretation of the treatment effect of
microcurrent therapy1 in the physiotherapy group, making strengthening alone. Similarly, only studies comparing CSI, PRP, and
interpretation of the results difficult. A systematic review by AB with a placebo control group were included, whereas previous

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systematic reviews included studies that comprised additional 7. Chesterton LS, Mallen CD, Hay EM. Management of tennis elbow. Open Access J
Sports Med 2011;2:53-9. https://doi.org/10.2147/OAJSM.S10310.
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8. Cohen J. Statistical power analysis for the behavioural sciences. Rev. ed. New
allocated treatment which may lead to confounding. The strict York: Academic Press; 1977.
inclusion criteria allowed us to confidently interpret the treatment 9. Collaboration TC. Rev Manager (Revman) [Computer program]. 2020. Cochran
effect of these individual modalities in isolation. Informatics and Technology Services (IT). Available at: https://training.
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included in the review; methodologic quality was not uniformly 10. Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid
high and design limitations were identified in most trials. The injection, physiotherapy, or both on clinical outcomes in patients with
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PRS.0000000000007440.
Conflicts of interest: The authors, their immediate families, and any 19. Lian J, Mohamadi A, Chan JJ, Hanna P, Hemmati D, Lechtig A, et al. Comparative
research foundations with which they are affiliated have not efficacy and safety of nonsurgical treatment options for enthesopathy of the
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randomized placebo-controlled trials. Am J Sports Med 2019;47:3019-29.
commercial entity related to the subject of this article.
https://doi.org/10.1177/0363546518801914.
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