Tennis Elbow Series (PART 2): Summary of the research

Loading (strengthening) – HIGH

As LE is a tendinopathy, loading the tendon is the most crucial part to its recovery to normal function. Dr. Peter Malliaras (tendon expert) states:   “We know that tendon is sensitive to load, this means that when you load it the cells sense this load and produce biochemical that lead to changes in the tendon, sometimes positive like homeostasis and adaptation, but also pathology changes under certain conditions (e.g. too much load too soon)”. (5)  

 

   

 

A review in 2016 stated that an exercise involving isometric contractions is more beneficial for LE than a contraction through range (2). This is due to the function of the elbow and often involving forceful grip activities (2). However, research suggests that the best analgesic effect is achieved through a combination of isometric and isotonic contractions – so an exercise involving contraction through range is also important.  

For videos of exercise examples to load your LE, go to Part 1 of my tennis elbow series HERE >>>

A loading program alone is rarely delivered as a treatment protocol in the management of LE. Strengthening exercises are also used in combination with a range of physiotherapy modalities namely soft tissue releases, rock-taping, bracing and extracorporeal shockwave therapy (ESWT).  

Extracorporeal Shockwave Therapy (ESWT) – MEDIUM-HIGH

ESWT for clients with lateral epicondylitis has been proven to be effective in multiple studies over many years. It is believed to be superior to other modalities due to its effectiveness in the short and long term, safety and non-invasiveness (3). ESWT also allows the client to continue with their usual working and daily lives and requires no rest period (3). 

A study in 2018 compared an ESWT group with a group that received NSAIDs, local topics, ultrasound and laser. The LE group receiving only ESWT had superior results when compared to the classical physical therapies in regards to pain, tendon thickness and function (18). The results are in table 1.

The research states that the ideal radial ESWT parameters to use on LE is 2000 shocks, at least 2 bar (or most energy tolerable to client) and to be used weekly (every 5-10 days) for 4-5 weeks (19).

Counterforce bracing – HIGH

The use of a counter-force or “tennis elbow” brace has been a popular modality used by clients and therapists for the past 40 years (8). Its mechanism of action is to divert some of the force placed on the wrist extensor origin to the padding of the brace. This, in theory, allows the tendon origin (that is sore and inflamed) to heal (8). The graphs below are from a comprehensive study published in 2019. They compared counter-force bracing with placebo bracing for acute LE over the course of 26 weeks.  

 

 

They concluded that the counterforce brace had significant reduction in clients frequency of pain and the severity of pain in the short term (2-12 weeks) (7). They also achieved significant improvement of overall elbow function at the 26 week mark, when compared to the group with the placebo brace (7).

Platelet-rich plasma (PRP) injection – HIGH

PRP injections use 5 times the amount of red blood cells when compared to normal blood (5). Through its concentrated red blood cells, it is hypothesised that this has a high content of growth factors that may be used as an effective healing agent (5).

Multiple studies have found a positive effect of PRP injections when used to treat LE. A study in 2011 found that chronic LE clients who received PRP had significant improvements regarding both pain and function with results exceeding the effects of corticosteroid injections even after the 2 year follow-up (17). Another study in 2015 showed PRP was a more effective treatment for chronic LE when compared to an autologous blood group (16).

These two studies are adjacent to a further study in 2016 that compared the short and long term effects of physiotherapy, ESWT, prolotherapy and PRP injections for those with a diagnosis of LE. All methods gained short term improvement (3 and 6 months) with the difference not being significant (14). However, at the 18 and 24 month marks, the PRP group had a significantly better DASH score compared to the physiotherapy and ESWT groups (14).

In 2015, researchers used 3 groups with chronic LE receiving either 1, 2 or 3 PRP injections (4 wk intervals). All groups gained significant pain relief and improvement of both function and quality of life 6 months post treatment – with no significant differences between frequency – indicating 1 injection may be sufficient (15).

Other studies have shown that PRP use for LE has short and long term improvement of tendon thickness and tendonosis on imaging (5). However, improvement on scans does not necessarily mean improvement in client’s function or outcomes.

Kinesio taping – MEDIUM-HIGH

Various studies have investigated the use of kinesio-taping (1) in reducing LE clients’ pain, grip strength and upper limb function. Mixed results have been achieved and with researchers believing the technique used, amount of tension and grip testing position having an effect (1). A study in 2017 used the diamond technique against sham taping (1). They achieved significant improvement in pain (VAS) and dash scores after 4 weeks (1, 6).

 

   

 

Another study on KT and LE gained pain relief via placebo, with another in 2016 achieving greater muscle strength of the wrist extensors when KT was applied (1, 6)

Corticosteroid Injection – MEDIUM-LOW

It has been demonstrated that corticosteroid injections can potentially improve pain and function of clients with LE in the short-term (4, 10). However, this benefit is not guaranteed and there remains little evidence for its effect in the long-term, with some researchers believing CS injections can delay resolution of LE and/or have permanent structural changes to the tendon (5, 11)

Dry Needling – MEDIUM

In 2017 a study compared the effects of dry needling vs ibuprofen and elbow bracing to improve pain and function of individuals with LE. The results showed that while both treatments had similar improvement at the 3 week mark – the dry needling group was more significantly effective for LE at the 6 month mark when compared to the other group (10).

Trigger points and myofascial release – MEDIUM

Im 2012, a study compared the effects of myofascial release against sham ultrasound therapy. They concluded that the myofascial group had significant improvements in pain and functional disability when compared to the control group (3). Results achieved at the 4 week follow up were more significant than the 12 week follow up – indicating that the effects of myofascial release are more prominent in the short term.

A further study in 2013 looked at myofascial release’s effect on clients with LE. It showed that both myofascial release and trigger point therapy reduce pain and improve function in LE clients (2).

Mobilisations and manipulations – MEDIUM

Treatments such as elbow mobilisations, neural mobilisations and manipulations of the elbow and/or neck have been shown to reduce pain and increase grip strength for the client in the short-term, however long-term clinical effects for manual therapy alone is of no significance (2,11).

 

For more information on LE or tennis eblow, visit part 1 of the Tennis Elbow Series HERE >>>. If youre experiencing elbow pain, it is important you get it looked at by a health professional. If you have any questions give us a call at POGO. Contact details are here>>>  

 

 

 

 

 

 

 

Alec Lablache POGO Physiotherapist

Featured in the Top 50 Physical Therapy Blog  

References

1. Cho, Y., Hsu, W., Lin, L., & Lin, Y. (2018). Kinesio taping reduces elbow pain during resisted wrist extension in patients with chronic lateral epicondylitis: A randomized, double-blinded, cross-over study. BMC Musculoskeletal Disorders, 19(1), 193-193. doi:10.1186/s12891-018-2118-3
2. Dimitrios, S. (2016). Lateral elbow tendinopathy: Evidence of physiotherapy management.World Journal of Orthopedics, 7(8), 463-466. doi:10.5312/wjo.v7.i8.463
3. Dobreci, D., & Dobrescu, T. (2014). The effects of extracorporeal shockwave therapy (ESWT) in treating lateral epicondylitis in people between 40 and 50 years old. Procedia – Social and Behavioral Sciences, 137, 32-36. doi:10.1016/j.sbspro.2014.05.248
4. Gialanella, B., & Prometti, P. (2011). Effects of corticosteroids injection in rotator cuff tears. Pain Medicine, 12(10), 1559-1565. doi:10.1111/j.1526-4637.2011.01238.x
5. Khattab, E. M., & Abowarda, M. H. (2017). Role of ultrasound guided platelet-rich plasma (PRP) injection in treatment of lateral epicondylitis. The Egyptian Journal of Radiology and Nuclear Medicine, 48(2), 403-413. doi:10.1016/j.ejrnm.2017.03.002
6. Kim, J. Y., & Kim, S. Y. (2016). Effects of kinesio tape compared with non-elastic tape on hand grip strength. Journal of Physical Therapy Science, 28(5), 1565-1568. doi:10.1589/jpts.28.1565
7. Kroslak, M., Pirapakaran, K., & Murrell, G. A. (2019). Counterforce bracing of lateral epicondylitis: A prospective, randomised, double blinded, placebo controlled clinical trial. Journal of Shoulder and Elbow Surgery, 28(8), e286-e287. doi:10.1016/j.jse.2019.04.030
8. Malliaras, P. (2016). What is the best way to load a pathological tendon. Tendinopathy Rehabilitation. Retrieved from: https://www.tendinopathyrehab.com/blog/tendinopathy-updates/what-is-the-best-way-to-load-pathological-tendon
9. Saccomanni, B. (2010). Corticosteroid injection for tennis elbow or lateral epicondylitis: A review of the literature. Current Reviews in Musculoskeletal Medicine, 3(1-4), 38-40. doi:10.1007/s12178-010-9066-3
10. Vicenzino, B., Cleland, J. A., & Bisset, L. (2007). Joint manipulation in the management of lateral epicondylalgia: A clinical commentary. Journal of Manual & Manipulative Therapy, 15(1), 50-56. doi:10.1179/106698107791090132
11. Wuori, J. L., Overend, T. J., Kramer, J. F., & MacDermid, J. (1998). Strength and pain measures associated with lateral epicondylitis bracing. Archives of Physical Medicine and Rehabilitation, 79(7), 832-837. doi:10.1016/S0003-9993(98)90366-5
12. Wuori, J. L., Overend, T. J., Kramer, J. F., & MacDermid, J. (1998). Strength and pain measures associated with lateral epicondylitis bracing. Archives of Physical Medicine and Rehabilitation, 79(7), 832-837. doi:10.1016/S0003-9993(98)90366-5
13. Ajimsha, M.S., Chithra, S., & Thulasyammal, R. P. (2012). Effectiveness of myofascial release in the management of lateral epicondylitis in computer professionals. Archives of Physical Medicine and Rehabilitation, 93(4), 604-609. doi:10.1016/j.apmr.2011.10.012
14. Lhee, S., Kim, J., Jeon, J., & Lee, D. (2016). prospective randomized clinical study for the treatment of lateral epicondylitis; comparison among prp (platelet-rich plasm), prolotherapy, physiotherapy and eswt. British Journal of Sports Medicine, 50(22), e4-e4. doi:10.1136/bjsports-2016-096952.10
15. Glanzmann, M. C., & Audigé, L. (2015). Platelet-rich plasma for chronic lateral epicondylitis: Is one injection sufficient? Archives of Orthopaedic and Trauma Surgery, 135(12), 1637-1645. doi:10.1007/s00402-015-2322-7
16. Thanasas, C., Papadimitriou, G., Charalambidis, C., Paraskevopoulos, I., & Papanikolaou, A. (2011). Platelet-rich plasma versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis: A randomized controlled clinical trial. The American Journal of Sports Medicine, 39(10), 2130-2134. doi:10.1177/0363546511417113
17. Gosens, T., Peerbooms, J., van Laar, W., & den Oudsten, B. L. (2011). Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: A double-blind randomized controlled trial with 2-year follow-up. The American Journal of Sports Medicine, 39(6), 1200-1208. doi:10.1177/0363546510397173
18. Rogoveanu, O. C., Mușetescu, A. E., Gofiță, C. E., & Trăistaru, M. R. (2018). The effectiveness of shockwave therapy in patients with lateral epicondylitis. Current Health Sciences Journal, 44(4), 368-373. doi:10.12865/CHSJ.44.04.08
19. Arıcan, M., Turhan, Y., & Karaduman, Z. O. (2019). Dose-related effect of radial extracorporeal shockwave therapy (rESWT) on lateral epicondylitis in active patients: A retrospective comparative study. Iranian Red Crescent Medical Journal, In Press(In Press) doi:10.5812/ircmj.90813 
20. The effects of KinesioTape on the treatment of lateral epicondylitis https://www.sciencedirect.com/science/article/abs/pii/S0894113017300054