Lateral Epicondyle Tendinopathy Toolkit: Summary of the Evidence

PURPOSE, SCOPE & DISCLAIMER: The purpose of this document is to provide physical therapists with a summary of the evidence for interventions commonly used to manage tendinopathy of the lateral epicondyle. This decision-making tool is evidence-informed and where there is insufficient evidence, expert-informed. It is not intended to replace the clinician’s clinical reasoning skills and inter-professional collaboration. ‘Acute’ refers primarily to symptoms of less than 3 months duration and ‘chronic’ to greater than 3 months. For studies which (1) included participants with symptoms that encompassed both acute and chronic stages or (2) did not clarify the duration of symptoms, the results have been reported within the ‘chronic’ stage.

Abbreviations

CAT = Critically Appraised Topic CS = Case Study LET = Lateral Epicondyle Tendinopathy
LLLT = Low Level Laser Therapy MA = Meta-Analysis MWM = Mobilization with Movement
NR = Narrative Review NSAID = Non-Steroidal Anti-Inflammatory Drug OS = Observational Study
RCT = Randomized Controlled Trial SR = Systematic Review SWT = Shock Wave Therapy
US = Ultrasound WALT = World Association of Laser Therapy


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


Explanation of Clinical Implications

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


Manual Therapy

Elbow Joint Mobilizations

Stage of pathology Acute Chronic
Clinical research evidence*

No

• 4 RCT
• 5 SR (21)
• 1 CAT (5)
• 1 wrist RCT

Published expert opinion

No

2 expert opinion narrative reviews

Take home message

There is no clinical evidence to support or refute the use of elbow mobilization in the acute stage.

There is a large amount of clinical evidence to support the use of elbow mobilizations for short term effects. There is a small amount of evidence that supports long-term effects.
There is a small amount of clinical evidence to support the use of radial head mobilization and neural tension techniques.
There is weak support for the use of wrist MWM.

Clinical implication

There is no direction provided by the literature on the use of elbow mobilization in the management of acute LET.

Strongly consider using MWM of the elbow as part of a multimodal treatment regime (manual therapy and exercise) in the treatment of chronic LET. The effects should be apparent within the first few treatments. (See Appendix B for details)
Consider using radial head mobilization and neural tension techniques.
Consider using MWM of the wrist as part of multimodal treatment regime.

Spinal Mobilization Techniques

Stage of pathology Acute Chronic
Clinical research evidence*

No

• 3 RCT
• 1 RCT pilot
• 1 chart review
• 1 case series

Published expert opinion

No

---

Take home message

There is no clinical evidence or expert opinion on the use of spinal mobilization for patients with acute LET.

There is clinical evidence to support the use of incorporating cervical and thoracic mobilizations into the treatment of LET. However, only 1 paper had follow up of ≥ 6/12 - the others report immediate or very short term responses.

Clinical implication

There is no direction provided by the literature on the use of spinal mobilization in the management of acute LET.

Consider using cervical mobilizations as part of a multimodal approach to treatment of chronic LET.
Consider using cervical and thoracic mobilization techniques in those with cervical and/or thoracic signs even if they do not report spinal symptoms, in addition to local treatment to the elbow. (See Appendix B for details)

Soft Tissue Techniques

Stage of pathology Acute Chronic
Clinical research evidence*

• 1 RCT

• 2 SR (7)
• 3 RCT

Published expert opinion

---

---

Take home message

There is weak clinical evidence to support the use of deep and superficial massage to achieve immediate pain relief.

Early SR found insufficient evidence to make recommendations. More recent SR found there is weak clinical evidence to support the use of soft tissue techniques, such as frictions.
There is a small amount of weak clinical evidence to support the use of soft tissue techniques in combination with other treatment modalities.

Note: some of the studies which examined the effect of frictions included the use of Mill’s manipulation.

Clinical implication

Consider using deep and superficial massage for immediate pain relieving effect in acute LET.

Consider using soft tissue techniques (deep transverse friction massage) as part of a multimodal treatment regime for chronic LET. (See Appendix B for details)


Exercise

Stage of pathology Acute Chronic
Clinical research evidence*

• 1 RCT

• 7 RCT
• 1 SR (3)
• 2 OS

Published expert opinion

---

---

Take home message

There is a small amount of clinical evidence to support the use of exercise in the acute stage.

There is a large amount of clinical evidence to support the use of exercise in the chronic stage. Eccentric exercise seems to be the most effective but almost all exercise studies showed improvement whether it was concentric, eccentric or isometric strengthening. Stretching was also found to be effective. Studies that instructed their subjects to exercise even with pain, as long as it wasn't debilitating, seemed to have better results.

Clinical implication

Consider using exercise in the management of acute LET.

Strongly consider using exercise in the chronic stage, especially eccentric exercise. (See Appendix C for details)
Consider instructing the patient to exercise even with mild pain as long as it is not disabling.


Acupuncture

Stage of pathology Acute Chronic
Clinical research evidence*

---

• 1 SR (6)

Published expert opinion

Yes

---

Take home message

There is a plausible physiological rationale (short-term pain reduction) to support the use of acupuncture for patients with acute LET.

There is weak but consistent clinical evidence to support the use of acupuncture for pain control in patients with chronic LET.

Clinical implication

May consider the use of acupuncture for short-term pain relief in patients with acute LET.

Consider the use of acupuncture for short-term pain relief in patients with chronic LET.


Low Level Laser Therapy (LLLT)

Stage of pathology Acute Chronic
Clinical research evidence*

• 1 RCT

• 6 SR (+/- MA) (16)
• 3 RCT
• 1 case report

Published expert opinion

---

---

Take home message

Laser at 905 nm may be effective when used in accordance with the WALT guidelines, when used in combination with exercise.

Laser at 904 nm and possibly 832 nm or 830 nm may be effective when used in accordance with the WALT guidelines, and particularly if used in combination with other treatments. The evidence in support of laser is stronger when only those studies that use an appropriate dose are included.

Clinical implication

Consider using laser (LLLT) at 905 nm with dosage as recommended by WALT guidelines. (See Appendix D for details)

Consider using laser (LLLT) at 904 nm with dosage as recommended by WALT guidelines. (See Appendix D for details)


Ultrasound (US)

Stage of pathology Acute Chronic
Clinical research evidence*

• 2 RCT

• 5 RCT
• 5 SR (13)
• 1 short-cut review

Published expert opinion

---

---

Take home message

Weak evidence for effectiveness of US in the management of acute LET. 1 MHz or 3 MHz, 0.5 – 1.0 W/cm2 5-10 minutes (pulsed 1:2-1:4 suggested).

Weak evidence for effectiveness of US in the management of chronic LET. 1 MHz or 3 MHz, 1.0 – 1.5 W/cm2 5-10 minutes (continuous suggested).

Clinical implication

Consider using US in the management of acute LET.

Consider using US in the management of chronic LET.


Extracorporeal Shock Wave Therapy (ESWT): Focused and Radial

Stage of pathology Acute Chronic
Clinical research evidence*

• 1 RCT

• 6 RCT
• 3 SR (8)
• 2 comparative studies

Published expert opinion

---

---

Take home message

Studies that have included subjects with a short period of lateral elbow pain (e.g., < 1 month) have not shown any benefit of SWT.

The benefits from SWT are dose-dependent. Most studies and reviews of high energy SWT (> 0.17 mJ/mm²) do not support SWT for lateral elbow pain compared to low energy SWT (< 0.15 mJ/mm²). Studies suggest that the use of anesthetic at the treatment site diminishes the effect of SWT. Studies also suggest that the delivery of focused or radial energy sources is equivalent. There is conflicting evidence for the use of low energy SWT for lateral elbow pain, and a need to create consistent protocols when comparing treatment outcomes. Qualitative reviews of low energy SWT with similar study designs support SWT. Systematic reviews that pool data in studies with dissimilar designs by meta-analysis do not support SWT for lateral elbow pain. An adequate follow-up time >3 months is recommended to measure the benefit of SWT.

Clinical implication

Consider NOT using SWT for acute stage. SWT in early onset of symptoms does not improve lateral elbow pain.

Consider using low energy SWT for subjects that have failed to respond to other conservative treatment; however, the patient should be informed that SWT is experimental.

Recommended dosage:
• Low energy SWT (focused or radial) <0.1.5 mJ/mm²
• 2,000 shocks
• 3 sessions, weekly intervals


Iontophoresis Using Dexamethasone

Stage of pathology Acute Chronic
Clinical research evidence*

• 1 RCT

• 1 RCT
• 1 comparative study

Published expert opinion

---

---

Take home message

A small amount of evidence supports the delivery of corticosteroid (Dexamethasone) by iontophoresis to treat acute lateral elbow pain for short term pain reduction, allowing the subject to participate in an earlier increase in exercise activity or return to work. Iontophoresis may have advantages over injection (less pain, decreased trophic changes in tissue), but may not be as cost effective.

Application of iontophoresis with Dexamethasone for degenerative lateral elbow tendon pain has no long term benefit and may be no better than placebo.
Studies comparing the delivery of corticosteroids for lateral elbow pain by iontophoresis or by injection have similar outcomes. In general, corticosteroids for chronic lateral elbow tendinopathy are not supported in the literature. (See Appendix C - Medical Interventions - corticosteroids)

Clinical implication

Consider a trial of iontophoresis with Dexamethasone for short-term pain control for acute LET.

Recommended dosage:
• 0.4% Dexamethasone Sodium Phosphate (aqueous)
• 40-80 mA-min
• 4-6 sessions, alternate days

Physician prescription required

Consider NOT using iontophoresis with Dexamethasone for the treatment of chronic LET.


Iontophoresis Using NSAID or Lidocaine

Stage of pathology Acute Chronic
Clinical research evidence*

• 2 comparative studies
• 1 experimental study

---

Published expert opinion

---

Yes

Take home message

There is a small amount of weak evidence to support the delivery of NSAID (Diclofenac, Salicylate, Naproxen) or local analgesic (Lidocaine) by means of iontophoresis for LET. Studies demonstrate short term benefit in pain management, which may be beneficial in early stages of treatment. No long term benefit is proven. Studies generally are designed with other concurrent treatment, so that the effects of iontophoresis of these drugs are inconclusive. In addition, studies of iontophoresis using NSAID involved a high number of treatments.

The studies using iontophoresis to deliver NSAID or Lidocaine do not adequately differentiate acute versus chronic conditions of LET. The physiological rationale for using NSAID may be applicable in the acute phase, but inflammatory cells are not considered part of the pathology in chronic LET.

Clinical implication

May consider a trial of iontophoresis with NSAIDs or Lidocaine for short term pain control for acute LET.

Physician prescription required.

Gel forms of NSAIDS should not be used for iontophoresis.


May consider a trial of iontophoresis with NSAID’s or Lidocaine for the treatment of chronic LET for short term pain control.

Physician prescription required.

Gel forms of NSAIDS should not be used for iontophoresis.


Orthotic Devices

Stage of pathology Acute Chronic
Clinical research evidence*

• 3 RCT

• 2 SR (7)
• 4 RCT

Published expert opinion

---

---

Take home message

There is some clinical evidence to support the use of splinting for pain relief for patients with acute LET.

There is some clinical evidence and expert advice to support the use of a counterforce brace in patients with chronic LET.

Clinical implication

Consider the use of splinting for patients with acute LET.

Consider the use of a counterforce brace for patients with chronic LET. (See Appendix E for details)


Taping

Stage of pathology Acute Chronic
Clinical research evidence*

No

• 2 experimental studies

Published expert opinion

No

• 1 narrative review

Take home message

There is no clinical evidence or expert opinion on the use of taping for patients with acute LET.

There is a plausible physiological rationale to support the use of taping for patients with chronic LET.

Clinical implication

There is no direction provided by the literature on the use of taping in the management of acute LET.

May consider a trial of taping for patients with chronic LET.


Relevant Outcome Measures

See Appendix F for details.

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


Performance based impairment measures such as:

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


Pain rating outcome measures such as:

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


Self-report questionnaires such as:


Download Lateral Epicondyle Tendinopathy Toolkit: Summary of the Evidence

http://physicaltherapy.med.ubc.ca/files/2013/07/Lateral-Epicondyle-Tendinopathy-Summary-of-the-Evidence-June-2013.pdf


Acknowledgements

Developed by the BC Physical Therapy Tendinopathy Task Force: Dr. Joseph Anthony, Dr. Angela Fearon, Diana Hughes, Carol Kennedy, Dr. Alex Scott, Michael Yates, & Alison Hoens.

A Physical Therapy Knowledge Broker project supported by: UBC Department of Physical Therapy, Physiotherapy Association of BC, Vancouver Coastal Research Institute and Providence Healthcare Research Institute.

June 2013


References by Topic

Manual Therapy

Elbow Joint Mobilizations

  1. Vicenzino, B. et al. Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia. Manual Therapy. Nov 2001; 6(4): 205-212.
  2. Kochar M and Dogra A. Effectiveness of a specific physiotherapy regimen on patients with tennis elbow: Clinical study. Physiotherapy, 2002;88(6): 333-341.
  3. Paungmali, A et al. Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Physical Therapy. Apr 2003; 83(4): 374-383.
  4. Bisset L, Paungmali A, Vicenzino B, Beller, E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine. 2005; 39: 411-422.
  5. Bisset L. et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomized trial. British Medical Journal. Nov 4, 2006; 333(7575): 939-941.
  6. Vicenzino B, Teys PA. Mulligan's mobilization-with-movement, positional faults and pain relief: Current concepts from a critical review of literature. Manual Therapy. 2007; (12): 98-108.
  7. Barr S, Cerisola F, Blanchard V. Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: A systematic review. Physiotherapy. Dec 2009; 95(4): 251-265.
  8. Pagorek S. Effect of manual mobilization with movement on pain and strength in adults with chronic lateral epicondylitis. Journal of Sport Rehabilitation. 2009; 18(3): 448-457.
  9. Bisset L, Coombes B, Vicenzino B. Tennis elbow. Clinical Evidence. June 27: 2011. Doi.pii:1117
  10. Trudel D, et al. Rehabilitation for patients with lateral epicondylitis: a systematic review. Journal of Hand Therapy. 2004; 17(2): 243-266.

Spinal Mobilization Techniques

  1. Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain. Nov 1996; 68(1): 69-74.
  2. Cleland JA, Whitman JM, Fritz, JM. Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis (including commentary by Vicenzino B.) Journal of Orthopaedic & Sports Physical Therapy. 2004; 34(11): 713-724.
  3. Cleland JA, Flynn TW, Palmer JA. Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: a pilot clinical trial. Journal of Manual & Manipulative Therapy. 2005; 13(3): 143-151.
  4. Fernandez-Carnero J, Fernandez-De-Las-Penas C, et al. Immediate hypoalgesic and motor effects after a single cervical manipulation in subjects with lateral epicondylalgia. Journal of Manual & Manipulative Therapy. 2008; 31(9): 675-681.
  5. Fernandez-Carnero J, Cleland A. Examination of motor and hypoalgesic effects of cervical vs. thoracic spine manipulation in patients with lateral epicondylalgia: A clinical trial. Journal of Manual & Manipulative Therapy. 2011; 34(7): 432-440.

Soft Tissue Techniques

  1. Verhaar JAN, et al. Local corticosteroid injection versus cyriax-type physiotherapy for tennis elbow. Journal of Bone and Joint Surgery. Jan 1996; British 78B(1): 128-132.
  2. Brosseau L, Casimiro L, Milne S, et al. Deep transverse friction Tendinitis massage for treating tendinitis. Cochrane Database Syst 2002; Rev. 4.
  3. Law LAF, et al. Massage reduces pain perception and hyperalgesia in experimental muscle pain: A randomized, controlled trial. Journal of Pain. Aug 2008; 9(8): 714-721.
  4. Nagrale, A. et al. Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia [sic]. Journal of Manual and Manipulative Therapy. 2009; 17(3): 171-178.
  5. Joseph M, Taft J, et al. Deep friction massage for the treatment of tendinopathy: A systematic review of a classic treatment in the face of a new paradigm of understanding. Journal of Sports Rehabilitation. 2012; 21: 343-353.
  6. Viswas R, Ramachandran R, Korde Anantkumar P. Comparison of effectiveness of supervised exercise program and cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial. The Scientific World Journal. 2012. Volume 2012, Article ID 939645, 8 pages doi:10.1100/2012/939645
  7. Ajimsha, MS, Chithra, S, Thulasyammal, RP. Effectiveness of Myofascial Release in the Management of Lateral Epicondylitis in Computer Professionals. Archives of Physical Medicine & Rehabilitation. 2012; 93(4): 604-609.

Wrist MWM

  1. Struijs, PAA, et al. Manipulation of the wrist for management of lateral epicondylitis: A randomized pilot study. Physical Therapy. July 2003; 83(7): 608-616.

Systematic Reviews/Meta-Analyses Evaluating Various Interventions and Regions

  1. Smidt N. et al. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Annals of Medicine. 2003; 35(1): 51-62.
  2. Bisset L. et al. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine. July 1, 2005; 39(7): 411-422.
  3. Herd CR, Meserve BB. A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia. Journal of Manual & Manipulative Therapy. 2008; 16(4): 225-237.
  4. Gonzalez-Iglesisa J, et al. Multimodal management of lateral epicondylalgia in rock climbers: A prospective case series. Journal of Manipulative & Physiological Therapeutics. 2011; 34(9): 635-642.

Exercise

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

Acupuncture

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

Low Level Laser Therapy (LLLT)

  1. Bisset L, Coombes B, & Vicenzino B. Tennis elbow. Clinical Evidence. 2011; 1-35.
  2. Chang W-D, Wu J-H, Yang W-J, & Jiang J-A. Therapeutic effects of low-level laser on lateral epicondylitis from differential interventions of Chinese-Western medicine: systematic review. Photomedicine and Laser Surgery. 2010; 28(3): 327-336. doi: 10.1089/pho.2009.2558
  3. Tumilty S, Munn J, McDonough S, Hurley D A, Basford J R, & Baxter G D. Low level laser treatment of tendinopathy: a systematic review with meta-analysis. Photomedicine and Laser Surgery. 2010; 28(1): 3-16. doi:10.1089/pho.2008.2470
  4. Bjordal J M, Lopes-Martins R A B, Joense J, Couppe C, Ljunggren A E, Stergioulas A, & Johnson M I. A systematic review with procedural assessments and meta-analysis of Low
  5. Level Laser Therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskeletal Disorders. 2008; 9(75). doi:10.1186/1471-2474-9-75.
  6. Bisset L, Paungmali A, Vicenzino B, & Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine. 2005; 39(7): 411-22.
  7. Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC. Rehabilitation for Patients with Lateral Epicondylitis. Journal of Hand Therapy. 2004; 17: 243-266. doi:10.1197/j.jht.2004.02.011
  8. Skorupska E, Lisinski P, & Samborski W. The effectiveness of the conservative versus myofascial pain physiotherapy in tennis elbow patients: Double-blind randomized trial of 80 patients. Journal of Musculoskeletal Pain. 2012; 20(1): 41-50. doi: 10.3109/10582452.2011.635846
  9. Emanet S K, Altan L I, & Yurtkuran M. Investigation of the effect of GaAs laser therapy on lateral epicondylitis. Photomedicine and Laser Surgery. 2010; 28(3): 397-403. doi:10.1089/pho.2009.2555
  10. Stasinopoulos D, Stasinopoulos I, Pantelis M, & Stasinopoulou K. Comparing the effects of exercise program and low-level laser therapy with exercise program and polarized polychromatic non-coherent light (bioptron light) on the treatment of lateral elbow tendinopathy. Photomedicine and Laser Surgery. 2009; 27(3): 513-520. doi: 10.1089/pho.2008.2281
  11. Oken O, Kahraman Y, Ayhan F, Canpolat S, Yorgancioglu Z R, & Oken O F. The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: A prospective, randomized, controlled trial. Journal of Hand Therapy. 2008; 21(1): 63-68. doi:10.1197/j.jht.2007.09.003
  12. Lam L K Y, & Cheing G L. Effects of 904-nm low-level laser therapy in the management of lateral epicondylitis: a randomized controlled trial. Photomedicine and Laser Surgery. 2007; 25(2): 65-71. doi:10.1089/pho.2006.2047
  13. Stergioulas A. Effects of low-level laser and plyometric exercises in the treatment of lateral epicondylitis. Photomedicine and Laser Surgery. 2007; 25(3): 205-213. doi:10.1089/pho.2007.2041
  14. Basford J R, Sheffield C G, & Cieslak K R. Laser therapy: a randomized, controlled trial of the effects of low intensity Nd:YAG laser irradiation on lateral epicondylitis. Archives of Physical Medicine & Rehabilitation. 2000; 81(11): 1504-1510. doi:10.1053/apmr.2000.17812

Ultrasound (US)

  1. Gunduz R, Malas F U, Borman P, Kocaoglu S, & Ozcakar L. Physical therapy, corticosteroid injection, and extracorporeal shock wave treatment in lateral epicondylitis. Clinical and ultrasonographical comparison. Clinical Rheumatology. 2012; 31(5): 807-812. doi:10.1007/s10067-012-1939-y
  2. Skorupska E, Lisinski P, & Samborski W. The effectiveness of the conservative versus myofascial pain physiotherapy in tennis elbow patients: Double-blind randomized trial of 80 patients. Journal of Musculoskeletal Pain. 2012; 20(1): 41-50. doi: 10.3109/10582452.2011.635846
  3. Akin C, Oken O, & Fusun Koseoglu B. Short-term effectiveness of ultrasound treatment in patients with lateral epicondylitis: Randomized, single-blind, placebo-controlled, prospective study. [Turkish]
  4. Lateral epikondilitli hastalarda ultrason tedavisinin ki{dotless}sa donem etkinligi: Randomize, tek kor plasebo kontrollu, prospektif callsma. Turkish Journal of Rheumatology. 2010; 25(2): 50-55.doi:10.5152/tjr.2010.01
  5. Oken O, Kahraman Y, Ayhan F, Canpolat S, Yorgancioglu Z R, & Oken O F. The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: A prospective, randomized, controlled trial. Journal of Hand Therapy. 2008; 21(1): 63-68. doi:10.1197/j.jht.2007.09.003
  6. Struijs P A, Damen P J, Bakker E W, Blankevoort L, Assendelft W J, & van Dijk C N. Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study. Physical Therapy. 2003; 83(7): 608-616.
  7. Kochar M, & Dogra A. Effectiveness of a specific physiotherapy regimen on patients with tennis elbow: Clinical study. Physiotherapy. 2002; 88(6): 333-341.
  8. Stratford PW, Levy DR, Gauldie S, Miseferi D, Levy K. The evaluation of phonophoresis and friction massage as treatments for extensor carpi radialis tendinitis: a randomized controlled trial. Physiotherapy Canada. 1989; (41): 93-9.
  9. Lundeberg T, Abrahamsson P, & Haker E. A comparative study of continuous ultrasound, placebo ultrasound and rest in epicondylalgia. Scandinavian Journal of Rehabilitation Medicine. 1988.
  10. Binder A, Hodge G, Greenwood A M, Hazleman B L, & Thomas D P Page. Is therapeutic ultrasound effective in treating soft tissue lesions? British Medical Journal. 1985.
  11. Ruane H, Hay L, & Callaghan M. Best Evidence Topic report. BET 2. Is electrotherapy useful for tennis elbow? Emergency Medicine Journal. 2010; 27(2): 142-144.
  12. Nimgade A, Sullivan M, & Goldman R. Physiotherapy, steroid injections, or rest for lateral epicondylosis? What the evidence suggests. Pain Practice. 2005; 5(3): 203-215.
  13. Bisset L, Paungmali A, Vicenzino B, & Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine. 2005; 39(7): 411-22. doi: 10.1136/bjsm.2004.016170
  14. Boisaubert B, Brousse C, Zaoui A, & Montigny J P. Nonsurgical treatment of tennis elbow. [French]
  15. Les traitements non chirurgicaux de la tendinopathie des epicondyliens. Annales de Readaptation et de Medecine Physique. 2004; 47(6): 346-355. doi:10.1016/j.annrmp.2004.05.002
  16. Trudel D, Duley J, Zastrow I, Kerr E W, Davidson R, & MacDermid J C. Rehabilitation for patients with lateral epicondylitis: a systematic review. Journal of Hand Therapy. 2004; 17(2): 243-266. doi:10.1197/j.jht.2004.02.011
  17. Smidt N, Assendelft W J J, Arola H, Malmivaara A, Greens S, Buchbinder R, et al. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Annals of Medicine. 2003; 35(1): 51-62.

Extracorporeal Shock Wave Therapy (ESWT)

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

Iontophoresis Using Dexamethasone

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

Iontophoresis Using NSAID or Lidocaine

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

Orthotic Devices

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

Taping

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