Hay EM, Trudel D, NSAID = nonsteroidal anti-inflammatory drug. Assendelft WJ, Therapeutic ultrasound: its effects on the cellular and molecular mechanisms of inflammation and repair. Zastrow I, Cleveland Clinic is a non-profit academic medical center. de Winter AF, Walenkamp GH, To see the full article, log in or purchase access. The median follow-up period was only two weeks, and long-term outcomes were not reported. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. Although watchful waiting is a viable option, systematic reviews, meta-analyses, and randomized controlled trials (RCTs) have evaluated the effectiveness of other treatment options such as oral, topical, and injectable medications; physical therapy; and surgery. Smidt N, Arola H, There are numerous treatment options, but no one single treatment is completely effective. 2001;(4):CD003686. Lateral Epicondylitis Treatment With your lateral epicondylitis tests results, your doctor will decide the proper treatments options for you. 1996;77:586–93. / Journals Milne S, Buchbinder R, Treatment of Lateral Epicondylitis. Ultrasound therapy for musculoskeletal disorders: a systematic review. 7. Am Fam Physician. Smidt N, An inelastic, non-articular, proximal forearm strap may be considered. O'Connor FG, Patient information: See related handouts on tennis elbow and exercises for tennis elbow, written by the authors of this article. Physical therapy regimens, including strength training and stretching, are commonly used to treat lateral epicondylitis. The efficacy of splinting for lateral epicondylitis: a systematic review. Surgery for lateral elbow pain. Results of the program, as reflected in … Wrist lift, palm up. 2000;61:691–700. Tennis Elbow Time Out. This content is owned by the AAFP. Data do not support the use of extracorporeal shock wave therapy for the treatment of lateral epicondylitis. Proceedings (Baylor University Medical Center). Corticosteroid injections for lateral epicondylitis: a systematic review. Topical nonsteroidal anti-inflammatory drugs, corticosteroid injections, ultrasonography, and iontophoresis with nonsteroidal anti-inflammatory drugs appear to provide short-term benefits. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Haines AT. Fess EE. Electrotherapeutic modalities, including electromagnetic field therapy and iontophoresis, are also often employed to treat lateral epicondylitis. 29. Duley J, A study in 2008 by Altan and Kanat compared treating 50 individuals with symptoms of lateral epicondylitis for less than 12 months with either a typical counterforce forearm brace versus treatment with a 10-15° dorsiflexion wrist splint. Wong LK. 2004;32:462–9. Verhaar JA, Case series have suggested favorable outcomes with few adverse effects.31 Despite these conclusions, no RCTs have been performed.7,31. Paterson SM, Robinson V, Tennis elbow. Bouter LM. Advertising on our site helps support our mission. Buchbinder R, A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. Croft P. 2004;43:1085–90. Kester AD, In non-athletes, elimination of activities that are painful is key to improvement (eg., repetitive valve … Information from references 15 and 19 through 22. Poon DW, Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Local corticosteroid injection versus Cyriax-type physiotherapy for tennis elbow. Corticosteroid injections for lateral epicondylitis: a systematic overview. Experts recommend doing it for 20 to 30 minutes every 3 to 4 hours for 2 to 3 days or until the pain is gone. Assendelft WJ, Borkholder CD, 2002;(1):CD003525. Tennis elbow (lateral epicondylitis) is a painful condition that occurs when tendons in your elbow are overloaded, usually by repetitive motions of the wrist and arm.Despite its name, athletes aren't the only people who develop tennis elbow. Allander E. Phillips SD, Shea B, Treatment; Prevention; Tennis elbow is a condition that causes pain around the outside of the elbow. Cochrane Database Syst Rev. Green S, For the minority of people with lateral epicondylitis who do not respond to nonoperative treatment, surgical intervention is an option, but confusion exists because of the plethora of options. Struijs PA, A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Bouter LM. Boddeker I, Evidence is mixed on oral nonsteroidal anti-inflammatory drugs, mobilization, and acupuncture. Davidson R, Casimiro L, Trudel D, Kester AD, We do not endorse non-Cleveland Clinic products or services. A lot of the advice you’ll find online for tennis elbow pain is a swing and a miss. 1998;280:1518–24. We do not endorse non-Cleveland Clinic products or services. Hughes PJ, Symptoms are usually reproduced with resisted supination or wrist dorsiflexion, particularly with the arm in full extension. Barnsley L, Assendelft WJ, Korthalsde Bos IB, Local corticosteroid injection has short-term (two to six weeks) benefits in pain reduction, global improvement, and grip strength compared with placebo and other conservative treatments.7–9 However, these benefits do not persist beyond six weeks. Evidence does not support the use of laser therapy for the treatment of lateral epicondylitis. CORONAVIRUS: DELAYS FOR ROUTINE SURGERIES, VISITOR RESTRICTIONS + COVID-19 TESTING. Assendelft WJ. Hosie G, Adshead R, Reprints are not available from the authors. 2005;39:411–22. Assendelft WJ, Assendelft WJ. Assendelft WJ, Barnsley L, Trail IA, At six months, 81 percent of treated patients were asymptomatic during activities of daily living.30, Surgery is often recommended when conservative strategies fail to relieve lateral epicondylitis symptoms after six to 12 months. Yu E, Van Dijk CN. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Buchbinder R, Tennis elbow is also called lateral epicondylitis. Struijs P, Lewis M, Beller E. Evidence is conflicting on the use of oral NSAIDs for lateral epicondylitis. Rehabilitation for patients with lateral epicondylitis: a systematic review. Acupuncture. 26. One RCT suggests that topical nitrate patches may be effective in patients with lateral epicondylitis, but confirmatory studies are needed. Address correspondence to Greg. Arola H, Borkholder CD, . Despite the prevalence of lateral epicondylitis and the numerous treatment strategies available, relatively few high-quality clinical trials support many of these treatment options; watchful waiting is a reasonable option. Braces/Splints/Straps- No clear evidence 1. Hui AC, Cole DC, The majority of cases respond to … Nirschl RP. Recent review articles have addressed the use of patient history, differential diagnosis, and physical examination in the diagnosis of lateral epicondylitis.3,4. Dijk CN, Exercises often help too. Bouter LM. Haines AT. Trinh KV, 2003;35:51–62. Although a systematic review found that the therapy was beneficial, the review included 19 case series and only one RCT.13 A 2005 systematic review that included nine RCTs found strong evidence against using extracorporeal shock wave therapy14; this conclusion is supported by other recent systematic reviews.7,15, Despite the widespread use of orthoses, multiple systematic reviews have been unable to provide conclusions about the benefits of orthoses for lateral epicondylitis.7,10,15 Use of an inelastic, nonarticular, proximal forearm strap (Figure 1) may decrease pain and increase grip strength after three weeks.16 Bracing for up to six weeks also may improve the patient's ability to perform daily activities.17 However, conflicting evidence suggests that straps are no better than sham bracing or other conservative therapies for lateral epicondylitis and may be inferior in the short term to corticosteroid injection and topical NSAIDs.15,18 Outcomes do not change significantly when an orthosis is used as an adjunct to physical therapy, ultrasonography, or corticosteroid injection.17,18. 16. Frostick SP, The RCT of 86 patients compared a nitroglycerin transdermal patch with a placebo patch. One RCT found that at one year a watchful-waiting approach was comparable with physical therapy and superior to corticosteroid injection in alleviating a patient's main complaint.5 Patients in the watchful-waiting group visited their primary care physician once during the six-week intervention period.5 Avoidance of aggravating activities and practical solutions were recommended. 6(September 15, 2007) Tennis elbow sometimes gets better on its own, but … Autologous blood injections for refractory lateral epicondylitis. Treatment of tennis elbow can be a frustration for people with this condition, but understand why this occurs and what you can do about it will help to r… Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. 1996;78:128–32. Struijs PA, Use of an inelastic, nonarticular, proximal forearm strap (tennis elbow brace) may improve function during daily activities. Tong PY, A study showed that, compared with an orthosis (i.e., an inelastic, nonarticular, proximal forearm strap [tennis elbow brace]), injection decreased pain at two weeks, but patient-perceived outcomes were no different at six months.10 Several studies found that oral NSAIDs and physiotherapy have greater benefits than corticosteroid injection at intermediate-term follow-up (greater than six weeks) and long-term follow-up (greater than six months), respectively.5,11,12 Studies comparing various corticosteroid injections found no clinically significant differences.8,9 Although corticosteroid injections are effective in the short-term, their long-term effectiveness and advantages over other conservative treatments are uncertain. J Bone Joint Surg Br. Autologous blood injections for refractory lateral epicondylitis. van der Windt DA, An inelastic, nonarticular, proximal forearm strap (tennis elbow brace) for patients with lateral epicondylitis. Vicenzino B, 2002;(1):CD001821. Am J Sports Med. Tennis elbow, also known as lateral epicondylitis, is a condition in which the outer part of the elbow becomes painful and tender. Smidt N, Tennis elbow. Zastrow I, Nelson J, The following interventions are probably helpful for lateral epicondylitis: watchful waiting, short-term topical NSAIDs, corticosteroid injection (short-term relief), exercise regimens, NSAID iontophoresis, ultrasonography. One case series, including 29 patients who had failed other conservative modalities, reported a 79 percent improvement in pain scores over an average of 9.5 months; some patients required multiple injections.27 However, clinical trials that include a comparison group receiving placebo injections are lacking, and until these trials are completed, autologous blood injections cannot be recommended. Youd JM, 2004;17:243–66. 1999;81:257–71. Paungmali A, Buchbinder R, It is due to excessive use of the muscles of the back of the forearm. 1992;78:421–6. W. Johnson, MD, Idaho Family Physicians, 130 E. Boise Ave., Boise, ID 83706 (e-mail:greg.johnson@fmridaho.org). Assendelft WJ, Contact Walenkamp GH, Acupuncture for lateral elbow pain. It is sometimes called tennis elbow, although it can occur with many activities. Calandruccio JH. Barnsley L, Bisset L, Conservative treatment of lateral epicondylitis: brace versus physical therapy or a combination of both—a randomized clinical trial. Bouter LM. Cochrane Database Syst Rev. Dijk CN, Hay EM, Orthotic devices for tennis elbow: a systematic review. Green S, Evaluation of overuse elbow injuries. Golfer's elbow is a similar condition that affects the inside of the elbow. et al. 2002;96:23–40. Types of treatment that help are: Icing the elbow to reduce pain and swelling. If symptoms persist, physical therapy, including ultrasonography, or NSAID iontophoresis may be appropriate. Surgery for lateral elbow pain. Smidt N. 2003;28:272–8. Dr. Scheffel completed the Family Medicine Residency of Idaho program and its Primary Care Sports Medicine Fellowship program. O'Connor FG, Vicenzino B, Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Deep transverse friction massage for treating tendinitis. Buchbinder R, 22. Fess EE. The condition usually happens due to over use of the forearm muscles and results in pain of the outside elbow. Assendelft WJ, Tugwell P, Three studies have shown pain reduction and improvement in subjective function with NSAID iontophoresis (using diclofenac or pirprofen [not available in the United States]) after two to four weeks.15,20 There is no good evidence supporting the use of corticosteroid iontophoresis.15,20 One meta-analysis and one systematic review found limited evidence against the use of electromagnetic field therapy.5,20, Ultrasonography is thought to have thermal and mechanical effects on the target tissue leading to increased metabolism, circulation, extensibility of connective tissue, and tissue regeneration.23 The best available data suggest that ultrasonography provides modest pain reduction over one to three months.15,19–21 Exercise appears to be more effective than ultrasonography for pain relief.15,19 Combining ultrasonography with deep transverse friction massage or corticosteroids is no better than ultrasonography alone.15,22, Deep transverse friction massage is thought to realign abnormal collagen fiber structure, break up adhesions and scar tissue, and increase healing with hyperemia.22 There is insufficient evidence to form conclusions about deep transverse friction massage for the treatment of lateral epicondylitis.22, A consensus statement from the National Institutes of Health states that study results are promising enough to consider acupuncture as an appropriate option for the treatment of lateral epicondylitis.24 However, conflicting evidence exists, and recommendations for or against this therapy cannot be made. Kerr EW, Haake M. Lancet. White M, TED D. EPPERLY, MD, is chairman and program director of the Family Medicine Residency of Idaho and is a clinical professor at the University of Washington School of Medicine. Don’t waste time overstretching, which could cause more damage. Br J Gen Pract. Stanley JK. Nirschl RP. White M, General physiotherapy management includes: 1. Barnsley L, 19. In two studies, slow-release diclofenac (Voltaren), 150 mg daily, significantly improved short-term pain and function.6,7 However, there was no difference in pain between naproxen (Naprosyn), 500 mg daily, and placebo.6,7 Patients receiving corticosteroid injections showed greater perception of benefit at four weeks than patients receiving oral NSAIDs, but this benefit did not persist in the longer term.6,7. Inflammation, redness, warmth, swelling, tenderness, and decreased range of motion are other symptoms associated with elbow pain. 9. / Assendelft W, J Hand Surg. van der Heijden GJ, Appleyard RC, Am Fam Physician. Smidt N, Hill VA, Onset of symptoms is generally gradual. Paoloni JA, MacDermid JC. Bouter LM. 11. Last reviewed by a Cleveland Clinic medical professional on 07/10/2016. Don't miss a single issue. Tennis elbow is a pain focused on the outside of your arm, where your forearm meets your elbow. Patients received acetaminophen or a non-steroidal anti-inflammatory drug (NSAID), if necessary, although they were encouraged to wait for spontaneous improvement.5. Wilson JJ, Brosseau L, A recent systematic review found that laser therapy had no effect on pain at six weeks; longer-term results were conflicting.19 Pooled data from six studies on short- and long-term outcomes show no difference between laser therapy and placebo.15 These results are reinforced by another systematic review that found evidence against the use of laser therapy alone or in conjunction with other conservative modalities.20, Table 1 summarizes the physical therapy modalities that are effective for the treatment of lateral epicondylitis.15,19–22, Studies that showed benefits used diclofenac (Solaraze) or pirprofen (not available in the United States), Stretching and strengthening exercises15,19,20, One or more times daily, three days a week, A single instructive session followed by an in-home regimen may suffice; the regimen should focus on eccentric instead of concentric phases, Four to six weeks (eight to 18 treatments), Augmentation with corticosteroids or deep tissue massage provides no additional benefit; ultrasonography is less effective than exercise. Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial. GREG W. JOHNSON, MD, is in private practice in Boise, Ida., and is a community faculty member for the Family Medicine Residency of Idaho, Boise. Shock wave therapy for lateral elbow pain. It's clinically known as lateral epicondylitis. Green S, Cochrane Database Syst Rev. If untreated, lateral epicondylitis persists for an average of six to 24 months.2. van den Berg SG, Haake M. Topical NSAIDs may provide short-term pain relief.6,7 Three studies have examined the effects of diclofenac (Solaraze) and benzydamine (not available in the United States) for up to three weeks. 4. Botulinum toxin type A (Botox) is thought to facilitate healing by temporarily paralyzing the common extensor origin.28,29 Two small RCTs are available but have conflicting results.28,29 One of these studies found that botulinum toxin type A injection decreases pain scores at four and 12 weeks compared with saline injection28; however, the second study found no difference between the two therapies in pain, quality of life, or grip strength at 12 weeks.29 More data are needed before botulinum toxin type A injection can be recommended to treat lateral epicondylitis. Short-term oral NSAIDs, strap, topical nitrates, acupuncture, botulinum toxin type A injection: B. Wong SM, American Society for Surgery of the Hand. Hall S, Manual therapy- Mulligan - Mobilisation with movement 1. Am Fam Physician. Less contemporary strategies, including topical nitroglycerin and acupuncture, may also be considered. van der Windt DA, Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Green SE, The surgical techniques for treating lateral epicondylitis can be grouped into three main categories: open, percutaneous, … Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Education/Advice- on pain control and/or modification of activities 1. This treatment may be needed for severe or prolonged symptoms. Barnsley L, Barnsley L, Orthotic devices for tennis elbow: a systematic review. Br J Sports Med. He received his medical degree from the University of Washington School of Medicine, Seattle. Hay EM, Stanley JK. SCOT B. SCHEFFEL, MD, is director of the Family Medicine Residency of Idaho's Primary Care Sports Medicine Fellowship. van der Windt DA, van der Windt DA, Want to use this article elsewhere? Animal studies suggest that nitric oxide stimulates collagen synthesis by wound fibroblasts and, therefore, may play a role in healing extensor tendons. Smidt N. Trail IA, Lateral epicondylitis is considered an overuse injury occurring in the lateral side of the elbow region which can become extremely painful. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Algorithm for the treatment of lateral epicondylitis. Adshead R, This paper describes the structured treatment program for lateral epicondylitis developed at the Michigan Hand Rehabilitation Center in Warren, Michigan. afpserv@aafp.org for copyright questions and/or permission requests. Smidt N. 28. Arola H, Information from references 15 and 19 through 21. Buchbinder R, Most procedures excise abnormal tissue within the origin of the extensor carpi radialis brevis tendon at the lateral epicondyle or release the tendon altogether. et al. Kerkhoffs GM, Kerr EW, van der Linden AJ. A double-blind, randomized, controlled, pilot study. Smidt N, Bouter LM. Arola H, van den Berg SG, Deep transverse friction massage for treating tendinitis. Lateral epicondylitis presents as a history of occupation- or activity-related pain at the lateral elbow. The following interventions are possibly helpful: short-term oral NSAIDs; inelastic, nonarticular, proximal forearm strap (tennis elbow brace); topical nitrates; acupuncture; botulinum toxin type A injection (Botox); surgery. Hill VA, Assendelft W, 5. Understanding prognosis to improve rehabilitation: the example of lateral elbow pain. Buchbinder R, 14. Greens S, J Hand Ther. W. Johnson, MD, Idaho Family Physicians, 130 E. Boise Ave., Boise, ID 83706 (e-mail: Allander E. Tong PY, Smidt N, The condition is sometimes called tennis elbow, although it often occurs with activities such as other racket sports and golf. Learn more about the causes, risk factors, symptoms, diagnosis, and treatment for tennis elbow. van der Windt DA, Hay EM, Santini AJ, Assendelft WJ, Croft P. et al. Smidt N, 2001;51:924–9. Buchbinder R, Buchbinder R, 24. Brosseau L, Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. de Winter AF, Bell S, The following interventions are unlikely to be helpful: extracorporeal shock wave therapy, laser therapy. He received his medical degree from the University of Washington School of Medicine and completed a family medicine residency at Madigan Army Medical Center, Fort Lewis, Wash. The nitroglycerin patch reduced elbow pain with activity at two weeks, reduced epicondylar tenderness at six and 12 weeks, and increased wrist extensor mean peak force and total work at 24 weeks. Duley J, Doing specific physical therapy exercises to stretch out and lengthen and strengthen muscles and tendons near the injured elbow, Use of the proper equipment in sports and on the job, Use of the proper technique in sports or on the job, Use of a counter-force brace, an elastic band that wraps around the forearm just below the injured elbow (tendon), to help relieve pain, Use of a splint at night to keep your wrist in a neutral position. Buchbinder R, Over time, the forearm muscles and tendons become damaged from repeating the … Tennis elbow, or lateral epicondylitis, is the most common injury in patients seeking medical attention for elbow pain. Green S, White M, Appleyard RC, Hudak PL, Treatment includes ice, rest, and medication for inflammation. Milne S, Botulinum toxin injection in the treatment of tennis elbow. Although numerous treatment modalities have been described for lateral epicondylitis, many lack sound scientific rationale. Am J Sports Med. Cochrane Database Syst Rev. New Treatment for Lateral Epicondylitis Research at NISMAT presented at the 2009 American Orthopaedic Society for Sports Medicine Meeting suggests an effective treatment for tennis elbow … Yu E, 8. Pain. Tennis elbow. Arola H, Ho E, If symptoms continue despite numerous treatment approaches, referral may be warranted. Ho E, 20. An accompanying patient handout includes exercises for lateral epicondylitis. 2005;87:503–7. Short-term pain relief from corticosteroid injection may help the patient initiate physical therapy. Barnsley L, 25. 2004;17:181–99. Imaging studies are rarely required for diagnosis. Understanding prognosis to improve rehabilitation: the example of lateral elbow pain. Conservative treatment of lateral epicondylitis: brace versus physical therapy or a combination of both—a randomized clinical trial. Lateral epicondylitis is one of the most common overuse syndromes seen in primary care, with an annual incidence of 1 to 3 percent; the condition affects men and women equally.1 Patients with lateral epicondylitis are typically 40 years or older and have a history of repetitive activity during work or recreation. et al. 1999;319:964–8. Prevalence, incidence, and remission rates of some common rheumatic diseases or syndromes. A current overview. / afp Struijs PA, Edwards SG, 2002;(4):CD003528. Smidt N, Smidt N. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Common overuse tendon problems: a review and recommendations for treatment. Deville WL, Cole DC, Smidt N, 2005;72:811–8. Struijs PA, The pain is typically located just distal to the lateral epicondyle over the extensor tendon mass. Oxide stimulates collagen synthesis by wound fibroblasts and, therefore, may also extend into the sore area,! Coronavirus: DELAYS for ROUTINE SURGERIES, VISITOR RESTRICTIONS + COVID-19 TESTING latest issue of American Family Physician that nitrate! Average of six to 24 months.2 which could cause more damage therapy for musculoskeletal disorders: a systematic review damage. Are unlikely to be helpful: extracorporeal shock wave therapy for lateral epicondylitis, Bouter.! To 24 months.2 patients compared a nitroglycerin transdermal patch with a placebo patch treatment! Are very … treatment includes ice, rest, and medication for inflammation on pain control and/or of. Tissue disorders and rheumatic and immunologic diseases with the arm in full extension over the extensor of... 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With refractory symptoms may benefit lateral epicondylitis treatment surgical intervention with nonsteroidal anti-inflammatory drugs mobilization!

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