22. non-steroidal anti-inflammatory drugs (NSAIDS), Resting and avoiding any activity that causes pain to the sore elbow, Use of a counter-force brace such as a tennis elbow strap on the forearm for forceful activities. Specific exercises are helpful for strengthening the muscles of the forearm. Haake M. Pain. Ann Intern Med. Orthotic devices for tennis elbow: a systematic review. Immediate, unlimited access to all AFP content. Both tennis elbow (lateral epicondylitis) and golfer’s elbow (medial epicondylitis) are painful conditions caused by overuse. Common overuse tendon problems: a review and recommendations for treatment. 2005;143:793–7. There are numerous surgical approaches, including open, percutaneous, and arthroscopic techniques. / Wong SM, It is due to excessive use of the muscles of the back of the forearm. 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. CORONAVIRUS: DELAYS FOR ROUTINE SURGERIES, VISITOR RESTRICTIONS + COVID-19 TESTING. Assendelft WJ, Corticosteroid injections for lateral epicondylitis: a systematic overview. Want to use this article elsewhere? Golfer's elbow is a similar condition that affects the inside of the elbow. Lewis M, Exercises- Strengthening and Stretching 1. Cleveland Clinic is a non-profit academic medical center. Brosseau L, Bouter LM. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Van Dijk CN. Typically this occurs as a result of work or sports, classically racquet sports. Cochrane Database Syst Rev. Bouter LM. Assendelft WJ, Casimiro L, Address correspondence to Greg. Tennis elbow is usually treated by medical means, and only rarely by surgery. 2004;17:181–99. There is relatively little evidence from well-designed clinical trials to support the numerous treatment strategies employed for lateral epicondylitis. 2003;35:51–62. 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. Orthotic devices for the treatment of tennis elbow. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Smidt N, Wrist lift, palm up. Tugwell P, Hughes PJ, de Winter AF, The following interventions are unlikely to be helpful: extracorporeal shock wave therapy, laser therapy. Tennis Elbow Time Out. Ultrasound therapy for musculoskeletal disorders: a systematic review. Kerkhoffs GM, Milne S, White M, 1996;78:128–32. White M, Shock wave therapy for lateral elbow pain. The condition usually happens due to over use of the forearm muscles and results in pain of the outside elbow. The diagnosis is Extracorporeal shock wave therapy, laser treatment, and electromagnetic field therapy do not appear to be effective. Symptoms are usually reproduced with resisted supination or wrist dorsiflexion, particularly with the arm in full extension. Over time, the forearm muscles and tendons become damaged from repeating the … et al. 21. van der Windt DA, Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial. Barnsley L, Cochrane Database Syst Rev. The median follow-up period was only two weeks, and long-term outcomes were not reported. Cochrane Database Syst Rev. Kester AD, 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. General physiotherapy management includes: 1. Hill VA, Manual therapy- Mulligan - Mobilisation with movement 1. Hay EM, Nonsurgical Treatment Physical therapy. van der Windt DA, Smidt N, Green S, Smidt N. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Evaluation of overuse elbow injuries. Rarely, surgery may be done to repair the tendon. Smidt N, (NSAID = nonsteroidal anti-inflammatory drug.). Br J Sports Med. Paungmali A, 10. Bouter LM. Tennis elbow is also called lateral epicondylitis. 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. Cole DC, Hay EM, Deville WL, Assendelft WJ, Murrell GA. Best TM. Santini AJ, Conservative treatment of lateral epicondylitis: brace versus physical therapy or a combination of both—a randomized clinical trial. Barnsley L, Wong LK. Wong SM, A current overview. The pain is typically located just distal to the lateral epicondyle over the extensor tendon mass. Kerkhoffs GM, Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. et al. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Hall S, 2002;96:23–40. de Winter AF, Fess EE. Buchbinder R, Greens S, 2002;359:657–62. Information from references 15 and 19 through 22. We do not endorse non-Cleveland Clinic products or services. et al. Evidence does not support the use of laser therapy for the treatment of lateral epicondylitis. Figure 2 is a suggested algorithm for the treatment of lateral epicondylitis.15,19–21 When the history and examination are consistent with lateral epicondylitis, a reasonable initial approach includes control of inflammation with topical or oral NSAIDs, short-term activity modification, correction in errors of biomechanics, and implementation of a home exercise regimen. Algorithm for the treatment of lateral epicondylitis. Lateral Epicondylitis Treatment With your lateral epicondylitis tests results, your doctor will decide the proper treatments options for you. 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. Hughes PJ, Deep transverse friction massage for treating tendinitis. Copyright © 2020 American Academy of Family Physicians. White M, et al. van der Windt DA, 25. Am J Sports Med. Orthotic devices for tennis elbow: a systematic review. Arch Phys Med Rehabil. van Mameren H, Physical therapy regimens, including strength training and stretching, are commonly used to treat lateral epicondylitis. 13. van Dijk CN, 1992;78:421–6. It often occurs after strenuous overuse of the muscles and … et al. Lateral epicondylitis presents as a history of occupation- or activity-related pain at the lateral elbow. To see the full article, log in or purchase access. Am Fam Physician. Assendelft WJ, Don't miss a single issue. Assendelft WJ. 1998;280:1518–24. 2007 Sep 15;76(6):843-848. Smidt N, Arola H, van der Windt DA, Assendelft W, W. Johnson, MD, Idaho Family Physicians, 130 E. Boise Ave., Boise, ID 83706 (e-mail:email@example.com). 28. GREG W. JOHNSON, MD, KARA CADWALLADER, MD, SCOT B. SCHEFFEL, MD, and TED D. EPPERLY, MD, Family Medicine Residency of Idaho, Boise, Idaho. Paoloni JA, Buchbinder R, One RCT suggests that topical nitrate patches may be effective in patients with lateral epicondylitis, but confirmatory studies are needed. 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. 29. Although most cases can be self-healing, the optimal treatment strategy for chronic lateral epicondylitis remains controversial. Cole DC, Robinson V, Deville WL, 2000;29:463–9. MacDermid JC. Physiotherapy. Bouter LM. Short-term oral NSAIDs, strap, topical nitrates, acupuncture, botulinum toxin type A injection: B. Instead, try these 3 lateral epicondylitis exercises. 2002;(1):CD003525. Zastrow I, Borkholder CD, Barnsley L, Zastrow I, van der Heijden GJ, Nirschl RP. Address correspondence to Greg. The majority of cases respond to … van der Linden AJ. Malmivaara A, Shea B, Your therapist may also... Steroid injections. Robinson V, Green S, Van Dijk CN. Lateral epicondylitis can be treated with rest and medicines to help with the inflammation. Short-term pain relief from corticosteroid injection may help the patient initiate physical therapy. Green S, Green SE, 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. 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. 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. SCOT B. SCHEFFEL, MD, is director of the Family Medicine Residency of Idaho's Primary Care Sports Medicine Fellowship. Advertising on our site helps support our mission. Evidence is conflicting on the use of oral NSAIDs for lateral epicondylitis. Santini AJ, More commonly known as tennis elbow, lateral epicondylitis …  Parameters of pain at rest and with extension, sensitivity, hand grip strength, and a subj… 2003;31:915–20. W. Johnson, MD, Idaho Family Physicians, 130 E. Boise Ave., Boise, ID 83706 (e-mail: Allander E. 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. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Malmivaara A, Cleveland Clinic offers expert diagnosis, treatment and rehabilitation for bone, joint or connective tissue disorders and rheumatic and immunologic diseases. She received her medical degree from the University of California, San Francisco, School of Medicine. The condition affects men and women equally and is more common in persons 40 years or older. 1. Haines AT. Nirschl RP. Boddeker I, Exactly what causes tennis elbow is unknown, but it is thought to be due to small tears of the tendons that attach forearm muscles to the arm bone at the elbow joint. 5. Trinh KV, Patient information: See related handouts on tennis elbow and exercises for tennis elbow, written by the authors of this article. Borkholder CD, 76/No. National Institutes of Health Consensus Conference. 1999;319:964–8. Buchbinder R, Best TM. Topical nonsteroidal anti-inflammatory drugs, corticosteroid injections, ultrasonography, and iontophoresis with nonsteroidal anti-inflammatory drugs appear to provide short-term benefits. Croft P. Lancet. Smidt N, The surgical techniques for treating lateral epicondylitis can be grouped into three main categories: open, percutaneous, … Lateral epicondylitis is considered an overuse injury occurring in the lateral side of the elbow region which can become extremely painful. Orthopade [German]. 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… Hall S, NSAID = nonsteroidal anti-inflammatory drug. Struijs PA, Greens S, O'Connor FG, Wilson JJ, Bouter LM. Am J Sports Med. Botulinum toxin injection in the treatment of tennis elbow. Case series have suggested favorable outcomes with few adverse effects.31 Despite these conclusions, no RCTs have been performed.7,31. Use of an inelastic, nonarticular, proximal forearm strap (tennis elbow brace) may improve function during daily activities. Appleyard RC, Smidt N, Braces/Splints/Straps- No clear evidence 1. Adshead R, Bisset L, van der Windt DA, Assendelft WJ, Training and stretching, are also often employed to treat lateral epicondylitis: a systematic review results! Daily activities … lateral epicondylitis with botulinum toxin type a injection: B sore area by! 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