Lateral elbow tendinopathy: Evidence of physiotherapy management

Abstract

Lateral elbow tendinopathy (LET) is a common musculoskeletal/sports injury. A plethora of physiotherapy techniques has been proposed in the management of LET. The exercise programme is the most common treatment in the management of LET. The optimal protocol of exercise programme is still unknown. The effectiveness of the exercise programme is low when it is applied as monotherapy. Therefore, exercise programme is combined with other physiotherapy modalities such as soft tissue techniques, external support, acupuncture, manual therapy and electrotherapy, in the treatment of LET. Future research is needed to determine which treatment strategy combined with exercise programme will provide the best results in LET rehabilitation.

Key Words: Tennis elbow, Isometric exercises, Physical therapy, Electrotherapeutic modalities, Eccentric training, Stretching, Physical modalities, Manipulation, Lateral epicondylitis, Lateral elbow tendinopathy

Core tip: An effective treatment approach in the management of lateral elbow tendinopathy (LET) is an exercise programme. Exercise programme improves patients’ symptoms but the ideal exercise protocol for the management of LET is still under investigation. Exercise programme as a sole treatment approach does not respond positively in many patients with LET. Thus, physiotherapists combine exercise programme with other physiotherapy techniques like electrotherapy, manual therapy, taping/bracing and acupuncture. Research to determine which treatment approach combined with exercise programme will provide the best results in the management of LET is needed.

MAIN BODY

Lateral epicondylalgia, lateral epicondylosis, tennis elbow and/or lateral epicondylitis are inappropriate clinical diagnostic terms due to pathophysiological, anatomical aetiological and factors[1]. Therefore, lateral elbow tendinopathy (LET) is the most appropriate clinical diagnostic term. LET is related to sport or arm work pain disorder. It is defined as a cause of pain in the lateral epicondyle[2] that failed healing tendon response rather than inflammatory or may be degenerative[3]. LET is characterized by the absence of inflammatory cells, glycosaminoglycans and proteoglycans, disorganized and immature collagen vascular hyperplasia, the increased presence of fibroblasts[4]. The most commonly affected structure is the origin of the extensor carpi radialis brevis[4]. LET is common between 30 and 60 years of age, the disorder appears to be more severe and of longer duration in females[3,5] and the most commonly affected arm is the dominant arm[2,6].

The main complaints of LET patients are decreased function and pain[2,3]. Both symptoms affect daily activities. Pain can be reproduced with one of the following ways: (1) palpation on the facet of the lateral epicondyle; (2) with the elbow in extension, resisted wrist extension and/or resisted middle-finger extension; and (3) gripping activities[2,3,7]. The Patient-Rated Tennis Elbow Evaluation questionnaire has been translated and culturally adapted into German[8], Italian[9], Swedish[10] and Greek[11] and provides a quick, standardized, and easy quantitative description of functional disability and pain in LET patients[8].

Although the diagnosis of LET is not difficult, the proper management is unknown. Physiotherapy is usually recommended for the management of LET[7,12]. A plethora of physiotherapy techniques, electrotherapeutic and non-electrotherapeutic modalities, has been recommended for the management of LET[2,3,7,12-15]. The aim of these treatments is the same, improving function and reducing pain, but the theoretical mechanism of action of these treatments is different. Therefore, more research is needed to find out the most effective treatment approach in LET patients since this variety of treatment techniques suggests that the most proper treatment technique is not known[2,3].

One of the most common physiotherapy treatments for LET is a supervised or in clinic exercise programme[2,3,7,12,14]. Malliaras et al[16] concluded that instead of eccentric loading in lower limb tendinopathy, clinicians should consider eccentric-concentric loading alongside. A Heavy Slow Resistance (HSR) program is recommended in the management of lower limb tendinopathy for young active people[17,18]. There are not similar studies for the upper limb. A similar loading program may be beneficial for the management of LET[2,3,7,12,14].

Alfredson et al[19] were first proposed the eccentric training of the injured tendon, the most commonly used conservative technique in the management of tendinopathy. Systematic review[20,21] and RCT[22] favor eccentric over other types of contractions in the management of LET, but using only eccentric training of the injured tendon is not effective treatment approach for some patients with upper and lower limb tendinopathies[23]. Thus, eccentric contractions of the injured tendon is combined with stretching exercises, especially static, of the injured tendon in the rehabilitation of tendinopathies as it was proposed by Stanish et al[24]. The patients in the Stanish exercise program, perform a five-steps program. A general, whole-body warm-up exercise is the first step. Static stretching exercises for the injured tendon are carried out in the second step. Next, the eccentric training is carried out once daily (3 sets of 10 repetitions) for six weeks and after six weeks, the patients are carried out three times per week for six more weeks 3 sets of 10 repetitions. Discomfort, or pain, is experienced in the last set of 10 repetitions. The eccentric training is described in detailed in the Stanish et al[24] article. Every treatment ends with the same stretching exercise as described in the second step. Ice on the «injured» tendon for about 5-10 min after the program is used by the patients. There are not studies to support the efficacy of the Stanish exercise protocol in LET patients.

It was stated by Martinez-Silvestrini et al[25] that isometric contraction, which would be more beneficial than eccentric contraction in LET because it is often related to forceful grip activities. Recently, isometric training has been recommended to decrease and manage the pain of tendon increasing the strength at the angle of contraction without producing inflammatory signs[26]. Forty five second isometric mid-range quadriceps exercise reduced the pain of patellar tendon for 45 min post exercise[26]. The dosage of isometric contractions in the present is based on clinical experience[26-28] and their effect on LET pain requires further research. Therefore, it was hypothesized that the simultaneous use of these two kinds of contractions (isotonic and isometric) and static stretching exercises will further enhance the analgesic effect of contractions in the treatment of LET, increasing the arm function[29]. However, the optimal protocol of exercise training needs to be investigated although the supervised exercise program is more effective than the home exercise program[30].

Exercise program is rarely delivered as a treatment in isolation in the management of LET[2]. An exercise program is usually combined with a range of physical therapy modalities. Furthermore, many manual therapies for the management of LET have been advocated, but the evidence to support the effectiveness of manual therapy in the management of tendinopathy is minimal[31]. The most common manipulative techniques for the treatment of LET are Cyriax manual technique, Mulligan manipulation, mobilization of the neck, manipulation of the wrist and radial neural mobilization are[32]. Manual therapy may increase grip strength and reduce pain immediately following treatment, but the evidence of any long-term clinical effects for manual therapy alone is insufficient[2,3,7,12,14].

Treatment focusing on trigger points reduces pain and improves function in LET patients[33]. A solid conclusion will be formulated when high and large quality RCTs are carried out[2]. Myofascial pain management methods such as deep transverse friction, low level laser, dry needling, etc., should also be evaluated[2]. The additional effect of myofascial methods, it would be interesting to determine on exercise program or other treatment methods used in management of LET[2,12,14].

Electrotherapeutic modalities such as low level laser, transcutaneous electrical nerve stimulation, extracorporeal shockwave therapy, pulsed electromagnetic field therapy therapeutic, ultrasound and iontophoresis are commonly used to manage LET[7,12,14,15,29,34]. Well-conducted trials are needed to determine the effectiveness of the above reported modalities in the management of LET. It is believed that the exercise training alone in the rehabilitation of LET is less effective therapeutic approach than the combination of exercise training with electrotherapeutic modality/ies[2,3,7,12,14,15].

External support such as bracing/taping is recommended for the management of LET[2]. The evidence for the effectiveness of bracing/taping in the improvement of function and reduction of pain is conflicted[35]. There was no compelling evidence that any one kind of bracing/any type of taping is superior to another in the short term, or that adding an external support to another treatment provides any additional benefit[7,12].

At the end of the treatment and/or at the short-term follow up acupuncture is an effective LET treatment[2,7,12]. The pathology of tendinopathy does not reverse using acupuncture, but it improves the signs of LET, reducing pain and increasing the function, but it[36]. To draw definite conclusions about the effectiveness of acupuncture, more research with well - designed clinical trials are needed.

Finally, the most promising treatment approach in the management of LET is the exercise training but more research is needed to investigate the optimal protocol of exercise training. When the exercise program is applied as part of the rehabilitation process its effectiveness is higher than it is applied as monotherapy[2,7,12,37]. More research to find out which treatment approach combined with exercises is needed to provide the best results in the management of LET.