Lateral epicondylitis is a common overuse syndrome of the extensor tendons of the forearm. It is sometimes called tennis elbow, although it can occur with many activities. The condition affects men and women equally and is more common in persons 40 years or older. 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. Topical nonsteroidal anti-inflammatory drugs, corticosteroid injections, ultrasonography, and iontophoresis with nonsteroidal anti-inflammatory drugs appear to provide short-term benefits. Use of an inelastic, nonarticular, proximal forearm strap (tennis elbow brace) may improve function during daily activities. Progressive resistance exercises may confer modest intermediate-term results. Evidence is mixed on oral nonsteroidal anti-inflammatory drugs, mobilization, and acupuncture. Patients with refractory symptoms may benefit from surgical intervention. Extracorporeal shock wave therapy, laser treatment, and electromagnetic field therapy do not appear to be effective.
Most Popular
Today’s Best Part-Time Jobs
5 Regular Mistakes In Public Speaking
10 Jobs That Pay $30 An Hour
13 Job Interview Mistakes To Avoid
3 Questions No Job Seeker Ever Wants To Be Asked?
**********
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. The condition is sometimes called tennis elbow, although it often occurs with activities such as other racket sports and golf. Repetitive wrist dorsiflexion with supination and pronation causes overuse of the extensor tendons of the forearm and subsequent microtears, collagen degeneration, and angiofibroblastic proliferation. If untreated, lateral epicondylitis persists for an average of six to 24 months. (2)
Diagnosis
Lateral epicondylitis presents as a history of occupation- or activity-related pain at the lateral elbow. Symptoms are usually reproduced with resisted supination or wrist dorsiflexion, particularly with the arm in full extension. The pain is typically located just distal to the lateral epicondyle over the extensor tendon mass. Imaging studies are rarely required for diagnosis. Recent review articles have addressed the use of patient history, differential diagnosis, and physical examination in the diagnosis of lateral epicondylitis. (3,4)
Treatment
There is relatively little evidence from well-designed clinical trials to support the numerous treatment strategies employed for lateral epicondylitis. 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.
WATCHFUL WAITING
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. Patients received acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID), if necessary, although they were encouraged to wait for spontaneous improvement. (5)
NSAIDS
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. The median follow-up period was only two weeks, and long-term outcomes were not reported. No significant differences were found in grip strength or range of motion, and none of the studies evaluated quality of life or time to return to work.
Evidence is conflicting on the use of oral NSAIDs for lateral epicondylitis. 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)
CORTICOSTEROID INJECTION
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. 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.