“Tennis elbow,” a diagnosis that strikes fear into the hearts of clinicians the world over! (OK… that may be a slight overstatement). Why is this condition so dreaded? Because when treating tennis elbow, everything works and nothing works. Tennis elbow is one of the most commonly diagnosed and discussed musculoskeletal conditions known to humankind.
An article by Arnett et al. on the evaluation and treatment of lateral epicondylitis reported a 2-percent incidence in the general population, with a significantly higher rate among manual laborers.1 It can also be one of the most difficult conditions to treat as a clinical specialist. Why? I believe the reasons are ambiguity in its definition and a misunderstanding of its etiology and histopathology.
There have been many names for lateral elbow pain, such as tennis elbow, lateral epicondylosis, lateral epicondylalgia, and lateral epicondylitis.1 So what difference does a name make? All the difference in the world. Words have meaning, and when we can accurately describe the condition, we can then choose an effective treatment regimen.
I believe that Jane Fedorczyk, MS, PT, CHT, ATC, has written a landmark article on the topic of tendon histopathology.1,2 She demonstrates an evidence-based, logical guideline of how we should be evaluating this condition based on clinical presentation and sound histopathology.
In my experience, most of what we deal with in the clinical setting are chronic symptoms when it comes to treating patients with tennis elbow. Very rarely if ever have I assessed a competitive athlete with “acute” tennis elbow. The clear majority have had symptoms for more than four to six months, received one or two cortisone injections, gone for formal physical/occupational therapy, and worn a myriad of straps/braces.
By the time they come to us, there have been significant changes in pain patterns, altered movement strategies, and physiologic changes on the cellular level at the tendon/bone interface. So for the purposes of this article, I’ll use the term “lateral epicondylosis,” which is based on sound science and more accurately paints a picture of the histopathology of tendinopathies.2
A ton of ink has been spilled on treatment strategies and interventions for lateral epicondylosis, while various systematic reviews and meta-analyses have been conducted to shed light on interventions for this diagnosis. A systematic review/meta-analysis of 28 studies by Bisset, Vicenzino, and Beller looked at manual techniques, orthotics/taping, acupuncture, laser, extracorporeal shock wave, ultrasound, phonophoresis, deep-friction massage and exercise.3
In a nutshell, the authors reported that consensus on management of lateral epicondylalgia is inconsistent, effectiveness of intervention varies, and more research needs to be conducted.4 Many more recent studies have demonstrated the same results.4,5,6,7,8 So what’s the rub? Why are outcomes all over the place?
I believe, as Fedorczyk has reported, that we’re asking the wrong questions.2,9 We need to take a holistic approach to each individual case, focusing on three very important questions:
- Where is your patient in regard to wound healing (acute vs. chronic)?
- What is the target tissue you want to impact (deep, superficial, ligamentous, soft tissue)?
- What are you trying to achieve (heat, heal, pain control)?
I’d also add another pertinent question: What are your leisure activities and occupation? In asking these clinical questions, we can then effectively choose the most appropriate evidence-based intervention for better outcomes, instead of throwing every modality/treatment imaginable at the people who come to us for help. We’re better than that and those we care for deserve our best!
I’ll give you an example of my assessment and intervention for patients with chronic, post-acute lateral epicondylosis. An in-depth interview is essential, regarding the who, what, when, where, and how that led to the individual seeking help for elbow pain. The utilization of qualitative data cannot be understated.
The Patient-Rated Tennis Elbow Evaluation (PRTEE) is an excellent outcome measure, which in turn helps direct treatment and demonstrates improvement in symptoms.10 A review of past medical history including medications is critical as well, along with a sound cervical screen for any radicular symptoms that can be masked as lateral elbow pain.11,12 A solid hands-on musculoskeletal assessment and differential diagnosis are also essential.2,5
Individualized Treatment Plan
Based on the outcome of my assessment, I’ll fashion an individualized treatment plan. In the case of chronic (greater than three months) lateral epicondylosis,2,9 I take a holistic multifaceted approach that incorporates ergonomic intervention, a home program and various treatment modalities in the clinic. For this article, I’ll focus on one of these interventions that has made a significant difference in my treatment of patients with chronic lateral epicondylosis.
After years of inconsistent outcomes in my early days as a clinician, I began to investigate the literature to help find answers to my questions. Understanding what you’re dealing with is just as important as how you’re going to address it! The utilization of instrument assisted soft tissue mobilization (IASTM) has demonstrated a positive impact on the management of soft tissue dysfunction, by decreasing pain and increasing blood flow in chronic musculoskeletal conditions that include lateral epicondylosis.13,14,15
When implementing IASTM treatment with HawkGrips for lateral epicondylosis, I scan the distal/lateral triceps, supracondylar ridge of the humerus, ECRB/ECRL (extensor carpi radialis brevis/extensor carpi radialis longus) origin to insertion, along with the anconeus, and then treat these areas accordingly. I’ll also integrate IASTM with a blend of eccentric/concentric exercise, as well as other treatment interventions.7,8,16 One study by Tyler et al. utilized a randomized controlled trial to demonstrate marked improvement in symptom reduction, when three sets of 15 repetitions of eccentric wrist extension were performed with a TheraBand FlexBar in conjunction with physical therapy.16
Coupled with other interventions such as periscapular strengthening,17 activity modification, and various modalities based on case-by-case assessment, I began to see significant improvement when treating this condition in the chronic stage. Much more can be stated about management of lateral elbow pain that’s beyond the scope of this article, which is simply intended to relate my experience with integrating research and evidence-based treatment modalities to help improve clinical outcomes. Isn’t that what we all want?
1. Arnett JJ, Mandel S, Brigham CR, Aydin SM. A review of the evaluation and treatment of lateral epicondylitis. SM J Orthop. 2016;2(4):1043.
2. Fedorczyk JM. Tendinopathies of the elbow, wrist, and hand: histopathology and clinical considerations. J Hand Ther. 2012;25(2):191-201.
3. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939.
4. Baker RT, Nasypany A, Seegmiller JG, Baker JG. Instrument-assisted soft tissue mobilization treatment for tissue extensibility dysfunction. International Journal of Athletic Therapy and Training. 2013;18(5):16-21.
5. Blanchette MA, Normand MC. Augmented soft tissue mobilization vs. natural history in the treatment of lateral epicondylitis: a pilot study. J Manipulative Physiol Ther. 2011;34(2):123-130.
6. Bhatt JB, Glaser R, Chavez A, Yung E. Middle and lower trapezius strengthening for the management of lateral epicondylalgia: a case report. J Orthop Sports Phys Ther. 2013;43(11):841-847.
7. Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005;39(7):411-422.
8. Coviello JP, Kak RS, Reynolds TJ. Short-term effects of instrument-assisted soft tissue mobilization on pain free range of motion in a weightlifter with subacromial pain syndrome. Int J Sports Phys Ther. 2017;12(1):144.
9. Fedorczyk JM. Tennis elbow: blending basic science with clinical practice. J Hand Ther. 2006;19(2):146-153.
10. MacDermid J. Update: the patient-rated forearm evaluation questionnaire is now the patient-rated tennis elbow evaluation. J Hand Ther. 2005;18(4):407-410.
11. Hall T, Quintner J. Responses to mechanical stimulation of the upper limb in painful cervical radiculopathy. Aust J Physiother. 1996;42(4):277-285.
12. Raman J, MacDermid JC, Grewal R. Effectiveness of different methods of resistance exercises in lateral epicondylosis—a systematic review. J Hand Ther. 2012;25(1):5-26.
13. Sims SE, Miller K, Elfar JC, Hammert WC. Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand. 2014;9(4):419-446.
14. Smidt N, Lewis M, Windt DA, Hay EM, Bouter LM, Croft P. Lateral epicondylitis in general practice: course and prognostic indicators of outcome. J Rheumatol. 2006;33(10):2053-2059.
15. Stasinopoulos D, Stasinopoulos I, Pantelis M, Stasinopoulous K. Comparison of effects of a home exercise programme and a supervised exercise programme for the management of lateral elbow tendinopathy. Br J Sports Med. 2010;44(8):579-583.
16. Tyler TF, Thomas GC, Nicholas SJ, McHugh MP. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. J Shoulder Elbow Surg. 2010;19(6):917-922.
17. Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev. 2016;1(11):391-397.
Dr. Jim Wagner is an occupational therapist and certified hand therapist who has specialized in treating upper-extremity and sports-related injuries for 24 years. He is currently team leader at the hand/upper-extremity center of The Guthrie Clinic in Sayre, PA, as well as an adjunct professor in the occupational therapy programs at both Keuka College in Keuka Park, NY, and Ithaca College in Ithaca, NY.
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