Epicondylitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

The majority of patients afflicted with epicondylitis will have complete resolution of their symptoms with arm rest and non-steroidal anti-inflammatory drug (NSAID) therapy.[4][24][56]

Additional therapy may be required if there is no improvement after 6 weeks, or if symptoms are refractory to treatment.

Initial presentation

The mainstay of initial treatment for medial and lateral epicondylitis is rest, ice, and activity modification of the wrist, elbow, and forearm for 6 weeks.[1][4][24][57]

Oral NSAIDs are recommended during the initial 10-21 days following injury. Short-term studies have demonstrated that oral diclofenac for 28 days is associated with improved pain in lateral epicondylitis, but does not statistically improve grip strength.[58][59]

In addition to NSAIDs, an inelastic, non-articular, proximal forearm strap for lateral epicondylitis may be used. Short-term use of this bracing technique (counterforce bracing) for up to 12 weeks after injury has been shown to be beneficial.[60] There is no difference in symptom improvement using a counterforce brace confined to a forearm compared with a brace with a strap above the elbow.[61] Conservative treatment should be continued for about 6 weeks.

The use of transcutaneous electrical nerve stimulation (TENS) devices does not appear to provide additional benefit.[62]

No response to initial treatment at 6 weeks

If the patient fails to improve with rest, NSAIDs, and bracing, the physical examination should be repeated to re-evaluate for other aetiological processes. Radiographic and/or electrophysiological studies may also be indicated to further evaluate the patient.

Formal physiotherapy procedures, with or without local injections of local anaesthetic, may be beneficial and should include an eccentric loading programme.[63][64][65][66][67][68]

Radial nerve mobilisation techniques have also been found to provide effective short-term pain relief in a small randomised controlled trial (RCT).[69]

Patients should be monitored every 6-8 weeks for 6 months to assess progress, such as whether they have returned to work or are participating in any sport.

Other conservative measures

An overview of systematic reviews of the clinical effectiveness of conservative interventions suggested uncertainty as to the effectiveness of many conservative interventions for the treatment of lateral epicondylitis. This was mainly due to the small sample sizes in the RCTs that have been reported. Conclusions regarding cost-effectiveness were also unclear.[70]

A meta-analysis of pooled data from RCTs indicated a lack of intermediate- to long-term clinical benefit after non-surgical treatment of lateral epicondylitis compared with observation only or placebo. Non-surgical treatments included injections (corticosteroid, platelet-rich plasma, autologous blood, sodium hyaluronate, or glycosaminoglycan polysulfate), physiotherapy, shock wave therapy, laser, ultrasound, corticosteroid iontophoresis, topical glyceryl trinitrate, or naproxen.[71]

While corticosteroid injections have been shown to improve short-term pain relief (4-6 weeks) compared with both placebo and bracing, there is evidence that the long-term outcome following corticosteroid injection for treatment of tennis elbow is worse than no treatment or physiotherapy alone.[72][73] One randomised controlled trial found that the use of corticosteroid injection versus placebo injection resulted in worse clinical outcomes after one year.[74]

If a decision is reached to administer corticosteroid injections, care must be taken to avoid both the nerve medially (paralysis) and subcuticular adipose tissue (necrosis).[24][37][57][72][75][76]

Refractory to treatment 6-12 months after initial presentation

Patients with epicondylitis who do not improve with the initial therapeutic interventions are referred to an orthopaedic consultant. Another thorough history and physical examination should be performed.

If recalcitrant epicondylitis is diagnosed (pain has persisted for 6-12 months after initial or recurrent presentation), surgical interventions will be considered. The use of injections with autologous blood/platelet-rich plasma, or extracorporeal shock wave therapy (ESWT), may be considered as alternative treatments to surgical intervention, but the evidence for these therapies is currently limited. [ ]

Surgical interventions

Surgical intervention for both medial and lateral epicondylitis is limited to recalcitrant cases.[4][24][57] All patients should be informed pre-operatively of possible decreased grip strength after surgery.[4]

Lateral epicondylitis

Systematic reviews have suggested that the current evidence is insufficient to support or refute the effectiveness of surgical intervention.[77][78]

Systematic reviews and one randomised controlled trial (published subsequent to systematic review searches) report no significant differences between arthroscopic and open surgery (e.g., functional outcomes, failure rate, pain relief) in patients with lateral epicondylitis.[79][80][81] One review found that post-operative complications (such as mild flexion-extension limitation, haematoma, wound infection, revision requirement, forearm paresthesias for 2 weeks after surgery) were significantly more common following open surgery.[79] Arthroscopic surgery was associated with increased operative time.[80][81]

Long-term follow up data are limited. Single-surgeon series (with mean follow-up >9.8 years) report subjective overall improvement in >90% of patients who underwent an open surgical procedure for lateral epicondylitis.[82][83] In one series, patient satisfaction averaged 8.9/10.[82]

Medial epicondylitis

Surgical intervention for medial epicondylitis involves the open debridement and excision of the undersurface of the flexor pronator mass. Mean subjective estimate of elbow function has been found to improve from 38% to 98% of normal after surgery for medial epicondylitis.[84]

Possible adverse effects of surgery include injury to the ulnar nerve and/or weakness with wrist flexion.[Figure caption and citation for the preceding image starts]: Surgery for refractory medial epicondylitis: probe placed on area of degenerative tendon showing loss of normal tendon appearanceFrom the collection of Dr Brian Fitzgerald, Naval Medical Center San Diego, CA; used with permission [Citation ends]. com.bmj.content.model.Caption@5f9988d7 [Figure caption and citation for the preceding image starts]: Surgery for refractory medial epicondylitis: pick-ups lifting off area of degenerative tendon after elliptical incision to excise this areaFrom the collection of Dr Brian Fitzgerald, Naval Medical Center San Diego, CA; used with permission [Citation ends]. com.bmj.content.model.Caption@4e446710 [Figure caption and citation for the preceding image starts]: Markings for swing incision location for patient with chronic refractory medial epicondylitisFrom the collection of Dr Brian Fitzgerald, Naval Medical Center San Diego, CA; used with permission [Citation ends]. com.bmj.content.model.Caption@388bb544 [Figure caption and citation for the preceding image starts]: Surgery for refractory medial epicondylitis: degenerative tendon removedFrom the collection of Dr Brian Fitzgerald, Naval Medical Center San Diego, CA; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: Surgery for refractory medial epicondylitis: medial epicondyle exposedFrom the collection of Dr Brian Fitzgerald, Naval Medical Center San Diego, CA; used with permission [Citation ends]. com.bmj.content.model.Caption@316b63b1

Ultrasound-guided minimally invasive tenotomy

Ultrasound-guided minimally invasive tenotomy has shown symptomatic improvement in non-randomised studies.[85]

It is a safe and effective treatment option for chronic refractory lateral and medial elbow tendinopathy, showing significant pain and function improvements over one year. Further research is required to assess its effectiveness in diverse patient populations using controlled study designs.[86]

Dry needling

Dry needling is a low-cost, minimally invasive, and low-risk therapy for refractory lateral epicondylitis. It involves multiple needle insertions into the extensor carpi radialis brevis tendon and is usually performed percutaneously under local anaesthetic. Dry needling has been shown to provide symptomatic improvement in a few small studies.[87][88]

Extracorporeal shock wave therapy

Extracorporeal shock wave therapy (ESWT) may be effective in patients desiring to avoid surgery or in people with risk factors precluding surgery.[89]

ESWT is not indicated in cases of medial epicondylitis. Systematic reviews suggest that extracorporeal shock wave therapy may be of modest benefit in the management of lateral epicondylitis, but high-quality RCTs are required.[90][91]

Injection therapy

Injection modalities, including autologous blood, platelet-rich plasma, hyaluronic acid, and botulinum toxin, have been proposed as treatments for recalcitrant lateral and medial epicondylitis.

Autologous blood or platelet-rich plasma

Injected into the tendons for medial and lateral epicondylitis and is thought to stimulate a local inflammatory response.

The use of injections with autologous blood/platelet-rich plasma, or extracorporeal shock wave therapy (ESWT), may be considered as alternate treatments to surgical intervention, but the evidence for these therapies is currently limited.[92][93] The National Institute for Health and Care Excellence (NICE) recommends autologous blood products for the treatment of tendinopathy; however, their effectiveness is uncertain.[94]

Two systematic reviews in patients with lateral epicondylitis reported that autologous blood or platelet-rich plasma significantly improved pain and elbow function in the intermediate term (12-26 weeks), and that platelet-rich plasma injection improved function and pain at 24 weeks, compared with corticosteroid injections.[95][96]

However, a subsequent Cochrane review concluded that autologous blood/platelet-rich plasma injections provide little or no clinically important benefit for pain or function in patients with lateral elbow pain.[97] It also reported that it is uncertain whether the injections improve treatment success or pain relief (>50%).[97] [ ]

Botulinum toxin

Reduced pain following botulinum toxin injection has been reported in people with lateral epicondylitis, but there is also a high risk of complications, including digital paresis and weakness.[98][99][100][101]

Hyaluronic acid

Hyaluronic acid injections have been shown to improve pain and grip strength in patients with chronic lateral epicondylitis when compared with placebo. No serious adverse effects were reported and improvement persisted after 1 year.[102] However, few high-quality studies are available.

Low-level laser therapy

Optimally dosed low-level laser therapy administered directly to the lateral elbow tendon insertions may offer short-term pain relief and less disability in lateral epicondylitis, both alone and in conjunction with an exercise regimen. There is conflicting evidence for the efficacy of this intervention.[103][104][105][106][107]

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