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Dr Brooke K Coombes PhD1,2, Dr Leanne Bisset PhD3, Professor Bill Vicenzino PhD2*
The authors certify that they have no affiliations with or financial involvement in any
organization or entity with a direct financial interest in the subject matter or materials
discussed in the article. No financial support was received for this manuscript
Contact author
Bill Vicenzino
School of Health and Rehabilitation Sciences: Physiotherapy
The University of Queensland, Building 84A, St Lucia QLD 4072
Phone: + 617 3365 2781
Email: b.vicenzino@uq.edu.au
SYNOPSIS
Clear guidelines for the clinical management of individuals with lateral elbow tendinopathy
(LET) are hampered by the proposal of many potential interventions and the conditions
prognosis ranging from immediate resolution of symptoms following simple advice in some
our lack of understanding of the complexity of the underlying pathophysiology. In this paper,
we collate evidence and expert opinion on the pathophysiology, clinical presentation, and
differential diagnosis of LET. Factors that might provide prognostic value or direction for
physical rehabilitation, such as the presence of neck pain, tendon tears, or central
10
11
12
13
14
proposed. Further research is needed to evaluate whether such an approach leads to improved
15
16
17
18
19
Pain over the lateral epicondyle of the humerus during loading of the wrist extensor muscles
20
21
age.43 The above symptom is associated with a clinical diagnosis of lateral elbow
22
tendinopathy (LET), also known as tennis elbow or lateral epicondylalgia. LET affects
23
approximately 1-3% of the general population,43, 97, 114 with individuals who smoke,97 manual
24
workers,63 and tennis players41 being at increased risks. LET results in significant functional
25
disability from work, sports, and leisure activities, and high costs due to productivity loss and
26
healthcare use.97
27
28
There is a lack of consensus on the best treatment approach for LET, resulting in frustration
29
for patients and practitioners alike.64, 99 Complexities associated with the anatomy,
30
31
described in the literature. One of the challenges for managing LET is the wide range in
32
prognosis among individuals with the condition. For many patients, symptoms of LET are
33
self-limiting, with randomized controlled trials indicating that 83-90% of patients assigned to
34
a wait and see approach reporting significant improvement, although not always complete
35
resolution, in the condition within a year.11, 100 However, up to a third of patients have
36
37
proportion of patients experience recurrence of their symptoms following the initial episode.9,
38
14, 50
39
interventions and undergo surgery, with variable outcomes reported in the literature.55, 61
40
41
42
and differential diagnosis of LET. We propose that applying a single intervention, or a one
43
size fits all approach to all presentations of LET is unlikely to be effective in every case.
44
Instead, interventions should be tailored to the pathology and clinical presentation and we
45
highlight 6 factors that may provide direction for physical rehabilitation. Finally, a
46
47
clinical decision-making guide, though it will require further refinement and validation.
48
49
PATHOPHYSIOLOGY
50
51
which suggests that tendon cellular and matrix changes are accompanied by alterations in
52
nociceptive processing and impairments in sensory and motor function.27 Recent studies have
53
provided support for some aspects of this model,47, 66 although the relationships between
54
55
discordance between clinical severity and tendon pathology in patients with tendinopathy.34,
56
46
57
58
and possibly psychological factors, when diagnosing and managing patients with LET.
59
60
The histological features of LET are similar to those of other common tendinopathies and
61
62
and neurovascular ingrowth.61 The most common sites of focal degeneration are the deep and
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anterior fibers of the extensor carpi radialis brevis (ECRB) component of the common
64
extensor tendon origin.7, 20 Anatomical studies have shown that the ECRB tendon merges
65
imperceptibly with the lateral collateral ligament (LCL), which in turn fuses with the annular
66
67
place between these structures and may explain progressive involvement of the LCL in more
68
69
70
CLINICAL EXAMINATION
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72
provocatively load the affected tendon. Physical examination should reproduce pain in the
73
area of the lateral epicondyle in at least 1 of 3 ways: by palpation of the lateral epicondyle,
74
resisted extension of the wrist, index, or middle finger, or by having the patient grip an
75
object. A more comprehensive physical examination to identify (or rule out) coexisting
76
pathologies or other primary sources of pain is required in individuals who have persistent
77
78
79
Elbow, wrist, and forearm range of motion, as well as accessory motion of the radioulnar,
80
81
muscular restriction. In patients whose symptoms are suggestive of elbow instability (eg,
82
clicking, loss of control, or difficulty with pushing up with the forearm supinated) several
83
clinical tests are available to determine the presence/absence of the condition, including the
84
Posterolateral Rotary Drawer Test74 and Table Top Relocation Test.5 However, signs of
85
instability on physical examination are commonly subtle and may need to be combined with
86
results of imaging.54
87
88
Evaluation of the cervical and thoracic spine and of radial nerve function should also be a
89
priority, particularly where there is concomitant neck pain or diffuse arm pain or
90
paraesthesia. Reproduction of lateral elbow pain during manual palpation and/or active,
91
passive, or combined movements of the cervical spine, should raise suspicion of radicular or
92
referred pain.112 Increased sensitivity of the radial nerve to mechanical stimuli may be
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evaluated by neurodynamic testing and palpation of the nerve along its length.96 Radial nerve
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neurodynamic testing, may be performed by moving the upper limb in the following
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internal rotation, forearm pronation, wrist and finger flexion, followed by shoulder abduction
97
(FIGURE 1).16, 24 A positive test requires reproduction of the patients lateral elbow pain and
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102
Analysis of posture and movement within the whole kinetic chain is recommended,3 to
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identify potential risk factors that may be modifiable through rehabilitation. Insights gained
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from such analysis along with evaluation of functional tasks undertaken in occupational and
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sport specific activities, as well as sensory and motor function testing will provide direction
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107
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OUTCOME MEASURES
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For greater consensus and standardization between research trials and clinical practice, we
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recommend use of at least the pain free grip test and the Patient Rated Tennis Elbow
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Evaluation (PRTEE) as outcome measures. The pain-free grip test is a reliable, valid, and
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grip force applied until the point of onset of pain.67 Most protocols recommend testing, with
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the elbow in relaxed extension and forearm pronation, 3 times with 1-minute intervals, using
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the average of these 3 repetitions to compare between affected and unaffected sides. An
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alternative testing position with the elbow flexed to 90 and forearm in neutral rotation can
117
also be used.67 The pain-free grip test is preferable to measurement of maximal strength,
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which is not always impaired, and is likely to provoke exacerbation of an individuals pain,
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questions, 5 related to pain and 10 related to functional limitation from daily activities, work,
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and sport. Both subscales contribute equally to the total score, which ranges from 0 (no pain
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or disability) to 100 (worst possible pain and disability). In a previous cluster analysis, scores
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greater than 54 were considered to represent severe pain and disability, and scores less than
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33 were considered to reflect mild pain and disability,28 although validation of such cut-offs
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The Patient Specific Functional Scale (PSFS) is another valid, reliable and responsive
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outcome measure, which may be used to measuring progress in individual patients with upper
133
extremity problems.48 Patients nominate 3 to 5 activities that they are having difficulty doing
134
because of their problem and rate these activities on an 11 point scale, where 0 is unable to
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perform the activity and 10 is able to perform the activity at preinjury level. A minimum
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DIAGNOSTIC IMAGING
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Ultrasound and magnetic resonance imaging (MRI) demonstrate high sensitivity, but limited
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(MRI). Meta-analysis of MRI studies found signal changes in 90% of affected and 50% of
143
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found tendinopathic changes in 90% of patients with LET and 53% of asymptomatic
145
controls.46An exception was disruption of fibrils within the common extensor tendon, which
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showed 100% probability of LET.46 Most studies find a lack of association between the
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severity of tendon changes and symptoms in both LET,17, 115 and other chronic
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tendinopathies.57 However, the presence of a LCL tear and the size of any intrasubstance
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tendon tear detected by ultrasound were significantly associated with poorer prognosis in
150
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While changes on imaging that are apparent in both affected and unaffected limbs require
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cautious interpretation, negative ultrasound findings can be used to confidently rule out LET
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as a diagnosis,34, 46 and prompt the clinician to consider other causes of elbow pain. If the
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arthrography may be used to detect other pathologies, such as loose bodies, articular cartilage
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damage, ligament injury, or elbow synovial fold (plica) syndrome.39, 60 Ultrasound may also
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swelling and hypoechogenicity of the nerve or identifying secondary causes such as cysts.59,
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60
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DIFFERENTIAL DIAGNOSIS
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TABLE 1 lists other potential sources of lateral elbow pain, many of which lack universally
165
accepted definitions and diagnostic criteria.44, 51 The lack of clearly distinct diagnostic entities
166
might underpin differences in prevalence rates and prognosis of these conditions between
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studies. Included in this list is non-specific arm pain, a diagnosis often reached by exclusion
168
of other specific conditions.44, 51 There is little consensus regarding diagnostic criteria for
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radial tunnel syndrome, which shares similar clinical features to LET, and may occur in
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innervated by the posterior interosseus nerve (PIN) should be used as a requirement for a
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diagnosis of PIN entrapment.93 Early identification of the condition and referral of these
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permanent injury.56 It should also be recognized that LET might present as an isolated entity
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or coexist with other pathologies, making clinical differentiation difficult. For example,
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patients with chronic LET who sustain an acute injury with worsening of symptoms may
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There is no universally effective treatment for all patients presenting with LET.
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more likely to be successful if individually tailored. Based on current evidence and expert
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rehabilitation program.
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Tendon pathology
187
A continuum of tendon changes may be found in patients with tendinopathy, ranging from a
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and ligament disruption are also reported in more advanced cases of LET,15, 18, 86 their
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Cook et al21 suggest that rehabilitation should differ between stages of tendinopathy, although
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the authors recognize that clinical differentiation is difficult. Reactive tendinopathy, which
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modified loads, to give the tendon time to recover. In contrast, interventions such as eccentric
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exercise and prolotherapy injections which aim to stimulate increased production of collagen
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or ground substance and restructure tendon matrix might be more appropriate for
200
degenerative tendinopathy.21 Patients with LET, with a large intrasubstance tear or LCL tear,
201
are more likely to fail nonoperative treatment, including 6 months of eccentric loading, and
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LET may also present as a continuum of symptoms ranging from relatively mild, yet
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persistent annoyances during daily activities to severe and significant symptoms limiting all
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facets of life.118 There is strong evidence that patients with greater baseline pain and
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disability have a poorer long term prognosis,25, 100 warranting early intervention for this at
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risk population. Furthermore, patients with severe symptoms (PRTEE scores >54) have been
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found to display more pronounced sensory disturbances, which might be targeted by different
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by rest, use of an orthotic wrist splint, counterforce elbow strap, or taping (FIGURE 2), the
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latter helpful for patients with resting or night pain.107, 108 Where physical modalities (eg,
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exercise and manual therapy) are used, these should be initiated cautiously, performed below
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the individuals pain threshold and progressed more slowly to avoid provoking or sustaining
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central sensitization.73
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10
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Central sensitization
219
Central sensitization is implicated in the pathophysiology of LET and several other chronic
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In individuals with LET, there is evidence of heightened nociceptive withdrawal reflex,66 and
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pain and disability displayed cold hyperalgesia (mean 13.7C),28 while cold pain threshold
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was an independent predictor of short and long term prognosis in untreated individuals with
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LET.25 This is consistent with other musculoskeletal pain conditions such as whiplash
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associated disorder, where cold pain thresholds >13C have been linked to an increased risk
227
of persistent pain.103
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persistence of pain in LET might lead to more appropriate and targeted treatments.
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of symptoms to sites outside the injured area may provide the clinician with important clues
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Treatments for management of central sensitization in patients with musculoskeletal pain are
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described by Nijs and colleagues.73 The results of a systematic review indicate that cervical
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spine manual therapy reduces mechanical hyperalgesia at remote sites in people with and
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mobilization exercises might also be suitable for addressing central sensitization processes
11
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Neck pain is more common in patients with LET than an age-matched healthy population.8
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segmental levels in patients with relatively localized symptoms of LET.24 Moreover, self
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report of shoulder or neck pain in patients with LET presenting to general practice were
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comorbidities may be addressed during rehabilitation using manual therapy and exercise.
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Impairment in sensory and motor function is commonly seen in patients with LET and may
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persist beyond resolution of local tendon symptoms.2, 12 In addition to reduced pain-free grip
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force, affected individuals commonly grip with a more flexed wrist position13 and display
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weakness of the short wrist extensors (ECRB) but not the finger extensors.3 Widespread
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muscle weakness in the affected limb,3 and bilateral deficits in reaction time and speed of
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movement13 are also found in patients with unilateral LET. Recent investigation of the motor
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cortical organization may be maladaptive in patients with LET.95 Failure to recognize and
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address problems with motor control, strength, and endurance may be one explanation for
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Several work related physical and psychosocial factors have been associated with an
12
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increased occurrence of LET,42, 106 and poorer overall prognosis after 1 year.42 These include
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handling tools, handling of heavy loads, and repetitive movements, as well as low job
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control. Individuals adopting non-neutral wrist postures during work activity have been
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affected working adults, with a median duration of 29 days in the previous 12 month time
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period.113 Modification of physical factors could reduce the risk or improve the prognosis of
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LET. Design of workplaces and ergonomic modifications should focus on minimizing work
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tasks requiring deviated wrist postures, forceful exertions, highly repetitive movements and
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In contrast, the role of psychological factors in the development and persistence of pain in
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patients with LET is conflicting. Higher anxiety and depression were found in 2 small cross-
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sectional studies,1, 40 but not in a larger study of patients with LET. Longitudinal study of
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patients with LET did not find any association between psychological factors and prognosis,
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25
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resources by patients when wait and see was recommended by their primary practitioner.65
although another study found depression was associated with a greater use of medical
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POTENTIAL INTERVENTIONS
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Pharmacotherapy
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There is conflicting evidence for the role of oral non-steroidal anti-inflammatory medication
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in the management of LET.79 Based on findings of tendon cellular and matrix inhibition with
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indomethacin and naproxen, it has been speculated that these drugs may be more appropriate
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for use in patients with reactive than degenerative tendinopathy.21 There is strong evidence
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that corticosteroid medication provides short-term relief of pain, but leads to worse outcomes
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after 6 and 12 months compared to either a wait and see approach or physical therapy
13
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management, with substantial recurrence rates.26 More recent research showed that adding a
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multimodal physical therapy program (of elbow mobilization and resistance exercise) did not
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ameliorate the late delay in recovery or recurrence observed after a single corticosteroid
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injection.22 For these reasons we advocate that corticosteroid injection should not be
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considered a first-line intervention for LET. Other more centrally acting analgesics, such as
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antidepressant or antiepileptic drugs, might be appropriate for patients with severe pain where
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central sensitization is suspected, although no studies have been conducted in this population
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to date. A meta-analysis found strong evidence for antidepressant medication in the relief of
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pain in patients with fibromyalgia, another condition associated with central sensitization.45
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Prolotherapy and nitric oxide patches have demonstrated long term beneficial effects in
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patients with chronic (greater than 3months) LET.75, 87 Their efficacy may be dependent on
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appropriate physical stimulus, based on evidence of a lack of effect of nitric oxide patches
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when combined with stretching only.76 Despite large clinical interest, there is growing
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evidence that injection of autologous blood or platelet rich blood products are not effective in
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treating LET.32, 62
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Manual therapy
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There is moderate evidence for the immediate effects of several manual therapy techniques
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on pain and grip strength80, 109 and for short term clinical benefits when used in conjunction
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with graduated exercise.58 The ulnar-humeral lateral glide (FIGURE 3) and radial head
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posteroanterior glide (FIGURE 4) are 2 techniques which can be used following the
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approach known as Mulligan mobilization with movement, where the patient performs the
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techniques are to be used when they produce substantial immediate improvement (eg, 50%)
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in pain and impairment (eg pain-free grip force). There is also moderate evidence that manual
14
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therapy techniques targeting the cervical and thoracic regions provide additional clinical
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benefits beyond local elbow treatment alone in patients with LET and coexisting cervical or
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Exercise therapy
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Exercise is central to management of many patients with LET, with evidence of benefits from
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exercise alone,31, 82, 84, 105 or as a part of a multimodal physical therapy regime.10, 22 In patients
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with chronic LET, exercise has been shown to lead to greater and faster regression of pain,82
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less sick leave, fewer medical consultations, and increased work ability.83 Despite clear
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benefits, the most optimal exercise intensity, duration, frequency, and type of load for
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gradually increasing resistance, focusing on the extensor muscles of the wrist.102 Some
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studies favor eccentric over concentric exercise,81, 88 while others indicate no differences
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opinion on whether pain should be provoked during exercise. Some insist pain should be
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avoided during exercise,31, 107 while others suggest pain during exercise of less than 5 on a
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Given the heterogeneity in clinical presentation and pathology between patients with LET, it
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is likely that optimal modes and doses of exercise differ between patients with different
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Isometric exercises of the wrist extensor muscles have a role based on their wrist stabilizing
340
function in many activities, providing for optimal hand function.101 Although their effect on
341
pain in patients with LET requires further study, isometric contractions were shown to
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produce greater analgesic effect than isotonic exercise in patients with patellar
15
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daily, may be more appropriate for patients with reactive tendinopathy or irritable symptoms
345
than eccentric exercise, which will tend to aggravate pain. We recommend isometric exercise
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be initiated in a position of elbow flexion and neutral forearm rotation and progressed
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towards more forearm pronated and elbow extended positions, where the ECRB tendon may
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be exposed to greater compression and more pain.33, 89 Progression may also be achieved by
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increasing the duration of contraction (up to 90 seconds) and by increasing the load (through
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a free weight or resistance tubing). Exercises should also address motor control
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Concentric and/or eccentric exercise of the wrist extensors are advocated for patients with
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degenerative stage tendinopathy,21 commencing with the elbow in flexion and possibly
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restricting end of range wrist flexion (FIGURE 6). A similar approach restricting full ankle
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dorsiflexion during eccentric exercises was more successful for patients with insertional
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imaginable pain) may be acceptable during exercise, but not the following morning.
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Strengthening of muscles of the rotator cuff and scapula should be included in rehabilitation,
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based on previously identified deficits.2 For athletes involved in throwing or racquet based
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sports, plyometric exercises may be needed to improve tolerance to elastic loading during
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Education
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Patients with LET can be reassured, that most likely, the condition will resolve gradually
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with adequate rest and time. Instruction to avoid pain provoking activities (eg, by not lifting
16
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with a pronated forearm) and discussion about rest and recovery from high loads, is
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on minimizing work tasks requiring deviated wrist postures, forceful exertions, and highly
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Decision making regarding allocation and prioritization of treatment for the entire spectrum
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of patients with LET is currently inconsistent. Based on prognostic factors collated in this
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paper, we propose an algorithm which aims to identify 3 subgroups and link these groups
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with individually targeted, initial and subsequent treatment strategies (FIGURE 7). We
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recognize that other factors including patient preference, cost, or resource availability may
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also direct the clinician to particular interventions. It has been demonstrated that patients with
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LET assigned to wait and see sought significantly more not per protocol treatments than
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those assigned to physical therapy.10 49, 116In a recent economic analysis, a single
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were each compared over 1 year with a placebo injection.29 It concluded that the multimodal
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program (of elbow manual therapy and exercise) was highly likely to be cost-effective, while
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the cost-effectiveness of corticosteroid injection was more uncertain. Ultimately, the clinical
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utility and cost effectiveness of the proposed algorithm will be dependent on testing through
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a clinical trial, such as has been undertaken for low back pain.49, 116
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We propose that low risk patients with low pain severity and no negative prognostic
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indicators may be suitable for advice, and self-administered pain medication (eg nonsteroidal
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anti-inflammatory drugs) consistent with a wait and see policy. This approach may also be
17
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adopted where there is reason to believe the patient will not adhere to an exercise program
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and they are not continually exposed to activities that will perpetuate symptoms of LET. If
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For high risk patients with severe pain and disability (eg, PRTEE > 54/100), concomitant
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neck pain, or suspected central sensitization (eg, cold pain threshold greater than 13C,
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Isometric exercise may be commenced at loads below pain threshold, with progression to
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For the remaining population, herein described as moderate risk, a multimodal physical
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therapy regime is recommended as a first line management, with the goal of faster recovery
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strengthening and endurance exercise, and elbow manual therapy, consistent with what has
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Based on this model, diagnostic imaging is reserved for cases recalcitrant to physical therapy.
414
If findings on imaging are consistent with the presence of tendinopathy, the patient may be
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counseled regarding other second line interventions, such as prolotherapy injections or nitric
416
oxide patches. Patients with severe pain with LCL or tendon tears on imaging may require
417
18
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Monitoring of patient recovery may be achieved using repeated use of the PRTEE or PSFS
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questionnaires.48, 85 Timeframes and thresholds for recovery are provided as a guide for
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clinicians.
422
CONCLUSION
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Unraveling the complex aetiology and mechanisms underlying the persistence of pain in
424
patients with LET is challenging. We highlight several prognostic factors, including central
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sensitization, local structural damage (eg, tendon and ligament tears) and comorbid
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as a means of guiding clinical decision making regarding treatment options for patients with
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LET.
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Differential diagnoses
Key features
Local arthritis77
Intra-articular pathology60
Radiocapitellar
pathology60, 94
28
radiculopathy
Posterolateral rotatory
instability4
29
structure.
797
30
798
799
800
FIGURE 1. Radial nerve neurodynamic testing is performed by placing the upper limb in the
801
following series of positions: gentle shoulder girdle depression, elbow extension, shoulder
802
internal rotation, pronation, wrist and finger flexion, followed by shoulder abduction. A
803
positive test result (indicating mechanosensitivity of the radial nerve) reproduces the patients
804
lateral elbow pain, which alters with a sensitization maneuver, such as cervical lateral flexion
805
or scapular elevation.
806
31
807
808
809
FIGURE 2. Diamond taping is applied using rigid tape to unload painful tissues at the
810
common extensor tendon origin. The elbow is first placed in a position of comfort, then: A.
811
Starting from the anchor point (x), tape is tensioned in a proximal direction along the (solid
812
arrow), while the skin is moved toward the inside of the diamond (broken-line arrow). B.
32
813
Note the orange peel effect on the skin within the diamond tape, resulting from unloading of
814
tissues toward the site of pain (o). Reproduced with permission.108
815
816
33
817
818
819
FIGURE 3. Lateral elbow mobilization with movement: This technique consists of applying
820
and sustaining a lateral humero-ulnar accessory glide while the patient performs (and relaxes)
821
their painful action (eg, gripping). If significant improvement in pain-free grip is observed,
822
repeat the technique for a total 6 to 10 repetitions. A belt may be used to assist with the glide.
823
34
824
825
826
827
consists of applying and sustaining a posterior to anterior glide over the radial head while the
828
patient performs (and relaxes) their painful action (eg, gripping). If significant improvement
829
830
35
831
832
833
FIGURE 5. Sensorimotor palm slide exercise for retraining of wrist extension: With the
834
forearm resting in pronation on a table, the wrist should be slowly extended by sliding the
835
fingertips along the table and lifting the knuckles. Emphasis is placed on avoiding
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metacarpophalangeal extension and finger flexion. Return to the starting position and repeat
837
10 times.
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840
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FIGURE 6. Wrist extension exercise can be performed over the edge of a table with elastic
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tubing or free weights. Isometric holds (30-60sec duration) are advocated for reactive or
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irritable tendinopathy, while concentric and eccentric actions should be performed slowly (4
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seconds for each direction), completing 2-3 sets of 10 repetitions for patients with less
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deviation of the wrist (by aligning the middle metacarpal bone with the long axis of the
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forearm). Progression may be achieved by increasing load or performing the exercises with
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850
851
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elbow tendinopathy (LET) based on identified prognostic factors and targeted initial and
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subsequent treatments. Abbreviations: PRTEE Patient rated tennis elbow evaluation; CPT
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856
38