Physiotherapy for Tennis Elbow
Tennis elbow (lateral epicondylalgia (LE)) is the most common musculoskeletal condition of the elbow and affects up to 40% of the population at some stage in their lives. Recurrence and chronicity is common with over 50% of patients attending general practice reporting ongoing symptoms after 12months. The current paper outlines the current best evidence for diagnosis, assessment and treatment for LE by physiotherapists.
Diagnosis is based on clinical history and physical examination, with imaging only indicated for differential diagnosis. Assessment should include pain free grip strength testing and the PRTEE questionnaire. Treatment should include advice, education, exercise and Mulligans MWM’s in the first instance.
Patients will typically complain of lateral elbow pain that is aggravated by palpation, gripping and wrist or 3rd finger extension, therefore these 3 assessments should be included in the physical examination. Pain free grip strength should be assessed using a dynamometer for accurate baseline measurement. The Patient Rated Tennis Elbow Evaluation (PRTEE) questionnaire should be used as an outcome measure. For differential diagnosis, ligament stress testing of the medial and lateral collateral ligaments should be conducted as well as instability tests (posterolateral rotary drawer test and table top relocation test). Cervical spine examination, particularly at C4/5 and radial nerve tension tests should also be conducted. Imaging is only indicated for differential diagnosis as, with most tendinopathies, there is a poor correlation between disability and imaging findings.
Treatment in the first instance should include advice and education on tendinopathy, load management and tools/workstation setup. Exercise as a physical intervention has been the most widely researched and it is still unclear what type of exercise is most effective, however there is no doubt that it is more effective than US, placebo and friction massage. As a method of reducing pain immediately to allow for pain free exercise, the mulligans MWM has been shown to be effective in the short term. There is currently no evidence that manual therapy alone results in positive long term outcomes. There is also some evidence that cervical spine mobilisations/manipulations may be effective in reducing pain in the short term. There is some limited evidence that orthoses, taping, laser and acupuncture may be effective in pain reduction. The current evidence does not support US, friction massage or shockwave.
For those either with a score of greater than 54/100 on the PRTEE or have no improvement after 3months of treatment then imaging should be considered for differential diagnosis. Consideration should be given to the possibility of central sensitisation as well as referral to a pain management specialist for multimodal rehabilitation.
Please note injection therapy has not been included in this review, however a recent systematic review by Dong et al (2015) concluded that cortisone is NOT an effective treatment option.
> From: Bisset et al., J Physiother 61 (2015) 174-181. All rights reserved to Australian Physiotherapy Association. Click here for the Pubmed summary.