Jurnal Orthopaedi dan Traumatologi Indonesia - The Journal of Indonesian Orthopaedic & Traumatology

Volume 5, Number 3, December 2022 27

Literature Review
The Conservative Treatment of Lateral Epicondylitis: A Narrative Review

Maria Anastasia2, Leonard Christianto Singjie2, Erica Kholinne1,3, Maria Rosa Mistika Ole 2, Adrian Surya Cendana2, Pingkan
Naomi Tanex2, Micheline Chang2, Petra Julian Abigail2, Jonathan Mark Yobel2

1
St. Carolus Bone & Joint Center, St. Carolus Hospital, Jl. Salemba Raya No.41, RT.3/RW.5, Paseban, Kec. Senen,
Kota Jakarta Pusat, Daerah Khusus Ibukota Jakarta 10440, Indonesia
2
Faculty of Medicine, Universitas Katolik Indonesia Atma Jaya, Jl. Pluit Raya No.2, RW.8, Penjaringan, Kec. Penjaringan,
Kota Jakarta Utara, Daerah Khusus Ibukota Jakarta 14440, Indonesia
3
Faculty of Medicine, Universitas Trisakti, Jl. Kyai Tapa No.1, RT.5/RW.9, Tomang, Kec. Grogol petamburan,
Kota Jakarta Barat, Daerah Khusus Ibukota Jakarta 11440, Indonesia

ABSTRACT

Lateral epicondylitis, also termed “tennis elbow,” is the most common cause of elbow pain and dysfunction, mainly
due to repetitive gripping or wrist extension during various activities. Although widely known as tennis elbow, LE
often develops as a work-related condition. The exact pathogenesis revealed a failed reparative process rather than
active inflammation, which results in symptomatic degenerative process of the local tendon. Although in most cases
the disease can be self-healing, the optimal treatment strategy for chronic lateral epicondylitis still remains contro-
versial, with conservative treatment is still the first line for lateral epicondylitis. Despite the available treatment, it is
still currently debatable as there is still no strong evidence showing the most effective treatment for managing lateral
epicondylitis. This article presents an overview of the current knowledge on lateral epicondylitis, with a focus on
conservative management of lateral epicondylitis.

Keywords: Lateral epicondylitis, Tennis elbow, Tendinosis, Repetitive strain, Elbow pain, Treatment, Conservative treatment
https://doi.org/10.31282/joti.v5n3.108
Corresponding author : Erica Kholinne,, MD. Email : erica@trisakti.ac.id
The Conservative Treatment of Lateral Epicondylitis: A Narrative Review
INTRODUCTION
Lateral epicondylitis (LE) has been the most common
cause of nontraumatic lateral elbow pain. Although
widely known as tennis elbow, LE often develops as a
work-related condition. This condition is primarily due
to repetitive gripping or wrist extension. The risk of LE
becomes higher in heavy manual workers and in those
whose job requires repetitive motions.1 Approximately
1% to 3% of the population will experience LE during
their lifetime, especially between the 3rd to 5th decade,
with an equal distribution in both men and women.
Patients generally complain of lateral elbow pain that
radiates to the forearm, which is often followed by
functional weakness and disruption of fine motor skills2,3
Pathological studies have shown a failed reparative
process rather than active inflammation, which explains
why it is regarded as a tendinosis, or asymptomatic
degenerative process of the tendon. Histology showed
an absence of inflammatory cells; Instead, it showed an
angiofibroblastic hyperplasia process, characterized by
the replacement of normal tissue tissue at the proximal
site of the ECRB tendon with immature fibroblasts
and blood vessel hyperplasia. Therefore, tendinosis is
a more appropriate term than tendinitis.4 The several
avascular zones in the proximal insertion of the ERCB
tendon demonstrated the weakness of these areas: one
in the lateral epicondyle and the other 2-3 cm distal to
the origin of the extensor.5–7 Autonomic innervations of
blood vessels for ECRB also showed inconsistencies
between vasoconstrictor and vasodilator activities along
the watershed area that causes a disruptive healing
process. The lesions may progress to tears then to fibrosis
and calcification.8 Furthermore, the extensor muscles in
the forearm, especially ones that originate from common
extensor tendon, experience a high eccentric and
concentric stress that can cause microtear, along with
pathological process that occur in the shoulder area.9,10
A case series by LaBan et al.11 reported that there was an
increase in wrist flexion to compensate for loss of ROM
and place intense eccentric contractions on the extensor
muscles. The treatment of LE, especially in chronic cases,
remains controversial, as there is no single algorithm
for LE management. In most cases, LE usually resolves
spontaneously in 1 to 2 years. Management itself has been
changed from the inflammatory pathological process to
the degenerative process of the wrist extensor tendons
involving its origin, which is the lateral epicondyle of
the humerus.3,10
28
Nirschl and Ashman created a classification system
that has been used in research to describe intervention
responses, as in table 1.2
Table 1. Nirschl Classification of Tendinosis Pain Phase
Phases of
Pain description
Pain
Mild pain after exercise activity, >24
Phase I
hours
Pain after exercise activity, >48 hours,
Phase II
resolved with warm-up
Pain with exercise activity does not
Phase III
alter activity.
Pain with an exercise activity that
Phase IV
alters activity
Pain caused by heavy activity of daily
Phase V
living
Intermittent pain at rest that does not
Phase VI disturb sleep; pain caused by light
activities of daily living
Constant pain at rest and pain that
Phase VII
disturbs sleep
ANATOMY
The lateral elbow serves as the attachment of the com-
mon extensor muscles, which are made up of five mus-
cles. Extensor carpi radialis longus and brevis, extensor
digitorum communis, extensor digiti minimi, and exten-
sor carpi ulnaris. However, the extensor carpi radialis
brevis muscle (ERCB) has multiple origins, including
the lateral collateral ligament, the annular ligament and
the intramuscular septum3,4
CLINICAL PRESENTATION AND INVESTIGA-
TION
Physical examination revealed a point of tenderness
medial and distal to the lateral epicondyle that was often
exaggerated by extreme wrist flexion and resistance to
elbow extension. A clinical test is to ask the patient to
extend the wrist against resistance with the elbow flexed
to 90 degrees, which will cause pain on ECRB insertion.12
Pain will be more prominent in the extended elbow
position. The “chair test”, as shown in Figure 1, causes
lateral elbow pain when lifting a chair with a pronated
hand as described by Gardner et al.13 Radial tunnel
syndrome that causes PIN entrapment at the leading edge
The Conservative Treatment of Lateral Epicondylitis: A Narrative Review
of the supinator muscle often coexists with LE. Pain with
resisted supination and resisted long finger extension
(Maudsley’s test) suggests radial nerve entrapment in the
radial tunnel and ECRB, respectively.11
Figure 1. Chair test requires the patient to lift a chair with the
shoulder adducted, elbows extended, and forearms pronated.
Discomfort or pain in the area around the outer part of the
elbow suggests lateral epicondylitis.50
Plain radiograph of the elbow is usually used as the first
diagnostic imaging test to exclude any other possible
pathology. In a study of 294 patients, only 16% had
positive radiographic findings for calcification along the
lateral epicondyle.14 Another modality, such as ultrasound
(US), is also commonly performed in patients with lateral
elbow pain. The US shows a thickening of the common
extensor tendon, associated with diffuse heterogeneity
and areas of focal hypoechogenicity. There is often
associated intra-tendon calcification and bony irregularity
at the tendon insertion.15,16 The sensitivity of ultrasound
was 64-82% compared to magnetic resonance imaging
(MRI) 90-100%.17,18
MRI is not mandatory in most cases. It usually shows
an increase in T1 signal and thickening within the
extensor tendon due to microtears of collagenous fibers,
fibrovascular proliferation, and degeneration.19,20
As reported by Wittenberg et al.21 reported persistent pain
in LE patients after injection of the local anesthetic agent
as consideration for surgery. Intra-articular injection will
differentiate another intra articular pathology such as
plica syndrome.
TREATMENT OPTIONS
In the majority of cases, spontaneous resolution may be
29
expected within 8 to 12 months. Therefore, starting a
treatment for LE needs careful considerations, regardless
of the chosen treatment. Conservative treatment remains
the first line of treatment for LE. When conservative
treatment fails, some patients may require surgical
interventions. Table 2 shows the treatment option for
Lateral epicondylitis.12
Table 2. List of conservative therapy for LE
Conservative therapies for Lateral Epicondylytis
(LE)
1. Stretching, kinesiotaping & exercises
2. Cross-frictional massage
3. Counterforce bracing
4. Extracorporeal shock wave therapy (ESWT)
5. Ultrasonography
6. Electrical therapy
7. Laser therapy
8. Acupuncture
9. Viscosupplementation injection
10. Steroid Injection
11. Cell-based therapy
Stretching, Kinesiotaping, and Exercises
Physiotherapy remains the first-line conservative
treatment for LE. Stretching and exercises are among the
most widely used, and some exercise programs have been
significantly effective in reducing pain and improving
function. A recent RCT study by Stasinopoulos et al.22
showed that concentric training, eccentric training, and
concentric-eccentric training combined with isometric
training resulted in a significant pain reduction as
recorded in Visual Analog Scale (VAS), an increase
in function, and an increase in pain-free grip strength
within 4 and 8 weeks in 34 patients. Concentric-eccentric
training combined with isometric training produces
the largest effect at the end of treatment and follow-
up. Another study by Yoon et al.23 also concluded that
eccentric exercises had positive effects on pain reduction
compared to other exercises. However, the differences in
muscle strength and function between the other exercises
were not significant.24
Some additional therapy after exercise may improve the
pain score and function of LE. A study by Hoogvliet et
al.25 stated that there was a moderate effect for short-
and mid-term manipulation of the cervical and thoracic
The Conservative Treatment of Lateral Epicondylitis: A Narrative Review
spine as an additional therapy to concentric and eccentric
stretching plus mobilization of the wrist and forearm in
patients with LE. However, there is no strong evidence
to support the effectiveness of exercise or mobilization
techniques in improving symptoms in patients with LE.
Regarding the strengthening components as an additional
therapy in home exercise program, a study by McQueen
et al.26 showed that pain at rest and activity, along with
the result of the the result of the the result of the DASH
questionnaire, was not significant in a randomized
controlled trial involving 59 LE patients, compared to
the the the home exercise program alone.
Compared to corticosteroid injections, Karanasios et
al.27 conducted a systematic review and meta-analysis of
2123 subjects from 30 trials to assess the effectiveness of
exercise alone or as an additional intervention compared
to wait-and-see or injections in patients with lateral
elbow tendinopathy. Results of >12 months follow up
showed that there were significant differences in GROC,
pain rating, PFGS, and elbow disability (p-value <0.001
for all) when compared to corticosteroid injections.
However, for the wait-and-see policy comparison,
significant results were only found in elbow disability
and pain intensity.
Kinesiotaping is a relatively new technique in the
conservative management of LE. Based on an RCT carried
out by Eraslan et al.28 in 45 participants, kinesiotaping in
addition to physical therapy can improve functionality
(p<0.001), recover grip strength (p<0,001), and decrease
intensity of pain intensity (p<0,001) in patients with
newly diagnosed LE. However, kinesiotaping may not
be significantly effective compared to normal taping. A
randomized controlled trial conducted by Balevi et al.29
in 45 patients with chronic LE stated that the short-term
and residual effects of the kinesiotaping method on pain,
maximum strength of the handgrip, quality of life, and
functionality in LE are not superior to placebo. However,
in the true taping group, the positive effect obtained in the
early period, especially with regard to pain, continued for
up to six weeks as a residual effect.
Cross-Friction Massage
Deep transverse friction massage (DTFM) is a physical
therapy intervention that works by increasing blood flow
to the joint to reduce damage and scarring in the the
tissues around the joint, therefore reducing pain caused
by tendinitis.30
30
A recent study by Yi et al.31 showed an improvement
in pain, DASH score, and grip strength at the early
follow-up between 6 and 12 week following DTFM in
patients with lateral elbow pain. At the 6 months follow-
up, a significant recovery in VAS pain score, DASH
score, and grip strength was observed. There was no
significant change in the groups that received a splint
or cortisone injection. In conclusion, this study revealed
that deep friction massage has a lasting therapeutic effect
at 6 months of follow-up, while splinting or cortisone
injection demonstrated early benefit without long-lasting
effect.
Another RCT conducted by Akbar et al.32 concluded
that patients with LE treated with cyriax massage had
significantly better grip strength compared to those
treated with Mulligan Mobilization. The PRTEE score
revealed that the Mulligan group had significantly better
functional outcomes as compared to those treated with
Cyriax Mobilization. Overall, the cyriax manual therapy
or DTFM can improve the grip strength and has a
beneficial effect up to 6-months as shown in VAS and
DASH score.32
Counterforce Bracing
Proximal forearm brace, also known as the counterforce
brace is one of the more popular treatments for LE.
The brace is applied to the distal part of the elbow. In
doing so, the expansion of the wrist and finger extensor
muscles will be limited when a muscle contracts, thus
reducing the force on the damaged tendon origins in
the lateral epicondyle. There have been different results
on the efficacy of counter-force bracing. A study by
Nishizuka et al.33 with a total of 102 subjects showed
that the forearm band could have no more than a placebo
effect. Another study by Kroslak et al.34 showed that the
counterforce brace had satisfactory results during a short
time follow-up (2-12 weeks). In the five years follow-up,
the severity of pain improved from moderate or severe
to mild or none, and the frequency of pain was also
improved from always or daily to less than monthly. In
addition to this, there was also an improvement in grip
strength of 44% after counterforce bracing treatment at
long-term follow-up.
Extracorporeal Shock Wave Therapy (ESWT)
ESWT has been recommended and proven to be effective
in alleviating symptoms of LE over the years. The
The Conservative Treatment of Lateral Epicondylitis: A Narrative Review
mechanism of ESWT is to create an acute or new injury
at the site of the injury, which will trigger the self-repair
mechanism of the injured tissue. A meta-analysis by
Xiong et al.35 showed that patients treated with ESWT
had a greater improvement in VAS and grip strength at 12
weeks of follow-up. A greater clinical improvement was
seen in patients receiving corticosteroids injection, but
ESWT showed a better outcome in long-term follow-up.
A recent study by Yoon et al.23 mentioned that patients
with longer symptoms experienced a more beneficial
effect of ESWT than those with a symptoms duration
of less than 3 months. Meanwhile for ultrasonography,
a study by Yan et al.36 which compared ultrasound
and ESWT in the treatment of LE showed a greater
grip strength and VAS in the ESWT group which was
observed at 1, 3 and 6 months of follow-up, indicated
that ESWT offers more effective treatment for LE than
US. Another study by Dedes et al.37 concluded that both
ESWT and US treatment are useful in treating symptoms
in patients with LE. However, ESWT is significantly
better at relieving pain, improving functional score and
quality of life compared to US.
Electrical Therapy
Transcutaneous electrical nerve stimulation (TENS)
is another option for pain relief in patients with LE.
A study by Chesterton et al.38 showed that although
the VAS and functional score did not show significant
difference between patients treated with TENS and those
who were treated only by pharmaceutical therapy, TENS
delivered a better general satisfaction. This revealed
that there was greater satisfaction in patients receiving
additional treatment compared to the actual benefit of the
intervention itself.
Laser Therapy
Baktir et al.39 performed a comparative study to
investigate the effectiveness of low-level laser therapy
with other interventions which were phonophoresis and
iontophoresis in 3 weeks follow-up in LE patients. The
participants were randomly divided into 3 groups: 12
patients in a low-level laser therapy group, 12 patients
in the phonophoresis group, and another 13 participants
in the iontophoresis group. Among all the measured
outcomes (VAS for pain, pain pressure threshold,
PRTEE, and grip strength), significant differences were
only found in VAS for pain (at rest, activity, and night
with p-value = 0.015, 0.008, and 0.013, respectively) and
31
PRTEE (p-value = 0.04). Another study conducted by
Turgay et al.40 in 2020 which included a longer follow-up
time, also showed that ESWT gave significantly superior
results in terms of DASH score, PRTEE score, and
physical functioning score, compared to patients who
were treated with low-level laser therapy.
Acupuncture
Several articles have evaluated the efficacy of
acupuncture for LE treatment. Zhou et al.41 conducted a
systematic review and meta-analysis of 10 randomized
controlled trials on the effectiveness of acupuncture
compared to sham acupuncture, medicine therapy, and
blocking therapy. The study showed that acupuncture
outperformed other therapy, which was reflected by
the better VAS pain score.41 Another RCT by Bostrøm
et al.42 reported that there was no significant difference
in patients with manual therapy compared to those with
acupuncture as an addition to manual therapy in terms of
pain improvement after 12 weeks of follow-up.
Viscosupplementation Treatment
Viscosupplementation treatment is an intra-articular in-
jection with hyaluronic acid derivatives which can be
performed in outpatient clinics. Tosun et al.43 conducted
a prospective randomized trial comparing the effects be-
tween sodium hyaluronate-chondroitin sulfate and cor-
ticosteroids injection in LE. The study included 57 LE
patients, which were further divided into two groups
consisting of 27 patients receiving hyaluronic acid (HA)
and chondroitin sulfate (CS) and another group of 32 pa-
tients receiving steroids (triamcinolone and prilocaine).
At 3 months of follow-up, there were no significant dif-
ferences between both groups in pain score. However,
the patients receiving HA and CS were significantly su-
perior in the functional scores. At 6 months, both groups
maintained statistically better pain and function scores
than at their baseline assessments, but patients who re-
ceived HA and CS were significantly better in their pain
improvement and functional score.
Steroid Injection
Steroid injection is commonly used to treat severe pain
in LE. Due to the widespread use of steroids injections,
more recent studies were performed to investigate its
risks and benefits. A double-blind randomized controlled
trial investigated the effects of corticosteroid injection
The Conservative Treatment of Lateral Epicondylitis: A Narrative Review
with lidocaine injection in 61 patients with LE. At 2
months of follow-up time, VAS for pain improved
significantly in all patients who received corticosteroid
injection or lidocaine injection. However, there was no
difference in pain scale, grip strength and functional
score (DASH and PRTEE) between the compared group.
Corticosteroid injection was associated with several
adverse effects, such as tendon rupture, facial flush,
subcutaneous atrophy, or skin depigmentation. For this
reason, a lidocaine injection may be advantageous as an
initial treatment44
A systematic review of randomized controlled trials,
including 1.972 patients with LE with 1-year follow-
up, compared corticosteroids injection with other
treatments (NSAID, physical therapy, orthotic device,
platelet-rich plasma, sodium hyaluronate, botulinum
toxin, lauromacrogol). This showed strong evidence that
corticosteroid injection was beneficial if used less than
8 weeks, but worse than other options for a treatment
longer than 8 weeks treatment. It is concluded from this
study, that despite the effectiveness of corticosteroid
injections in the short term, non-corticosteroid injections
might be of benefit for the long-term treatment of LE.45
Cell-Based Therapy
Cell-based therapy is one of the most developed
therapeutic modalities that currently serves as one of
the conservative measures for lateral epicondylitis.
Mesenchymal stem cells as an emerging regenerative
therapy were found to be safe and effective in patients
with lateral epicondylitis. A pilot study by Lee et al.46
found that after 52 weeks the visual analog scale
(VAS) decreased in patients with chronic LE decreased
(p=.002). The elbow performance scores also improved
from 64.0±13.5 to 90.6±5.8 (p=.002).
Another cell-based modality was injectable human
collagen scaffold combined with autologous platelet-rich
plasma (STR/PRP), which promotes cell migration and
tissue repair. A clinical trial by Farkash et al.47 found that
STR/PRP is a safe modality that effectively improves the
symptoms of patients. The mean Patient-Rated Tennis
Elbow Evaluation score showed a 59% reduction after
six months (p<.001). The 12-Item Short-Form Health
Survey also showed an improvement of 7 points (30.7 to
37.7) at the final follow-up (p<.001). The grip strength
increased from 28.8kg to 36.8kg in 6 months (p<.001).
Radiographically, the tendon showed improvements
32
in 68% of the patients, as shown in the sonographic
appearance of the tendon.
Wang et al.48 conducted a study that used autologous
tenocyte injection (ATI) in torn tendons among patients
with resistant chronic LE, with a mean follow-up of
4.5 years. Their study found that ATI improved clinical
functions and radiological score. The mean VAS pain
score improved 78% at the final follow-up (from 5.73 to
1.21) (p<.001), with Quick Disabilities of Arm, Shoulder
and Hand (QuickDASH), Upper Extremity Functional
Scale (UEFS) and grip strength improved (84%, 64%
and 208%, respectively; P<0.001). The magnetic
resonance score system also found that the mean grade
of tendinopathy improved significantly from 4.31 to 2.88
in 1 year (p<0.001). Ninety-three percent of patients
were also highly satisfied or satisfied with ATI treatment.
However, it was found that the use of PRP or autologous
blood injections did not improve pain or function after 1
year of follow-up. Another study by Linnanmaki et al.49
has shown that the improvement by PRP injection was
not significant, as measured with DASH score and grip
strength.
CONCLUSION
Lateral epicondylitis is a disabling condition that is com-
monly managed with conservative treatment as the first
line. Despite the available treatment, there is currently
no strong evidence showing the most effective treatment
for managing lateral epicondylitis. Thus, it is essential to
recommend the least invasive treatment with the safest
profile to the patients as initial management.
CONFLICT OF INTEREST
None.
FUNDING
No funding was used in this study.
AUTHORS CONTRIBUTION
E. Kholinne: Conceptualization, Writing, Reviewing, and
Editing ; L.C. Singjie: Writing, Reviewing, and Editing;
M. Anastasia: Review and editing; M.R.M. Ole: Writing;
A.S. Cendana: Writing; P.N. Tanex: Writing; M. Chang:
Writing; P.J. Abigail: Writing; J.M. Yobel: Writing.
The Conservative Treatment of Lateral Epicondylitis: A Narrative Review
ACKNOWLEDGEMENT
None.
DATA AVAILABILITY STATEMENT
Data used to support the findings of this study are in-
cluded in the article.
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