Pain In Lateral Epicondylitis Research Articles

High Versus Low-Energy Extracorporeal Shockwave Therapy for Chronic Lateral Epicondylitis: A Retrospective Study

Background: Chronic lateral epicondylitis (LE), also known as tennis elbow, affects 1–3% of the population, primarily those over 40 years old. Most cases resolve with conservative treatments, but some require more advanced interventions. Extracorporeal shockwave therapy (ESWT) has emerged as a non-surgical treatment option, utilizing either low- or high-energy levels to alleviate pain and improve function. Objective: This study aimed to compare the efficacy of low-energy versus high-energy ESWT in the treatment of chronic LE, focusing on pain relief and functional improvement. Methods: A retrospective observational study was conducted including patients treated for chronic LE between 2021 and 2024. Participants were divided into two groups: low-energy ESWT (0.10 mJ/mm2) and high-energy ESWT (0.20 mJ/mm2). Both groups received 2400 pulses at a frequency of 6 Hz once a week for three weeks. Pain and functional outcomes were measured using a visual analog scale (VAS) and the Patient-Rated Tennis Elbow Evaluation Questionnaire (PRTEE) at the baseline, three months (T1), and six months (T2) post-treatment. Results: Forty-six patients participated, with 24 in the low-energy group and 22 in the high-energy group. Baseline demographics and clinical characteristics were similar across groups. At T1 and T2, the low-energy group showed significantly greater reductions in the VAS scores (T1: 4.45 ± 0.8 vs. 3.6 ± 1.7, p = 0.04; T2: 3.2 ± 1.2 vs. 2.1 ± 1.1, p = 0.004) and PRTEE scores (T1: 34.3 ± 6.9 vs. 26.8 ± 11.9, p = 0.03; T2: 25.3 ± 6 vs. 17.6 ± 9, p = 0.005). Significant treatment–time interactions were observed for both the VAS and PRTEE scores, indicating sustained improvements in the low-energy group. Conclusions: Low-energy ESWT was more effective than high-energy ESWT in treating chronic LE, providing greater and longer-lasting pain relief and functional improvement. These findings suggest that low-energy ESWT should be preferred in clinical practice for managing this condition. Future research should focus on larger sample sizes and randomized controlled trials to confirm these results and explore the underlying mechanisms of differential efficacy between energy levels.

A Study to Compare the Effectiveness of Concentric and Eccentric Training Program for Patients with Lateral Epicondylitis

Background: Lateral epicondylitis is considered to be the most prevalent overuse injury which affects 1% to 3% of the total population among all age groups and genders. The tendon of extensor carpi radialis brevis gets affected and can be strengthened by resistance exercises. It also affects plumbers, carpenters ,housewives etc. The daily activities are interrupted which increases pain in lateral epicondylitis can be treated conservatively and surgically. Purpose: To compare the effectiveness of concentric vs Eccentric training programs for lateral epicondylitis by reducing pain.Materials and Methods: 68 subjects were selected from Active physio care physiotherapy clinic based on the inclusion and exclusion criteria. The detailed procedure for performing the study was explained to the subjects, and the informed consent form was collected from them before starting the study. The pre and post test values were measured using the numerical pain rating scale (NPRS) and pain rated tennis elbow evaluation (PRTEE). The subjects selected based on the inclusion and exclusion criteria were divided into two groups: concentric group and Eccentric group (n = 34). Study period : November 2022 to April 2023.Results: Statistical analysis of numerical pain rating scale and pain rated tennis elbow evaluation post test result revealed that both groups show similar effect but Eccentric exercise Group (Group B) exceeds Concentric Exercise group (Group A) with p VALUE of p<0.0001.Conclusion: When comparing the concentric group to the Eccentric group, the Eccentric group indicates significant effects in improving the strength of the elbow, improving the functional activity and strength of the forearm

Demonstrating the relationship of ultrasonographic parameters with disease activity and pain in lateral epicondylitis.

To evaluate the relationship of ultrasonographic evaluation parameters with pain, muscle strength and disease severity in lateral epicondylitis (LE). 64 people were included in present retrospective, cross-sectional study. Activity and rest pain was questioned with Visual Analog Scale (VAS). Also, Patient Rated Tennis Elbow Evaluation (PRTEE) and the maximum grip strength were evaluated. Hypoechoic region, neovascularity, cortical irregularity, enthesopathy and peritendinous fluid or bursitis were evaluated by ultrasonography. 48 of the patients were female and 16 were male. Mean age was 48.53 ± 6.12, body mass index was 27.70 ± 4.75. 55 (85.9%) hypoechoic region, 31 (48.4%) neovascularity, 21 (32.8%) cortical irregularity, 19 (29,7%) enthesopathy, and 18 (28.1%) peritendinous fluid or bursitis were detected by ultrasonography. When the ultrasonographic findings and clinical findings of the patients were compared, no significant difference was found between the hypoechoic region, cortical irregularity, enthesopathy and clinical findings (P > .05), while the extension grip strength was found to be significantly lower in patients with neovascularity (P = .045). In addition, patients with peritendinous fluid or bursitis, were found to be significantly lower in both flexion (P = .033) and extension (P = .023) grip strength, while PRTEE function (P = .021) subgroup and total (P = .038) scores were significantly higher. Hypoechoic region, cortical irregularities and enthesopathy were not evaluated to be associated with disease severity, pain and muscle strength. Neovascularity was found to be associated only with extension grip strength. Peritendinous fluid or bursitis was found to be associated with both flexion and extension grip strength and disease activity, but not associated with pain.

Effect of Active Release Technique and Cyriax approach on pain, grip strength and functional performance in individuals with lateral epicondylitis: a randomized clinical trial protocol

Background: Tennis elbow, also known as lateral epicondylitis, is a painful condition characterized by irritation of the tendons that link the forearm muscles on the outside of the elbow, which can result from using the elbow too much. Active Release Technique (ART) is defined as a hands-on approach that manages cases to enable the identification and treatment of soft tissue injuries. Through the removal of fibrosis and adhesions that can develop in tissues as a result of overload from frequent use, the aim of ART, a soft tissue treatment, is to lessen tissue stress. Deep transverse friction (DTF) and Mill's manipulation, which are used shortly after DTF, have been used by Cyriax and Cyriax to successfully treat tennis elbow. ART and Cyriax techniques have shown promise for lateral epicondylitis sufferers. There hasn't yet been any research comparing these two approaches for participants with lateral epicondylitis. The aim is to examine the efficiency of ART with the Cyriax technique on lateral epicondylitis pain, strength, and function. Methods: A total number of 60 participants will be included as per the inclusion criteria and then they will be further divided into 30 in each group. The physiotherapy intervention will be given to Groups A (ART) and Group B (Cyriax technique) along with conventional 12 sessions spread across four weeks, three times per week. Each patient will be evaluated during and after treatment on the baseline and after four weeks using the Visual Analogue Scale (VAS), hand grip strength dynamometer, and Patient-rated Tennis Elbow Evaluation (PRTEE) scale. Conclusions: This physiotherapy intervention could be used in the treatment of lateral epicondylitis if our study's hypothesis is found to be accurate. Registration: CTRI (CTRI/2023/06/053660; 08/06/2023).

A systematic review of the effectiveness of wrist manipulative therapy in patients with lateral epicondylitis

Study DesignSystematic review. IntroductionSeveral treatment methods treat lateral epicondylitis, but there is no consensus regarding the most effective method. Research has suggested that joint mobilizations may help recover patients with lateral epicondylitis. Purpose of the StudyTo determine if wrist joint manipulations effectively improve pain, grip strength, ROM, and functional outcome in adults with lateral epicondylitis. MethodsSearches were performed in 6 databases to identify relevant clinical trials. Three reviewers independently extracted data and assessed the methodological quality using the PEDro scale. Standard data were extracted and summarized. ResultsA total of 4 studies met the inclusion criteria. A best-evidence synthesis was used to summarize the results. The included studies found effectiveness in favor of wrist manipulations given for at least 3 weeks to reduce pain in lateral epicondylitis against comparison groups comprising ultrasound, laser, friction massage, and exercises. Functional outcomes varied considerably among studies. Grip strength showed varied results, and no effect was seen on wrist ROM. ConclusionThe evidence is convincing that wrist joint manipulations positively affect pain in the short term, compared to comparison groups in the management of lateral epicondylitis. Future high-quality studies are recommended.

COMPARISON OF MOBILIZATION WITH MOVEMENT AND SOFT TISSUE MOBILIZATION ON PAIN SEVERITY, HAND GRIP STRENGTH AND FUNCTIONAL ACTIVITY IN TENNIS ELBOW PATIENTS

BACKGROUND AND AIM Lateral epicondylitis or tennis elbow is a pain pattern most commonly seen in tennis player due to forceful repetitive movements in a wrong way. So, the Objective was to determine the comparison of mobilization with movement and soft tissue mobilization on pain, grip strength and functional activity in patients with tennis elbow. METHODOLOGY In this Randomized Controlled Trial, Non probability sampling technique was used. Thirty tennis players having lateral epicondylitis pain were included in the study. Two interventions were used i.e. Mobilization with movement and soft tissue mobilization. Pain, Muscle power and function activity were 3 outcome measure in both groups. RESULTS In both groups the mean age of the participants was 24.30 ± SD 3.01. There was a significant Mean difference in the pain scores for MWM (5.34) and Soft Tissue Mobilization (3.74) after treatment. P value is significant for both group but there was greater difference with group MWM CONCLUSIONS The present study concluded that Mobilization with movement has greater effect than the Soft Tissue Mobilization in relieving pain and improving Hand grip strength and functional activity in patients with tennis elbow. Key words Movement, soft tissue, pain, grip, hand strength functional status, tennis elbow

Which injections are effective for lateral epicondylitis?

Placebo injections actually improve lateral epicondylitis at high rates. No other injections convincingly improve it better than placebo.Corticosteroid injection is not superior to saline or anesthetic injection (strength of recommendation [SOR] A, systematic review of randomized controlled trials [RCTs]). Platelet-rich plasma (PRP) injection is not superior to saline injection (SOR A, meta-analysis of RCTs).Botulinum toxin injection, compared to saline injection, modestly improved pain in lateral epicondylitis, but with short-term grip-strength weakness (SOR A, meta-analysis of RCTs). Prolotherapy injection, compared to saline injection, improved pain at 16-week, but not at 8-week, follow-up (SOR B, one small pilot RCT).Hyaluronic acid injection, compared to saline injection, resulted in a statistically significant pain reduction (6%) but did not achieve the minimum clinically important difference (SOR B, single RCT).Autologous blood injection, compared to saline injection, did not improve disability ratings (SOR B, one small RCT).

Magnetic resonance imaging and clinically controlled improvement of a combined autologous conditioned plasma combined with rh collagen type I injections in lateral epicondylitis.

The purpose of the study was to investigate the effect of combined autologous conditioned plasma and recombinant human collagen type I injections on lateral epicondylitis. Outcome was measured in 5 patients before the single application of ACP+rhCollagen type I (Arthrex ACP® Tendo) and after 10.60±3.58wks by means of (i) the Visual Analogue Scale for pain, (ii) range of motion for wrist extension/flexion as well as supination/pronation, and (iii) MRI-scans. VAS-scores significantly decreased from 6.40±1.14 at baseline to 1.80±2.49 at follow- up, and the effect was very large (p=0.04, dz=2.22). In addition, range of motion either improved or remained unrestricted, and MRI-scans showed healing of the extensor carpi radialis brevis tendon in most cases. A combined ACP+rhCollageninjection successfully reduces pain in lateral epicondylitis. Due to the small sample size, however, these promising preliminary results need further investigation in future research.

EFFECTS OF MULLIGAN AND CYRIAX APPROACH IN PATIENTS WITH SUBACUTE LATERAL EPICONDYLITIS

Objective: To determine and compare the effects of Deep Transverse Friction (DTF) Massage and Mill’s manipulation (Cyriax) with Mobilization with movement (MWM) and Taping (Mulligan) in lateral epicondylitis patients. Material & Methods: A Randomized Control Trial (NCT03848117) was conducted in Physiotherapy Department of DHQ Hospital Bahawalnagar after the approval from the competent authority. Non-probability convenient sampling technique was used to collect sample. The n=30 sample size was randomly allocated in two groups as Group A i.e. the Cyriax group (DTF Massage & Mill’s Manipulation) and Group B i.e. the Mulligan group (Taping & MWM), with 15 participants in each group having sub acute lateral epicondylitis. Data was collected in terms of age, gender, BMI and occupation. Patient related tennis elbow evaluation (PRTEE) questionnaire was used to determine the level of pain, functional disability and hand grip strength. Mann Whitney U statistics test was used for between the group analysis and Friedman with Wilcoxon signed ranks test was used for within the group analysis. The significance level was set at p<0.05. Results: The mean±SD age of subjects in Cyriax group was 33.60±6.864 years and in Mulligan group was 36.93±7.741 years. MWM with taping and Mill’s manipulation with DTF massage both showed significant improvement (p<0.001) in pain, function ability and handgrip strength throughout the treatment duration. When comparing the both group regarding pain, Cyriax approach showed significant improvement after 2nd week while mulligan’s approach showed more improvement than Cyriax approach (p<0.001) in functional ability from 2ndto 3rd week. Hand grip strength in both groups did not show any significant difference (p≥0.05). Conclusion: Mobilization with movement& taping (Mulligan) and mill’s manipulation with DTF massage (Cyriax), both are effective in improving pain, functional ability and handgrip strength in lateral epicondylitis. Cyriax approach is more effective in relieving pain in lateral epicondylitis as compare to Mulligan’s approach. On the other hand, functional ability, more improve with Mulligan’s approach. But both treatments are equally effective in improving hand grip strength in lateral epicondylitis. Keywords: Tennis elbow, mobilization with movement, hand grip strength, patient rated tennis elbow evaluation (PRTEE), Deep Transverse friction massage.

The Effect of Stretching and Strengthening Exercise in the Management of Lateral Epicondylitis

Background: Lateral Epicondylitis (LE) is a common overuse injury of Elbow that generates pain over the lateral aspect of elbow. LE is one of the most common causes of elbow and forearm pain encountered in clinical practice commonly associated with resistant wrist or finger extension and gripping activities. The management of LE is enlightened by various form physical modalities and therapeutic exercise like stretching and strengthening exercise. The purpose of this prospective study was to investigate the effects of stretching and strengthening exercises on pain and grip strength of LE. Materials and methods : Eighty patients were enrolled, non-randomized, and divided into 2 groups an experimental Group-A of 40 (44.5 ± 1.5 years) whose receive therapeutic exercise in the form of stretching and strengthening of common extensor forearm muscle and a control Group-B of 40 (41.4 ±2.5 years). Study duration was about one year. Both Group received UST over the lateral aspect of elbow with the 3MHz frequency and 0.5 watt/cm2 intensity for 5 min three sessions per week for six weeks. They were evaluated at every weeks of treatment for six weeks. Comparison between Group-A and Group-B was done with Wilcoxon Rank sum test and unpaired ttest. Results: By the end of the trial period, statistical data analysis in between the two groups showed a significant improvement in pain scores of VAS and the maximal isometric grip strength at sixth week. Conclusion: This study depicts that therapeutic exercise is more effective in reducing pain and improvement of grip strength. So, stretching and strengthening exercise should be considered as a main therapeutic armamentarium in the management of LE.
 JCMCTA 2019 ; 30 (1) : 36-42

Predictors for outcome in acute lateral epicondylitis

BackgroundLateral epicondylitis or tennis elbow is a frequent condition with long-lasting symptoms. In order to identify predictors for treatment success and pain in lateral epicondylitis, we used data from a randomized controlled trial. This trial investigated the efficacy of physiotherapy alone or combined with corticosteroid injection for acute lateral epicondylitis in general practice.MethodsThe outcomes treatment success and pain score on VAS were assessed at 6, 12, 26 and 52 weeks. We ran a univariate binary logistic regression with generalized estimating equations (GEE) and subsequently an adjusted multilevel logistic regression to analyze the association between potential prognostic indicators and the outcome success/ no success. To assess the changes in pain score we used a two-level multilevel linear regression (MLR) followed by an adjusted MLR model with random effects.ResultsThe most consistent predictor for reduced treatment success at all time points was a high Pain Free Function Index score signifying more pain on everyday activities. Being on paid sick-leave and having a recurring complaint increased short term treatment success but gave decreased long-term treatment success. The patients reporting symptoms after engaging in probable overuse in an unusual activity, tended towards increased treatment success at all time-points, but significant only at 12 weeks. The most consistent predictor of increased pain at all time points was a higher overall complaints score at baseline.Conclusions: Our results suggest that in treating acute lateral epicondylitis, a consideration of baseline pain, a registration of the patient’s overall complaint on a VAS scale and an assessment of the patient’s perceived performance in everyday activities with the Pain Free Function Index can be useful in identifying patients that will have a more protracted and serious condition.Trial registrationClinicalTrials.gov Identifier: NCT00826462. Date of registration January 22, 2009. The Trial was prospectively registrated.

Are botulinum toxin injections effective in reducing pain in lateral epicondylitis?

Mathews, Neilson MD; Brohm, Veronica DO; Banerjee, Elaine Seaton MD, MPH Author Information

Management of tennis elbow with topical glyceryl trinitrate.

The aim of this study was to evaluate the treatment results of the application of nitric oxide (NO) in the form of topical glyceryl trinitrate (GTN) for the treatment of lateral epicondylitis (LE). The study included 40 patients with LE randomized into 2 equal groups. Selection criteria included the presence of pain, tenderness, and positive pain stimulating maneuvers. Glyceryl trinitrate patches were applied to the area of maximal tenderness once a day in the treatment group and placebo patches in the control group. Outcomes in terms of pain relief was assessed using the visual analog scale (VAS) and were evaluated according to the criteria of Verhaar et al. Excellent or good results were considered successful. Differences in VAS scores between the two groups were calculated using the Mann-Whitney U-test and the chi-square test was used to investigate distributions of categorical variables (sex, affected side) and good and excellent results among groups. There were no significant differences in any of the baseline clinical parameters between groups. At the 3rd week follow-up, there were statistically significant differences in the pain measured using VAS between groups (mean VAS score of the control and treatment groups were 6.45 and 3.15, respectively) (p=0.001). Patients in the GTN group and control group had lower VAS pain scores and reduced elbow pain at 3 weeks (3.15 vs 8.05 in the GTN and 6.45 vs 8.80 in the control group). In the control group, no patient had excellent or good results while 18 (90%) patients in treatment group reported successful treatment. There was statistically significant difference in the VAS measured at 6 months between groups (mean VAS score of the control and treatment groups were 4.85 and 0.70, respectively) (p=0.001). The administration of NO directly over an area of tendinopathy through a GTN patch reduces pain and other symptoms in chronic LE.

Blood Flow to the Extensor Carpi Radialis Brevis Muscle Following Adrenaline Infusion in Patients With Lateral Epicondylitis

Based on previous evidence of muscle fiber injury and decreased blood flow in the extensor carpi radialis brevis (ECRB) muscle in lateral epicondylitis (LE), we hypothesized that there would also be an abnormal (vasoconstrictive) vascular response to adrenaline in the ECRB muscle in LE. In a case-control study, we measured skeletal muscle blood flow in 8 patients with LE and in 8 healthy controls in response to a 30-minute intravenous infusion of adrenaline. We used local clearance of technetium-99m in the main portion of the ECRB muscle to calculate muscle blood flow. In support of the hypothesis, the blood flow response to the adrenaline infusion was markedly different in the 2 study groups. Whereas the continuous decrease in technetium-99m clearance rate over time was interrupted by the adrenaline-induced vasodilatory effect in the control group, we detected no such effect in the patient group. In the ECRB muscle in LE, there is a shift in the balance of vasodilatory and vasoconstrictory influences of adrenaline, leading to vasoconstriction during low-dose adrenaline infusion. The adverse adrenaline effect is similar to what was previously observed after minor muscle injury. Whether the vasoregulatory change, by causing relative muscle ischemia, represents the primary etiology in LE or results from muscle injury cannot be determined, but it is likely to contribute to the development and continuation of chronic muscle pain in LE. New ways of thinking about the condition may be required, and pharmacological treatment might be an option to improve the blood supply and avoid further damage to the affected ECRB muscle-tendon unit.

The Myriad Uses of Botulinum Toxin

In this issue, Wong and colleagues report that botulinum toxin (BTx) was significantly more effective than placebo for reducing pain in lateral epicondylitis. Their findings also implied that pain ...

Extensor carpi radialis brevis. An anatomical analysis of its origin.

We studied the origin of extensor carpi radialis brevis using 40 fresh frozen human cadaver specimens. Ten were stained with haematoxylin and eosin and trichrome which showed the collagenous structure of the extensor tendons at their origin. Gross anatomical observation showed that there was no definitive separation between brevis and communis at the osseotendinous junction. The histological findings confirmed the lack of separation between the two tendons. The extensor tendons were in close proximity to the joint capsule but trichrome staining showed no interdigitation of the tendon with the capsule. The validity of ascribing the pain of lateral epicondylitis to extensor carpi radialis brevis must be questioned. It appears to arise more from the 'common extensor' origin.