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Elbow tendinopathy: lateral epicondylalgia

Bill Vicenzino

Diagnostic considerations
Pathologic considerations
Prognostic considerations
Considerations in conservative treatment


The common tendon of the extensor muscles of the wrist
and fingers is the most frequently implicated tendon in
elbow tendinopathy and will be the focus of this chapter.
There is contention as to the correct nomenclature for the
tendinopathy of the extensor muscles of the wrist and fingers. A number of terms are used in reference to this tendinopathy, such as, tennis elbow, lateral epicondylitis, lateral
epicondylosis and lateral epicondylalgia. Tennis elbow is
frequently used colloquially, but this term confuses many
patients, as the condition is also very prevalent in those
patients who do not play tennis. Epicondylitis infers
inflammation, which has long been shown not to be the
case (Nirschl & Pettrone 1979, Regan et al 1992, Potter
et al 1995, Kraushaar & Nirschl 1999, Alfredson et al
2000). Epicondylosis or tendinosis connotes a degenerative
change, but whilst there has been identified elements of
disarray, breakdown or degeneration of collagen fibrils in
such tendons (Regan et al 1992, Kraushaar & Nirschl
1999), the relationship to presenting pain symptoms and
associated clinical signs is not clear (Khan & Cook 2000).


Lateral epicondylalgia indicates that there is pain over

the lateral epicondyle which may be an accurate term to
use for the patient presenting with pain over the lateral
epicondyle, but it provides little information about the
underlying pathology. Recent reports of neovascularization and associated increased concentrations of algogenic
mediators such as glutamate, substance P and calcitonin
gene-related peptide (Ljung et al 1999, 2004, Alfredson
et al 2000, Zeisig et al 2006, du Toit et al 2008) suggests
that tendinopathy is far more complex than any of these
commonly used terms suggest. For this chapter, the term
lateral epicondylalgia will be used to describe the patient
who attends the clinic with pain over the lateral epicondyle, as will be highlighted, this may be due to some
pathology in the tendon, that is, tendinopathy, but the
pain may also be associated with other conditions, which
need to be considered to fully rehabilitate the patient.
Although there is no definitive evidence, the incidence
of lateral epicondylalgia varies from 1% to 3% in the
general population (Allander 1974, Verhaar 1994), which
contrasts to reports of prevalence rates as high as 3564%
in occupations requiring repetitive manual tasks
(Kivi 1982, Dimberg 1987, Feuerstein et al 1998), where
it is one of the most costly of all work-related injuries
(Kivi 1982, Dimberg 1987, Feuerstein et al 1998). A survey of United States of America Department of Labor,
Office of Workers Compensation Programs, accepted
claims of occupational upper extremity disorders demonstrated that lateral epicondylalgia was responsible for
approximately 27% and 48% of all work related claims
for upper limb tendinopathies and enthesopathies,
respectively (Feuerstein et al 1998). This chapter focuses
on the most common tendinopathy about the elbow,
lateral epicondylalgia, with specific consideration of the

2011 Elsevier Ltd.

DOI: 10.1016/B978-0-7020-3528-9.00023-6

Chapter | 23 |

Elbow tendinopathy

evidence in regards to diagnosis, pathology, conservative

management and prognosis.

Lateral epicondylalgia is usually identified or diagnosed
on the basis of a clinical examination. Classically, the
patient presents with pain over the lateral elbow and
may spread into the dorsal forearm as far as the wrist,
but no further than the wrist and not proximally to the
elbow (see Slater et al (2003, 2005) for patterns of pain
maps). Those with pain and symptoms into the hand
and fingers or proximal to the elbow should be considered to have concomitant problems (e.g. cervical spine
referral, neuropathy) in addition to, or instead of, lateral
epicondylalgia. Patients with lateral epicondylalgia will
have pain and weakness with tests that challenge the wrist
extensor muscles, for example, muscle contraction tasks of
gripping, wrist extension, and middle finger extension
(clinically described as a test of extensor carpi radialis brevis, largely due to the insertion of that tendon at the
wrist). It is commonly reported that stretch of the wrist
and finger extensors is present in these patients, though
while pain may be reproduced on stretching, it is not an
uncommon observation by this author that patients
exhibit increased length of these muscles (i.e. increased
range of flexion of the wrist and fingers) associated with
pain reproduction in those with chronic conditions. The
pain reproduction is limited to the lateral epicondyle
and at most some spread down into the dorsal forearm.
Palpation will identify areas of hyperalgesia in and
around the lateral epicondyle, at the site of the common
extensor tendon as well as in some cases pain into the
dorsal forearm muscles. These palpation findings need
to be present with impairment in muscle contraction; otherwise it is more likely that the symptoms could be largely
referred from other regions, such as the cervical spine.
Typically patients attending general practice with lateral
epicondylalgia will characteristically be in their 4th or 5th
decade of life. There is upper limb dominance bias, but
not sex. Patients who perform repetitive tasks requiring
sustained or repeated gripping of an implement or tool,
such as those playing tennis or undertaking manual
labour, may be outside of this decade (i.e. younger), but
there should be a higher degree of suspicion of an alternative underlying cause and diagnosis. For example, in
younger people consideration needs to be given to osteochondritis dissecans of the capitellum and radius in cases
with insidious onset, and bursitis, radio-humeral joint
synovitis and other soft tissue sprains in more acute onset
pain and swelling, whereas in more elderly patients the
practitioner will need to consider degenerative conditions
of the radio-humeral joint and referral from the cervical
spine (Brukner & Khan 2007).

Lateral epicondylalgia is by definition a clinical entity

not usually requiring confirmatory diagnostic imaging or
other medical pathology tests. Diagnostic imaging is likely
more helpful in excluding differential diagnoses. For
example, radiographs may be used to identify injuries of
bone, such as, fractures, apophysitis and sub-chondral
arthritic changes. Ultrasound has taken on a greater role
in the direct identification of grey scale hypoechoic
lesions, which imply dysfunction in the connective tissues. These grey scale changes are not necessarily linked
to pain in the tendon (Cook et al 2001, 2004, du Toit
et al 2008) and so they could be legitimately termed tendinopathy, meaning some pathology in the tendon, and
is most likely due to degenerative breakdown of collagen
fibrils (epicondylosis), though fusiform swelling may
be more indicative of cellular and matrix dysfunction
(Cook & Purdam 2009). Increasingly, evidence is pointing
towards a link between neovessels and symptoms, namely
pain (Cook et al 2001, 2004, du Toit et al 2008), with a
recent study showing that in a patient with longstanding
lateral elbow pain, which has failed to respond to treatment, the lack of neovessels strongly indicates that the
pain is not due to tendinopathy, thus prompting the practitioner to consider other diagnoses (du Toit et al 2008).
Magnetic resonance imaging may be used to follow up
recalcitrant cases where there are no radiographic or ultrasonographic changes present, but these cases will be in the

Nirschl & Pettrone (1979) described the underlying
pathology of lateral epicondylalgia to be one of angiofibroblastic hyperplasia with the following identified histological changes: (a) proliferation in the number of cells
and in ground substance, (b) neovascularization or vascular hyperplasia, (c) higher levels of algogenic substances,
as well as (d) disorganized immature collagen (Nirschl
& Pettrone 1979, Nirschl 1992, Regan et al 1992,
Fredberg et al 2008). In an effort to more adequately
explain different clinical presentations, Cook & Purdam
(2009) have recently proposed a clinical model of
histo-pathological changes across a continuum from: (a)
reactive tendinopathy, (b) tendon disrepair to (c) degenerative tendinopathy. A brief summary of this proposed
clinical model follows and the reader is referred to their
paper for more detail.
Reactive tendinopathy is a non-inflammatory proliferative cellular and matrix response in response to either an
acute tensile overload as may occur with a bout of unaccustomed physical activity or from a compressive overload due to a direct contact injury. This is likely to occur
in the younger athlete who rapidly increases the intensity
or volume of physical activity and is managed well with a


Part | 4 |

The elbow region

short period of absence from the increased loading activities before restoring pain free function. Consequently
the classic presentation of lateral epicondylalgia is not
likely to fall into this category, though it is important to
keep this category in mind for younger athletes such as
tennis players or manual labourers, as well as patients
who present with pain after an acute traumatic blow to
the common extensor origin at the elbow. At the other
end of the spectrum the degenerative phase is characterized by angiofibroblastic hyperplasia changes, with considerable breakdown in the collagen framework and
neovascularization. This tends to occur with chronic overloading in the older person; hence more appropriately fits
that which is likely to be present in a classical presentation of lateral epicondylalgia. There is a sound argument
that exercises need to be a fundamental inclusion in the
treatment plan for degenerative tendinopathy (Cook &
Purdam 2009, Khan & Scott 2009).

Lateral epicondylalgia is widely regarded as being self-limiting and resolving within 6 months to 2 years, however
this is low-level evidence as the natural history of this condition has not been definitively determined. Notwithstanding this, recently a number of randomized clinical
trials that have followed cases over 12 months (Smidt
et al 2002, Bisset et al 2006, 2007, Smidt & van der Windt
2006) and provide data that may be used in determining
The evidence from two randomized clinical trials (n
383) (Smidt et al 2002, Bisset et al 2006), which included
randomizing a group of patients to following a wait-andsee policy indicates that 87% of patients reported being
much improved or completely recovered 12 months after
inclusion into the study (Bisset et al 2007). When considering that patients had on average approximately 6
months duration of pain at inclusion into the study
(Bisset et al 2007), an approximate indicative natural
history of the condition is in the order of 18 months for
the majority of sufferers. It is important to keep in mind
that the patients allocated to the group following the wait
and see policy were given advice on avoiding aggravating
activities (e.g. ergonomic advice on how to lift objects
and manipulate implements without aggravating pain)
as well as being closely monitored in a clinical trial (and
thereby prone to the Hawthorne effect), which is not necessarily the same as a person with lateral epicondylalgia
not seeking out advice and doing nothing about the condition. Furthermore, Bisset et al (2006) reported that
those in the group allocated to wait and see policy were
2.7 times more likely to seek out other treatments than
those allocated to a mobilization with movement and
exercise group (OR, 95% CI: 4.7, 2.110.3), which is


not the same as doing nothing about the lateral epicondylalgia. To the contrary it tends to indicate that despite
being recruited into a clinical trial and being closely monitored patients do not feel comfortable in doing nothing
about their condition.
Smidt et al (2006) prospectively followed 349 patients
from two randomized clinical trials (Hay et al 1999, Smidt
et al 2002) over a 12-month period and found that those
who had more severe pain of longer duration had greater
likelihood of a worse outcome (more severe pain) at 12
months. Another prognostic factor of poor outcome was
concomitant neck pain (Smidt et al 2006). This finding is
interesting because it indicates that the patient pool
recruited in this study had a heterogenic pain presentation,
including cases with more complex presentations (e.g. lateral epicondylalgia plus neck pain) and did not consist
solely of patients with isolated lateral epicondylalgia.

A wide range of conservative treatments, such as, medication, electrophysical agents, exercise and manual therapy
are advocated for lateral epicondylalgia, which usually is
an indication that no one treatment has proven superiority, but also in part a product of an inconclusive understanding of the underlying pathology of the condition.
Corticosteroid injections are the most common conservative medical intervention for lateral epicondylalgia and
accordingly they have been studied the most in high quality rigorous clinical trials. There is level 1 evidence from a
number of randomized clinical trials of short term efficacy
with success rates over 80% in the first 46 weeks
(Hay et al 1999, Smidt et al 2002, Bisset et al 2006,
2007, Smidt & van der Windt 2006), but this needs to be
considered in light of post-6 weeks poorer outcomes in
the form of lower success rates compared to the adoption
of a wait and see policy (Smidt et al 2002, Bisset et al
2006, 2007, Smidt & van der Windt 2006), higher recurrence rates (70% vs 8%) and greater use of other not per
protocol co-interventions (49% vs 21%) than those
patients undergoing mobilization with movements and
exercise intervention (Bisset et al 2006, 2007). The poorer
downstream effects are sufficient to prompt caution in
their use and some have advocated against their use in
lateral epicondylalgia (Young et al 1954, Osborne 2009,
Vicenzino 2009), at least in the first instance without a
concerted attempt at other interventions that do not have
such a poor longer-term effect on the condition. Others
have advocated combining the use of these injections with
physiotherapy (Coombes et al 2009a, Olaussen et al
2009), but there has not been the same level of enquiry.
There is a sound level of evidence in support of exercise
in treating lateral epicondylalgia, but unlike in lower limb

Chapter | 23 |

Elbow tendinopathy

tendinopathy, eccentric exercise is not necessarily better

than concentric exercise (Woodley et al 2007). Perhaps
the most illustrative evidence comes from a randomized
clinical trial comparing an exercise programme versus
ultrasound in a group of patients who had recalcitrant lateral epicondylalgia having failed other treatments including corticosteroid injections and other common
modalities (Pienimaki et al 1996). Follow up some 3
years later revealed that the exercise group required fewer
medical consultations, had less surgery (NNT 3) and
586 fewer sick days than the group that had ultrasound
(Pienimaki et al 1998). The exercise programme was
graduated and progressive from isometric to isotonic contractions of the wrist and forearm muscles, culminating
in pragmatic exercises that replicated patients required
function. It was supervised two times per week for approximately 8 weeks. A recent study has shown that supervision of the exercise programme returns superior effects
to a home based one (Stasinopoulos et al 2009), which
should be considered when prescribing exercise.
Electrophysical agents such as LASER, ultrasound, and
extracorporeal shock wave therapy (ESWT) have attracted
attention. Low level LASER therapy has been shown to
be effective in improving pain levels in the short term
compared to control, but only at wavelength of 908 nm
(Bjordal et al 2008). There appears to be less conclusive
evidence and some contention for or against the use of
ultrasound and ESWT in the treatment of lateral epicondylalgia, perhaps because of a lack of specification and
stratification of dosage parameters.
Elbow orthotics or tennis elbow bands that fit about the
proximal forearm are frequently used, often on a selfselection basis by patients. Systematic reviews have been
unable to find sufficient high quality clinical trials to support or refute their use (Struijs et al 2001, 2002, 2004).
Joint (high and low velocity) and soft tissue manipulations have been proposed for use in treatment of lateral epicondylalgia (Lee 1986, Vicenzino et al 2007a). The initial
effects of elbow mobilizations with movement (Vicenzino
2003) used as a single modality have been shown in a number of studies (Vicenzino et al 1996, 2001, 2007b, Abbott
et al 2001, Paungmali et al 2003) and shown to be effective
when used in combination with exercise (Kochar & Dogra
2002, Bisset et al 2006). There are conflicting interpretations
of the literature regarding the use of Mills manipulation and
friction massage, also referred to as Cyriax physiotherapy
(Vicenzino et al 2007a, Kohia et al 2008), which may be
in part due to the lack of high quality clinical trials (Bisset
et al 2005). There is a randomized clinical trial that has
shown that wrist manipulation was efficacious when compared to ultrasound, friction massage and exercise (Struijs
et al 2003).
As identified in a prognostic analysis, patients with concomitant neck pain have a poorer outcome (Smidt et al
2006), but the neck was not treated and so it is not possible to determine if it would have been beneficial to have

added neck treatment to the elbow treatment. However,

there are several other studies that show benefits of adding treatment of the cervical spine to elbow treatment
(Gunn & Milbrandt 1976, Cleland et al 2004, 2005).
Gunn & Milbrandt (1976) treated 50 recalcitrant cases of
lateral epicondylalgia with non-thrust manipulation and
traction of the cervical spine and showed an 86% success
rate after treatment that persisted at 6 months. In a retrospective case audit of 112 cases, Cleland et al (2004)
showed significantly fewer treatments were required for
those (n 51) who received additional manual therapy
to the cervical spine in the form of non-thrust oscillatory
manipulations, mobilization with movements and/or
muscle energy techniques. More recently in a pilot trial
of 10 cases, Cleland et al (2005) reported a better result
on pain free grip force and the Disability of the Arm,
Shoulder and Hand questionnaire. Furthermore, there
are a number of studies that show both high and lowvelocity manipulations of the cervical spine produce an
initial improvement in pain at the elbow (Vicenzino
et al 1996, 1998, Fernandez-Carnero et al 2008). This evidence provides a basis for the cervical spine to be treated
if found to be implicated on physical examination, especially since there have been reported significant differences in pain provocation on manual examination of
the cervical spine and significant reductions in sagittal
plane motion in patients with lateral epicondylalgia when
compared to age-matched controls (Waugh et al 2004,
Berglund et al 2008).
The challenge facing the practitioner is how to best select
a treatment approach for each individual patient, who is
likely to be somewhat different in their individual clinical
presentations. The continuum model of presentation of
tendinopathy (Cook & Purdam 2009) outlined above
along with the proposed integrative model of lateral
epicondylalgia (Coombes et al 2009b) may provide some
guidance on how the practitioner may wish to select from
the many proposed treatments. In brief, Coombes et al
(2009b) propose that each patient presents with a different
proportional representation of dysfunction in the pain and
motor systems as well as in tendon structure and physiology, which could be used to select specific interventions.
For example, if a patient presents with relatively greater
pain system impediment as would be seen clinically with
large deficits in pressure pain thresholds and high pain
severity scores, then pain relieving medications, electrophysical agents and manual therapy should be favoured. In
contrast, a patient who presented with a progressed stage
of degenerative tendinopathy with moderate to low levels
of pain would be managed more so with specific exercise
(Coombes et al 2009b, Khan & Scott 2009) and possibly
injections of medication/materials (Rabago et al 2009) or
glyceryl trinitrate transdermal patches (Paoloni et al 2003,
2009, Murrell 2007) that promote collagen synthesis.
Further detail regarding the integrative model of lateral epicondylalgia can be found in Coombes et al (2009b).


Part | 4 |

The elbow region

Tendinopathy at the elbow is commonly experienced
over the lateral epicondyle. Over the past decade there
has been an increase in the knowledge of our understanding of the underlying pathology, conservative management and prognosis of this pain condition. While this

has provided more information and data for practitioners to consider when treating patients with lateral
epicondylalgia, the challenge still remains to selectively
apply specific treatments to individual patients in
order to drive optimum outcomes. This chapter provides
a synopsis of the recent evidence and some indication
of possible means by which to apply such evidence

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