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Corresponding author. Department of Rehabilitation Medicine, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan. Fax: +81 4 2996 5223.
Lateral Epicondylitis Clinical Practice Guidelines Development Committee, JapanDepartment of Rehabilitation Medicine, National Defense Medical College Hospital, Japan
Lateral Epicondylitis Clinical Practice Guidelines Development Committee, JapanDepartment of Orthopaedic Surgery, St. Marianna University School of Medicine, Japan
Lateral Epicondylitis Clinical Practice Guidelines Development Committee, JapanDepartment of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Japan
Lateral Epicondylitis Clinical Practice Guidelines Development Committee, JapanDepartment of Orthopaedic Surgery, Higashihiroshima Medical Center, Japan
Lateral Epicondylitis Clinical Practice Guidelines Development Committee, JapanDepartment of Orthopaedic Surgery, Japan Community Health Care Organization, Hoshigaoka Medical Center, Japan
Lateral Epicondylitis Clinical Practice Guidelines Development Committee, JapanTsuchiura Clinical Education and Training Center, Tsukuba University Hospital, Japan
Lateral Epicondylitis Clinical Practice Guidelines Development Committee, JapanDepartment of Orthopaedic Surgery, Okazaki Medical Center, Fujita Medical University, Japan
The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society.
Methods
The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the “Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014”, which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.
Results
The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature.
Conclusions
The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.
1. Introduction
The first edition of the lateral epicondylitis clinical practice guidelines was published in 2006; the second edition was revised based on the concept of evidence-based medicine (EBM) issued by the Japan Council for Quality Health Care and was implemented as per the “Handbook for Clinical Practice Guideline Development 2014 (MINDS 2014)” [
]. During the creation of clinical practice guidelines, evidence, such as that from research treatises, is collected in a systematic manner using an established method called systematic review, and all the evidence adopted is evaluated and integrated as a whole. Further, the guidelines emphasize the importance of “balance between benefit and harm”. The clinical practice guidelines compare multiple intervention methods (diagnosis, treatment, prevention, etc.) that may be selected in a clinical situation and recommend the method that is considered to be the most effective. However, the intervention is equivalent to the effectiveness of the intervention. Attention should also be paid to the harmful aspects. MINDS 2014 proposed preferred methods of guideline preparation in Japan based on The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, Cochrane Collaboration, Agency for Healthcare Research and Quality (AHRQ), and the Oxford EBM center. In the MINDS 2014, the preparation procedures of the guidelines have been defined precisely; in particular, the importance of a viable body of evidence was emphasized. For clinical questions (CQ), study reports were collected using a systematic method and were evaluated as per the outcome data and study design. The results were evaluated in light of a viable body of evidence and were required to emphasize the balance between risk and benefit. Clinical and epidemiological characteristics, natural history, pathology, and diagnosis were not incorporated into the CQ; therefore, a commentary on these characteristics was added as background question (BQ). With respect to the treatment methods that are not covered by Japanese National Health Insurance (insurance), we do not present any recommendations at present and have listed them as future research questions, trusting that in the future, more extensive research will be conducted on this subject. The guidelines are designed to assist the clinician in easily identifying areas of concern and allow him/her to quickly select appropriate treatments for lateral epicondylitis.
The diagnostic criteria for lateral epicondylitis of the humerus followed the diagnostic criteria in the first edition of the guidelines.
1
Most tenderness is experienced at the origin of the extensor muscles of the lateral epicondyle.
2
Resisted wrist dorsiflexion causes pain on the outside of the elbow.
3
Exclude cases wherein the condition is attributable to disorders at sites other than the origin of the extensor muscles, such as disorders of the humero-radial joint.
This disorder is regarded as a disorder of the origin of the extensor muscle group among the disease groups presenting lateral elbow pain and is regarded as an enthesopathy among the disorders of the origin of the extensor muscle group. It is not possible to completely exclude lesions of the humero-radial joint that continuously affect enthesis, such as the annular ligament; however, at least radial tunnel syndrome that is considered entrapment neuropathy of the posterior interosseous nerve is excluded. Since the publication of the first edition, there have been remarkable advances in the treatment of refractory patients who do not respond to conservative therapy, and research is ongoing on the pathophysiology. This edition of the guidelines is applicable to cases of lateral epicondylitis refractory to conservative therapy, synovitis in the elbow joint, synovitis of the humero-radial joint, synovitis fold disorder, degeneration of the humero-radial joint, etc. We also examined lateral humero-radial joint degeneration in a lecture that included periarticular disorders.
2. Results of the literature search
In preparation for the second edition revision, the authors performed a MEDLINE search of the literature to identify papers published from January 2008 to May 2016. In this search, we used the search formula presented in Table 1 and extracted 414 papers. In addition, a Japanese Igaku-Chuo Zasshi search was performed to identify articles published from 2008 to 2016. This search was performed using the search formula presented in Table 2 and yielded 370 articles. In the initial screening, articles that did not match the CQ based on their titles and abstracts were excluded. In the literature search, the primary selection work was performed for 779 cases, excluding duplicates. There were 402 adoptions and 377 exclusions, with an acceptance rate of 51.6%.
Table 1Search formula.
Search formula
Medline search
ID
Hits
Search Criteria
Explanation
L1
1404
TENNIS ELBOW + AUTO/CT
L1-L3: tennis elbow and lateral epicondylitis (included in the title or main theme)
L2
1679
TENNIS? (W) ELBOW#
L3
1118
LATERAL? (3A) EPICONDYL? AND (HUMER? OR ELBOW#)
L4
2048
L1 OR L2 OR L3
L5
1694
L4 AND (ENGLISH OR JAPANESE)/LA
Limited to English and Japanese
L6
1675
L5/HUMAN OR (L5 NOT ANIMALS + NT/CT)
Limited to humans
L7
988
L6 AND 2003–2016/PY AND 20030101–20160,531 UP NOT EPUB?/FS
Limited to a certain age (January 2003–May 2016)
L8
10,901
CASE (1W) SERIES/TI
L9
434
L7 OR L8
L10
414
L9 NOT (LETTER OR EDITORIAL OR COMMENT? OR NEWS?)/DT
3. Preparation of structured abstract and evaluation of the articles
The authors selected 102 clinicians who are experts in the treatment of elbow joints from the Japan Elbow Society Board of Trustees. These individuals constituted a systematic review (SR) team. The SR team performed a secondary screening for the full text of 402 articles and prepared structured abstracts from the articles selected in the secondary screening. Moreover, the SR team performed evaluations for the individual reports. The structured abstracts were based on the MINDS 2014 recommendations. The members of the SR team were assigned specific areas of the lateral epicondylitis guidelines. These team members evaluated the content of the articles based on the structured abstract. As a rule, the selected articles were closely associated with various clinical questions.
4. Strength of evidence and recommendations
The selected articles were evaluated as per the outcome data. Factors, such as risk, lack of direction, inconsistencies, inadequacies, and publication bias, were evaluated to formulate a viable body of evidence. The evaluation and definition of the strength of the body of evidence were determined as described in Table 3. The recommended text was created for each CQ, and the strength of the recommendation was determined by the committee members using a GRADE grid as described in Table 4. The opinions of ≥70% of the voters were considered to determine the recommended final decision. If a consensus of ≥70% of the voters could not be obtained, a discussion and a secondary voting were required. The recommended texts were prepared as per the current practice of orthopaedic surgeons, physiotherapists, etc., as well as the various levels of treatment for lateral epicondylitis. In addition, the authors considered that laypersons, including patients, might also read the second edition for understanding the treatment guidelines.
For the second edition, each selected article was evaluated as per the CQ, outcome data, and final body of evidence. Unlike in the previous edition, we did not evaluate the evidence level of each article. When formulating the body of evidence, the strength of the outcome data of studies, such as randomized controlled trials (RCT), was considered from the initial evaluation (A). The strength of the outcome data from observational studies was evaluated from the initial evaluation (C). Appropriate operations were performed to raise or lower the level of each article that was being evaluated.
6. JOA 2019 clinical guidelines for lateral epicondylitis of the humerus
6.1 BQ-1 What is the natural history (epidemiology) of lateral epicondylitis?
Lateral epicondylitis is common among individuals in their late 30s and 50s, with no sex-based differences. The onset is not associated with labor or the dominant hand side; however, it is associated with the performance of sports activities wherein rackets are used, such as tennis and badminton.
Lateral epicondylitis is less common in young people in their 20s, with most of the affected subjects being in their late 30s–50s [
]. To the best of our knowledge, no studies have described in detail the most common age of onset among heavy laborers or those that perform sports activities [
]. Although some studies have stated the recurrence rate, as per our literature search, no articles have specifically described the sex-based differences in the incidence [
]. There were no sex-based differences in the incidence of lateral epicondylitis caused by loads placed on the upper limbs during sports activities. The incidence of lateral epicondylitis caused by working conditions, including manual work, tends to be slightly higher in women than in men under similar working conditions. With respect to the sex-based differences in the prognosis of lateral epicondylitis, two articles have described that these differences were not associated with symptom relapse following physical therapy intervention and local injection treatment. However, one article stated that in refractory cases, recurrence was more common in women [
]. A study of 266 patients with lateral epicondylitis who were receiving physical therapy intervention showed that sex-based differences were not associated with symptom relapse at 1 year [
Prognostic factors in lateral epicondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice.
Although there are no identifiable risk factors for lateral epicondylitis in adults who lead a typical lifestyle, including sex, age, dominant or non-dominant arm, smoking, and alcohol intake, engagement in work that involves squeezing the hands with the forearm in the protonation position is a potential risk factor among heavy labor workers. A prospective study of highly active workers showed that the prevalence of lateral epicondylitis was 4.91 per 100 persons [
]. In addition, engagement in work that involved clenching of the fists with the forearm of the dominant arm in the pronation position was a risk factor for the development of lateral epicondylitis [
]. Although 3.8% of people living in mountainous areas with a mean age of 61 years are affected by lateral epicondylitis, there was no association with sex, age, engagement in heavy labor, dominant arm involvement, smoking, or alcohol consumption history [
]. A study on 1,777 subjects from the general population showed no evidence of an association with sex, age, smoking, or alcohol preference. However, subjects with a HbA1c ≥ 6.5% had an incidence of lateral epicondylitis that was 3.37 times higher than that in subjects with a HbA1c ≤ 5.5%. Therefore, a chronic hyperglycemic state may contribute to the development of lateral epicondylitis [
In terms of the association between lateral epicondylitis and sports, lateral epicondylitis, also known as tennis elbow, is the most common upper limb disorder resulting from the performance of sports activities wherein a racket is used, such as tennis and badminton. A study comparing groups with and without symptoms of lateral epicondylitis in female tennis players at a recreational level found that the former group tended to have weaker trapezius muscles and wrist extensors [
]. As per a questionnaire survey on injuries and disorders in 328 amateur badminton players, lateral epicondylitis was the most common diagnosis and was more common in players with a higher BMI [
]. To the best of our knowledge, no studies have addressed the differences in the prognosis of patients as per the cause (sports activities or other causes).
The relationship between lateral and medial epicondylitis is unclear. The frequency of lateral epicondylitis tends to be slightly higher; however, both, lateral epicondylitis and medial epicondylitis are upper limb disorders that can develop in workers [
Nirschl surgical technique for concomitant lateral and medial elbow tendinosis: a retrospective review of 53 elbows with a mean follow-up of 11.7 years.
6.2 BQ-2 What is the pathology of lateral epicondylitis?
The site of injury is the proximal insertion of the extensor carpi radialis brevis (ECRB) tendon, and intra-articular lesions are found in the humero-radial joint. The main cause of pain is ECRB tendon enthesopathy that includes the degeneration of the insertion and rupture of the tendon fibers as well as synovial folds and articular cartilage degeneration in the humero-radial joint and damage to the annular ligament. Central sensitization is involved in patients with long-term chronic pain.
The main lesion site of lateral epicondylitis is the proximal insertion of the ECRB tendon in the wrist extensor muscles [
]. The lesion was enthesopathy, and micro-rupture, partial or complete rupture, and calcification of the tendon fibers associated with degeneration of the attachment were observed on ultrasonography [
]. Pathological findings include degenerative rupture of the collagen fibers, fibroblast proliferation, and capillary proliferation, and their association with pain has been pointed out. Furthermore, as per a report, perivascular sympathetic nerve distribution is increased with a decrease in the sensory nerve distribution on the lower surface of the ECRB tendon [
Richly innervated soft tissues covering the superficial aspect of the extensor origin in patients with chronic painful tennis elbow - implication for treatment?.
Marked expression of TNF receptors in human peritendinous tissues including in nerve fascicles with axonal damage - studies on tendinopathy and tennis elbow.
Arthroscopic findings in refractory cases may reveal intra-articular lesions of the humero-radial joint. In particular, the presence of synovial folds in the humero-radial joint has been considered a cause of pain [
]. By contrast, as per another report that questioned the causal relationship between synovial folds and pain, there was no significant difference based on the presence or absence of additional resection of synovial folds in patients with ECRB tendon enthesopathy [
]. In addition, stenosis and rupture of the annular ligament, radial head cartilage degeneration, and joint capsule rupture of the humero-radial joint have been reported as comorbid lesions [
Alignment abnormalities, such as dilatation of the proximal radial joint, have been pointed out as musculoskeletal features that may be involved in the onset of this disorder. Moreover, nerve root symptoms and radial nerve disorders are included as causes of pain on the outside of the elbow, and differentiation of these diseases is necessary [
]. Neurokinin 1 (NK1) receptors have been shown on the central nervous system to be expressed in patients with lateral epicondylitis that may involve central sensitization associated with chronic pain [
The protonation, lifting motion, and repeated gripping work are identified as causative motions that cause pain, and the onset is often on the dominant-hand side [
]. There are significantly more recipients of welfare and workers' accident compensation as background factors, suggesting that illness gain is involved [
6.3 BQ-3.1 What is the importance of physical findings?
Physical findings include tenderness and weakness of the extensor carpi radialis longus and brevis (ECRL, ECRB) tendons, the resisted wrist dorsiflexion test (Thomsen test), middle finger extension test, and extensor grip test.
According to the physical findings, the diagnosis of lateral epicondylitis is established using the resisted wrist dorsiflexion test (Thomsen test) and the middle finger extension test, and the positive rate is reported to be 77%–100%. The positive rates of these tests in patients who were diagnosed with lateral epicondylitis and the effectiveness in diagnosing these tests have not been discussed [
]. However, the positive rate is as high as 100% when performed in the elbow extension and the forearm pronation position, and its usefulness is expected. The extension grip test is positive if the examiner presses the wrist extensor muscles during wrist dorsiflexion and pain is suppressed; this test was recommended, and showed a positive rate of 55%–60% [
6.4 BQ-3.2 Is radiography or electromyography useful for diagnosis?
No studies have evaluated the effectiveness of simple radiography and simple CT in establishing a diagnosis. CT arthrography can diagnose synovial folds. Electromyography is useful for diagnosing differential diseases.
Lateral epicondylitis rarely causes diagnosable deformity or calcification on radiographic examination and is rarely used for diagnosis; however, misalignment, such as dilation of the joint space in the proximal radial joint may be shown. As per our literature search, no studies have shown its usefulness in the diagnosis of osteosclerosis and calcific tendinitis at the extensor carpi radialis brevis tendon attachment. In addition, although simple CT examination is rarely used for diagnosis, the presence or absence of synovial folds can be diagnosed with CT arthrography. However, to the best of our knowledge, no studies have examined its effectiveness for diagnosis, and it cannot be said that it is a useful test considering its invasiveness and radiation exposure.
Electromyography reportedly reduces the muscle activity in the extensor tendons of lateral epicondylitis [
]; however, the usefulness of this technique has not been reported. Electromyography is often used for exclusion diagnosis of radial canal syndrome or radiculopathy.
6.5 BQ-3.3 Is MRI useful in the diagnosis of lateral epicondylitis?
High-signal-intensity lesion on T2 weighted MRI image at the common extensor origin is frequently observed; however, similar findings are seen in the contralateral elbow or among healthy volunteers; therefore, MRI images should be interpreted in reference to the clinical findings.
MRI is frequently used to assess patients with lateral epicondylitis. Lateral epicondylitis is diagnosed as per the physical findings and provocative tests; MRI is of assistance but cannot be used independently for establishing a diagnosis. In patients with clinically diagnosed lateral epicondylitis, increased signal at the common extensor origin is commonly observed on T2-weighted/fat suppression MRI image. As per a systematic review, increased signal in the common extensor tendon was noted in 90% of the patients [
Magnetic resonance imaging of patients with chronic lateral epicondylitis: is there a relationship between magnetic resonance imaging abnormalities of the common extensor tendon and the patient's clinical symptom?.
]. The pathology of the high-signal-intensity lesion is considered to indicate angiofibroblastic hyperplasia caused by degeneration and rupture of the collagen fibers and proliferation of fibroblasts and capillary vessels without inflammatory cell infiltration. No significant correlation was observed between high-signal-intensity lesion on MRI and joint capsule rupture at the ECRB tendon origin. Signal increase in the common extensor tendon can be observed in 14% of healthy volunteers and 50% of the contralateral elbow in patients with lateral epicondylitis [
]. In addition to high-signal-intensity lesion on T2 weighted MRI image, thickening or thinning of the extensor or high-signal-intensity lesion on T1 weighted MRI image may be observed. When the size of the synovial fold is >25% of the diameter of the radial head on MRI, Mullett type 3 synovial fold could be predicted with 83% sensitivity. There was no significant difference in the anconeus and brachioradialis muscles signal change or bone marrow edema between patients and healthy volunteers [
]. Whether MRI findings are correlated to the symptom severity remains controversial. One report has shown a positive correlation between the grading score and Patient-Rated Tennis Elbow Evaluation (PRTEE) [
Magnetic resonance imaging of patients with chronic lateral epicondylitis: is there a relationship between magnetic resonance imaging abnormalities of the common extensor tendon and the patient's clinical symptom?.
], or significant negative correlation between the length of tendon separation in common extensor origin from the lateral epicondyle and both the quick Disability of the Arm, Shoulder, and Hand (DASH) score and maximum pain levels [
]. Two studies have reported on the treatment and MRI findings. In a study that compared patients treated with 20 mg methylprednisolone injection and patients immobilized with a wrist splint, both the groups showed symptom alleviation after 6 weeks; however, MRI findings persisted in 11 of the 16 patients in the injection group and 9 of the 14 patients in the splinting group [
]. In a study on arthroscopically treated chronic lateral epicondylitis patients, the postoperative DASH score was significantly higher in the group wherein hyper-intensity T2-weighted MRI images were not observed pre-operatively [
6.6 BQ-3.4 Is ultrasonography useful for the diagnosis of lateral epicondylitis?
Ultrasonography is useful for diagnosis; however, it has a high false-positive rate, and the result is dependent on the inspector's experience and skills and the equipment performance.
Lateral epicondylitis is diagnosed using physical findings and provocation tests; therefore, ultrasonography is only a supplementary examination and cannot be used independently for the diagnosis. Ultrasonography findings characteristic of lateral epicondylitis include swelling, thickening, hypoechoic region, and calcification of the extensor digitorum tendon insertion [
Many studies that have compared the results of ultrasonography of the extensor tendon attachment in patients with lateral epicondylitis and healthy subjects have exhibited high sensitivity and low specificity of diagnosis. Furthermore, the positive predictive value is low, and the negative predictive value is relatively high. A systematic review of 10 papers showed that the sensitivity of this examination for diagnosis was 0.82 [95% confidence interval (CI): 0.76–0.87] and the specificity was 0.66 (95% CI: 0.60–0.72); this examination offers the advantages of being non-invasive, cost-effective, and faster than MRI and arthroscopy. However, this method is easily affected by several factors, such as the experience and skill of the operators, equipment, and stage of pathology [
]. There is no consensus on the relationship between ultrasonography findings and treatment effectiveness. One report has suggested that the size of the intra-tendon tear and the lateral collateral ligament rupture on ultrasonography showed a negative correlation with the treatment outcomes [
]; by contrast, another study has shown no significant difference between ultrasonography findings before conservative treatments and the degree of improvement in the symptoms after treatments [
6.7 CQ- 4.1 Is drug therapy useful for lateral epicondylitis?
Evidence is insufficient although drug therapy is widely used with short-term effectiveness (Recommendation 2, Agreement ratio 82%, Level C).
Oral administration of 150 mg diclofenac for 28 days significantly reduced pain and improved the grip strength as compared to placebo; however, no improvement in the ability to perform activities of daily living (ADL) was observed [
]. The application of diclofenac epolamine gel was useful because it significantly reduced pain and improved the ability to perform ADL; however, the administration and evaluation period was only 10 days, and only immediate effects were investigated [
Analgesic efficacy of a lecithin-vehiculated diclofenac epolamine gel in shoulder periarthritis and lateral epicondylitis: a placebo-controlled, multicenter, randomized, double-blind clinical trial.
]. When the glyceryl trinitrate patch was applied for 8 weeks, the pain reduced significantly; however, there was no difference in the grip strength, limiting the usefulness [
]. The drug therapies in these 3 papers differ in terms of the dosage form and pharmacological action and should not be considered in an integrated manner. Further, although short-term immediate effects can be expected for each, without long-term evaluation, it cannot be known whether they eventually cured the patient.
6.8 CQ-4.2 Are local injections of corticosteroid effective for lateral epicondylitis?
Local injections of corticosteroid are effective for lateral epicondylitis during the short-term period and are recommended for conservative treatment. (Recommendation 2, Agreement ratio 100%, Level A).
Local corticosteroid injection is recommended for reducing pain, improving the ability to perform ADL, and increasing the grip strength in patients in the short-term (within 3 months) [
Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial.
Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial.
].. With respect to a mid-term effect (within 6 months), the injection is recommended to reduce pain and increase the ability to perform ADL in the patients; however, there is limited evidence showing that the injection improves grip strength for >3 months. By contrast, there is strong evidence indicating that local corticosteroid injections did not reduce the pain level, improve the ability to perform ADL, and increase grip strength in the long term (for >6 months) [
Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial.
Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial.
Most RCTs have reported the effects of a single local injection of corticosteroid on lateral epicondylitis. Few studies have described whether multiple injections, rather than a single injection, can be recommended. The control groups in those studies included patients who were undergoing various treatments, such as oral administration of nonsteroidal anti-inflammatory analgesic drugs, plate rich plasma injection, extracorporeal shockwave therapy, physical therapy, and orthosis. Most of the studies demonstrated the efficacy of corticosteroid injection on lateral epicondylitis based on the comparative evaluation of symptoms before and after the administration of the injection. These issues appear to be the limitations of the studies. In addition, the inclusion criteria for local injection of corticosteroid as well as the dose and types of steroids used to treat patients with lateral epicondylitis in these studies are controversial.
Adverse events reported in these studies were minor and transient and included no serious problems; however, there is limited evidence in support of the use of a single injection. The incidence of minor adverse events, including skin atrophy, depigmentation, pruritus, rash, redness, and skin hypersensitivity is high. However, a previous report on 3 cases showed that multiple local injections of triamcinolone (15–40 mg/injection) caused posterolateral rotatory instability of the elbow based on iatrogenic injury of the corticosteroid injection to the lateral collateral ligament [
Thus, local injections of corticosteroid are recommended for the treatment of lateral epicondylitis based on previous studies with a high level of evidence. To establish the treatment effectiveness of local injections of corticosteroid for lateral epicondylitis, we need further evidence regarding the effects of multiple injections and long-term treatment, the influence of dose and type of steroids on the treatment efficacy, and the frequency and severity of potential adverse effects.
6.9 CQ-4.3 Is elbow band useful for lateral epicondylitis?
An elbow band is useful for patients with lateral epicondylitis. (Recommendation 2, Agreement ratio 100%, Level C).
Elbow band is widely known by different names, including tennis band, tennis elbow band, elbow counterforce brace, lateral counterforce brace, and forearm support band. Based on the mechanism of the elbow band, 2 RCTs have investigated the immediate effect of elbow band and have showed its effectiveness in reducing painful symptoms [
There were no significant differences between the groups for 4–6 weeks of use, although pain reduced and the grip strength and the ability to perform ADL improved in both the groups [
]. One of these trials was a comparative study of the clinical outcomes of elbow brace applied for 4 weeks with high-intensity laser therapy. At 12 weeks after the treatments, both the treatments were concluded to be effective in lowering pain and improving the ability to perform ADL and grip strength [
]. One trial was a comparative study of the clinical outcomes of low-level laser therapy, elbow band, and ultrasound therapy. Each treatment included an additional stretching exercise program. Although pain reduced in all the groups, there were no significant differences between the groups at 6 weeks. However, elbow band showed early effects in pain reduction and laser therapy was more effective than elbow band and ultrasound therapy in terms of improved grip strength [
]. One trial was a comparative study of the clinical outcomes of elbow band with stretching exercise. Both the groups showed significant reduction in pain and improvement in grip strength; stretching exercise was more effective at 9 months [
Radial epicondylalgia ('tennis elbow'): treatment with stretching or forearm band. A prospective study with long-term follow-up including range-of-motion measurements.
Elbow band is a useful medical tool because its basic concept is common, and several types of elbow bands are commercially available at a reasonable cost. However, to the best of our knowledge, no studies have reported on the after long term use of elbow bands and the associated patient prognosis. In fact, the use of an elbow band does not always reduce the symptoms substantially in clinical settings. Moreover, to the best of our knowledge, there is no conclusive evidence regarding patient satisfaction, confirming whether symptom modification using an elbow band fulfills their expectations. Thus, the use of an elbow band is suggested as a treatment for lateral epicondylitis because the satisfaction level is mainly based on the patient's judgment in terms of comparing the cost, using an elbow band, and improvement of symptoms by its use.
6.10 CQ-4.4 Is physiotherapy effective for lateral epicondylitis?
Physiotherapy is a safe, relatively low-cost, and effective therapy for lateral epicondylitis. (Recommendation 1, Agreement ratio 83%, Level B).
A wide variety of interventions have been described as physiotherapy techniques for lateral epicondylitis, including stretching [
Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review.
Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review.
Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening.
Improvement of pain and functional activities in patients with lateral epicondylitis of the elbow by mobilization with movement: a randomized, placebo-controlled pilot study.
Comparison of effects of Cyriax physiotherapy, a supervised exercise programme and polarized polychromatic non-coherent light (Bioptron light) for the treatment of lateral epicondylitis.
Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial.
], thermotherapy, and ice therapy; all these methods are effective.
The effectiveness of physiotherapy has most commonly been compared with the benefits of steroid injections, with respect to other conservative treatments. In addition, the effectiveness of a forearm band, acupuncture, and physiotherapy methods have also been compared. More than 10 trials have compared the effectiveness of steroid injections, with different follow-up periods and physiotherapy methods. Two of these studies showed that steroid injections were more effective than physiotherapy in the short term [
Muscle energy technique versus corticosteroid injection for management of chronic lateral epicondylitis: randomized controlled trial with 1-year follow-up.
Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial.
Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial.
]. One of the reasons is that the effects of steroid injections are limited, and recurrence may occur. Another reason is that acute lateral epicondylitis is a self-limiting condition and most patients recover within 52 weeks without active treatment. Few studies have investigated the benefits of combined treatment with injections and physiotherapy [
Radial epicondylalgia ('tennis elbow'): treatment with stretching or forearm band. A prospective study with long-term follow-up including range-of-motion measurements.
]. In a comparison of manipulation with acupuncture, both, manipulation and acupuncture showed effectiveness, and the manipulation method appeared to be more effective for providing pain relief during the first few treatments than acupuncture [
Manipulation therapy relieved pain more rapidly than acupuncture among lateral epicondylalgia (tennis elbow) patients: a randomized controlled trial with 8-week follow-up.
]. Regarding the methods of intervention in physiotherapy, it was reported that the effects of structured home-based exercise without supervision could be superior to that with other conservative treatments (steroid injections, stretching, or no intervention) [
]. By contrast, two studies that compared the effectiveness of Cyriax physiotherapy and a supervised exercise program showed that the supervised exercise program achieved greater improvement [
Comparison of effects of Cyriax physiotherapy, a supervised exercise programme and polarized polychromatic non-coherent light (Bioptron light) for the treatment of lateral epicondylitis.
Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial.
It has been pointed out that lateral epicondylitis is a self-limiting condition that may improve using the “wait-and-see” approach. In a study where the effects of physiotherapy and those of the “wait-and-see” approach were compared, physiotherapy was superior to the “wait-and-see” approach in the short term; however, no differences were observed in the groups at 52 weeks [
]. After 1 year of follow-up, physiotherapy showed more beneficial effects than the other 2 interventions. However, it involves a higher cost. Physiotherapy showed slightly superior clinical effects; however, the “wait-and-see” approach was slightly less costly than physiotherapy.
Multiple physiotherapy interventions have been recommended for treating lateral epicondylitis, and their treatment efficacy has also been compared. However, there is no consensus on the most effective physiotherapy technique [
]. Moreover, the effectiveness of physiotherapy might be similar to that of the natural course. Moreover, physiotherapy is harmless, effective, and available at a relatively low cost in Japan.
6.11 CQ-4.5 Is acupuncture treatment effective for lateral epicondylitis?
There is no clear evidence in support of this treatment.
Three RCTS have studied the effectiveness of acupuncture at the elbow [
Manipulation therapy relieved pain more rapidly than acupuncture among lateral epicondylalgia (tennis elbow) patients: a randomized controlled trial with 8-week follow-up.
]. In another study, acupuncture was performed at locations other than the elbow to decrease the pain caused by lateral epicondylitis. Although acupuncture treatment lowered the pain, increased the grip power, and decreased DASH score, the effectiveness of this method was lower than that of the manual therapy that was used for the control group [
]. Few studies on small samples have been conducted on this subject; therefore, we cannot definitively recommend acupuncture treatment for lateral epicondylitis.
6.12 CQ-4.6 Is extracorporeal shock wave therapy useful for lateral epicondylitis?
Extracorporeal shock wave therapy (ESWT) is not clearly recommended for patients with lateral epicondylitis. (Recommendation level: 5, Agreement rate: 36% Evidence level C).
] showed its effectiveness in improving the ability to perform ADL; however, the timing of evaluation varied. None of the studies the effectiveness of ESWT in improving grip strength. We considered that resting pain and loading pain were optimal for evaluation among the various pain conditions. In a meta-analysis of each pain, there was no significant difference in the resting pain scores of those who received ESWT and those who received placebo in the short-term, within 3 months and for 6–12 months (95% CI: −13.21–1.63, I2 = 73% and −40.61–22.50, I2 = 99%) (Fig. 1, Fig. 2). By contrast, the pain score under the load by the Thomsen test after ESWT was significantly reduced than that with placebo in the short term, within 3 months (95% CI: −23.04–1.88, I2 = 91%). However, there was no significant difference in the subsequent 6–12 months (95% CI: −42.86–12.61, I2 = 97%) (Fig. 3, Fig. 4). Moreover, in the evaluation method that pain reduction of 50% or more in the Thomsen test after ESWT was a significant improvement in the short term within 3 months (95% CI: 0.02 to 0.25, I2 = 62%); however, there was no significant improvement in the subsequent 6–12 months (95% CI: −0.19–0.25, I2 = 71%) (Fig. 5, Fig. 6). With respect to ADL as the second outcome, two papers [
] showed no effect in the 12-month evaluation. Regarding the final third outcome of grip strength, 9 papers comparing placebo including RCT did not show a significant improvement after ESWT, and meta-analysis also showed no significant difference (95% CI: 0.72 to 9.21, I2 = 19). %) (Fig. 7).
Fig. 1Comparison of ESWT and placebo in terms of resting pain-short time.
Adverse events in patients who had undergone ESWT included a high degree of pain and redness of the skin; however, these symptoms were mild and transient at the time of treatment [
]. However, events of fainting, patient's desire to discontinue, need for local anesthesia, and the possibility of bone invasion depending on the irradiation method were also reported, and these events were not necessarily mild.
With respect to cost effectiveness, steroid injection therapy was significantly more effective than ESWT in reducing pain [
]. Thus, the meta-analysis on the effectiveness of ESWT shows weak evidence, and no clear recommendation can be made, considering the benefits and disadvantages, including the uncertainty of patient values and preferences, low cost-effectiveness, and non-insurance coverage in Japan.
6.13 CQ-4.7 Is a local injection of peripheral whole blood beneficial for lateral epicondylitis?
Local injection of peripheral whole blood is not strongly recommended in the short term for patients with lateral epicondylitis. (Recommendation level 2, Agreement rate 80% Evidence level C).
Among four published RCTs that addressed the efficacy of local injection of peripheral whole blood in lateral epicondylitis, three RCTs that compared the clinical outcomes after local steroid injection showed that the local injection of peripheral whole blood was more effective in alleviating symptoms, improving grip strength, and improving functionality than local steroid injection in the short term (>90 days after dosing). Moreover, it was more convenient and beneficial in terms of cost [
]. However, only few RCTs addressing the local injection of peripheral whole blood provide limited evidence for the benefit. Two published RCTs that have compared local injection of peripheral whole blood and platelet-rich plasma (PRP) injection therapy have shown that PRP therapy was slightly superior in terms of pain relief, although no statistical significance was found [
6.14 CQ-4.8 Is plate rich plasma (PRP) local injection useful for lateral epicondylitis of the elbow?
There is no significant difference in the comparison with all control local injections (steroids, whole blood, local anesthetics, saline solution); however, the long-term usefulness of PRP local injection is confirmed. (Recommendation 2, Agreement ratio 60%, Level B).
All the studies that have compared the effectiveness of PRP local injection with that of local steroids injection [
Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up.
Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up.
] have shown the effectiveness of PRP; however, there was no significant difference (Fig. 11, Fig. 12). A comparison with local anesthetics injection [
Inefficacy of ultrasound-guided local injections of autologous conditioned plasma for recent epicondylitis: results of a double-blind placebo-controlled randomized clinical trial with one-year follow-up.
] showed that both PRP and saline solution injections are effective, and the difference in the effectiveness is not statistically significant (Fig. 13, Fig. 14). Based on the above results, there was no significant difference in the comparison with all control local injections (steroids, whole blood, local anesthetics, saline solution); however, the long-term usefulness of PRP local injection for lateral epicondylitis of the elbow was confirmed in all the studies. Although the PRP adjustment method and injection procedure are not constant at present, and although the treatment cost may be high due to lack of insurance coverage in Japan, to the best of our knowledge, no studies have reported serious adverse events with self-blood-derived ingredients, and there are fewer adverse effects than those with steroids, and PRP local injections are slightly more effective than control.
Fig. 8Comparison of PRP and steroid injection in terms of the VAS score at 4 weeks.
6.15 CQ-4.9 Is laser therapy useful for lateral epicondylitis?
Low-level laser exerts no obvious effects on lateral epicondylitis, and there were no adverse events. However, the use of the low-level laser is covered under the Japanese National Health Insurance. (Recommendation 2, Agreement rate 72.7%, Evidence Level C).
A systematic review of clinical studies on low-level laser therapy for lateral epicondylitis did not report the effectiveness; however, there were no adverse events. A well-designed RCT is needed to establish the absolute and relative effectiveness [
]. By contrast, meta-analyses comparing low-level lasers with placebo have demonstrated the effectiveness of low-level lasers in relieving pain and improving grip strength ([
] EV level 1). There was an overlap between the two papers and heterogeneity in the treatment methods (Output/Wavelength/Time). In 2004, the World Association for Laser Therapy criteria were established for laser treatment protocols, stating power, time, and frequency, to enable the formulation of recommendations.
(https://waltza.co.za/documentation-links/recommendations/dosage-recommendations/). Thereafter, 3 RCTs using placebo laser in the control group have been performed [
]. These 3 RCTs showed reduction in pain and increase in grip strength in the relatively short term (3–12 weeks after the laser treatment) in comparison to that with the placebo laser. Using these 3 RCTs, a meta-analysis was performed to assess pain at rest, grip strength, and the ability to perform ADL (DASH score). The low-level laser did not show a significant difference in pain immediately after the treatment ended and at the time of final follow-up as compared with the placebo laser; however, grip strength and ADL were superior to those with placebo (Fig. 15, Fig. 16, Fig. 17, Fig. 18, Fig. 19, Fig. 20). Therefore, while the effect on pain reduction is unclear, grip strength and ADL are expected to improve.
Fig. 15Comparison of LLLT and placebo in terms of resting pain immediately after the treatment.
All the reported RCTs use instruments with wavelengths of 904–905 nm. However, low-level lasers with these wavelengths are not currently approved in Japan. (The wavelength is 810/830 nm in two approved devices available in Japan.) There are no reports on the adverse events associated with low-level laser therapy. Furthermore, although there is no report on the cost, it is included in the Japanese National Health Insurance coverage as low-level laser therapy, at 350 yen per day. The indication is “for relief of pain in chronic noninfectious inflammatory diseases of muscles and joints".
6.16 CQ-4.10 Is surgery useful for conservative-treatment-resistant lateral epicondylitis?
Surgical therapy is administered when conservative therapy is ineffective for lateral epicondylitis. Surgery reduces pain without complications or decreased range of motion. (Recommendation 2, Agreement rate 100%, Evidence Level C).
Although some reports have shown that surgery under direct vision is effective, most studies have compared and examined the surgical methods, and none has shown that it is more effective than conservative treatment. Surgical therapy is administered when conservative therapy is ineffective for lateral epicondylitis. Surgery types include open surgery, arthroscopic surgery, and percutaneous surgery. In this CQ, we examined the accepted papers related to open surgery with lateral release under direct vision [debridement and repair of the extensor carpi radialis brevis (ECRB) tendon attachment: 46 elbows] and lateral release under arthroscopy (incisor blade). Comparing partial resection of the joint capsule with synovectomy and debridement at the ECRB tendon attachment without repair (29 elbows), the Verhaar Score for pain was excellent or fair in 69% of those in the direct vision group and 72% of those in the arthroscopic group. There was no significant difference [
]. In a study wherein the Hohman method (dissection of the origin of the extensor conjoined tendon) was performed under direct vision (10 elbows) and under an arthroscope (20 elbows) and the clinical results were compared retrospectively, postoperative pain level was indicated by a VAS score of 2.6 under direct vision and 1.95 under speculum, representing a non-significant difference [
]. Two studies that compared open and arthroscopic surgery were effective with both the procedures; however, no significant difference was found between the two groups. As per the evaluation of the treatment results of the V–Y slide method of the extensor tendon (22 patients, 23 elbows, average observation period: 41.2 months), all the patients were satisfied with the results and were in excellent or good condition. There were no complications or decreased range of motion [
]. A comparison of the preoperative and postoperative VAS scores for refractory lateral epicondylitis under direct vision, arthroscopic surgery, and percutaneous surgery were 4.9 and 1.1, 5.2 and 1.0, and 5.4 and 1.2, respectively. All patients showed improvement as compared to before the surgery; however, there was no significant difference [
]. With respect to change in grip strength, one representative study showed that the average grip strength improved significantly. The Japanese Orthopaedic Association-Japan Elbow Society Elbow Function Score at follow-ups was significantly higher than that before the surgery in 2 articles (Fig. 22). The rate of excellent or good outcomes as per Mayo Elbow Performance Scores was 73% (95% CI -0.68–2.14) in 2 articles [
70° frontal visualization of lateral compartment of the elbow allows extensor carpi radialis brevis tendon release with preservation of the radial lateral collateral ligament.
]. A meta-analysis of 3 studies that compared arthroscopic and open surgery showed that open surgery was associated with significantly higher percentages of excellent or good evaluation than arthroscopic treatment [
] (Fig. 23). Deep infection, elbow contracture, elbow instability, or nerve injuries were not reported. In 12 studies, the rate of failure was 10% (95% CI 0.06–0.14). [
70° frontal visualization of lateral compartment of the elbow allows extensor carpi radialis brevis tendon release with preservation of the radial lateral collateral ligament.
6.1.8 FRQ1: Is the use of radiofrequency effective for treatment of lateral epicondylitis?
Use of radiofrequency for patients with lateral epicondylitis may reduce pain, improve grip strength, and enhance the ability to perform ADL. However, an exclusive device is required, and there is insufficient evidence for determining the recommendation level. Further high-quality interventional studies are needed.
Radiofrequency refers to a high-frequency electromagnetic wave; it is employed in clinical practice, e.g., local ablation and heat coagulation using a needle electrode or deep hyperthermia therapy using a body surface electrode. The former is utilized in radiofrequency ablation for hepatic cancer, catheter ablation for arrhythmia, and neural block at pain clinics and is covered under the Japanese National Health Insurance (insurance), while the use for lateral epicondylitis is not covered under the insurance. The latter is generally claimed for the insurance as anti-inflammatory analgesic treatment. With respect to the use of radiofrequency for treating lateral epicondylitis, three research papers were selected; radiofrequency microtenotomy wherein the electrode is placed on the extensor tendon under direct vision [
Clinical and ultrasonographic results of ultrasonographically guided percutaneous radiofrequency lesioning in the treatment of recalcitrant lateral epicondylitis.
]. These procedures are reported to provide good pain control without major complications and are less invasive than conventional surgical procedures. However, the evidence level is low, especially in the latter 2 studies, and the confidence in the estimation efficacy is limited. Further interventional studies with higher quality are warranted.
6.19 FRQ2: Is bone marrow aspirate concentrate (BMAC) local injection useful for lateral epicondylitis?
There is insufficient evidence regarding BMAC local injection. Large-scale RCTs and long-term observation of safety are required.
BMAC originally gained attention as an emerging, novel treatment for various bone and cartilage injuries. BMAC contains mesenchymal and hematopoietic stem cells, platelets, growth factors, cytokines, and anti-inflammatory and immunomodulatory cells. Similar to hyaluronic acid and PRP, BMAC is considered to restore the natural micro-environment of the damaged or diseased tissue. Apoptosis and elevated rates of autophagic cell death have been also observed in the ECRB tendon of patients with chronic lateral epicondylitis; therefore, recent studies have attempted to identify methods to directly deliver functional cells, such as BMAC, skin fibroblasts, and tenocytes, which are capable of synthesizing extracellular matrix and repairing damaged tissue in the area of tendon injury [
]. Regarding the efficacy, it has been reported that a single local injection of BMAC mixed with a local anesthetic administered to patients with lateral epicondylitis showed a significant improvement in Patient Related Tennis Elbow Evaluation (PRTEE) after 2, 6, and 12 weeks of injection 5); in patients with lateral or medial epicondylitis for whom conservative treatment was ineffective, a single local injection of BMAC mixed with a local anesthetic after arthroscopic debridement achieved a significant improvement in the VAS score and the Mayo Elbow Performance Score (MEPS) 6 months after the injection, and ultrasonography examination resulted in the repair of the extensor tendon attachment [
]. However, these studies have the limitations of lack of control group, absence of long-term follow-up, and no hematological analysis to determine the number of nucleated cells or platelets in BMAC. With respect to the risks of bone marrow aspirate (BMA), no complications were reported in the above 2 papers. However, hemorrhage, especially that associated with anticoagulation therapy, superficial infections, pain at harvest site, neurovascular injury, fat embolism, pulmonary infarction, pathological fractures in patients with osteoporosis and osteomalacia, and death due to the formation of a retroperitoneal hematoma after an aspirate from the posterior iliac crest have been reported [
]; however, we have not reached a conclusion regarding the optimal method.
6.20 FRQ 3: Is botulinum toxin useful for lateral epicondylitis?
No clear recommendation can be made regarding the usefulness of botulinum toxin therapy.
Botulinum toxin therapy is a treatment wherein the botulinum toxin neurotoxic protein produced by the bacterium Clostridium botulinum is intramuscularly injected to relieve muscle tension and reduce pain. The effect on pain has been described in 6 studies, including 5 RCTs and 1 case–control study. Using a VAS, the mean and standard deviations of pain intensity have been described in 2 studies with a follow-up duration of 4 weeks [
]. In these papers, the botulinum-treated group showed a significant reduction in pain (p < 0.00001) at 4 weeks as compared to the control (saline) group, and the efficacy of pain reduction had continued even after 12 weeks (p < 0.00001). The effect on grip strength was described in 6 papers, including 5 RCTs and 1 case–control study. The mean and standard deviation of grip strength have been described in 2 placebo-controlled studies [
] with follow-up durations of 4 and 12 weeks. There was a significant (p < 0.002) decrease in the muscle strength in the botulinum-treated group as compared to that in the control (saline) group at 4 weeks; however, there was no significant difference at 12 weeks [
]. The ability to perform ADL during treatment has been described in 5 papers, including 3 RCTs and 2 observational studies; however, the method of examination varied from study to study, making a comparison difficult. Except in one article [
], there was no significant difference in the effect of botulinum toxin administration between the botulinum-treated group before administration and the control group after ≥3 months. Currently, botulinum toxin administration for this disease is not covered by the Japanese National Health Insurance. The treatment has a pain-relieving effect and is expected to be useful owing to its effect in increasing the grip strength at 12 weeks. However, there are no reports in the Japanese literature regarding this; therefore, clinical results are required to be examined in a large-scale RCT. We recommend that high-intervention research be performed on this topic in the future.
6.21 BQ 5-1 Is there a difference in the prognosis (at > 5 years) with conservative therapy?
No studies have reported the long-term prognosis (> 5 years) with conservative therapy.
In a meta-analysis that summarized the effects of the placebo alone, > 99% of the patients had mild pain or less on VAS after 26 weeks, and this result shows the possibility of spontaneous healing. One report also showed that symptoms significantly decreased after 1 year, with or without treatment [
Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial.
]. A comparison of PRP and steroid injections showed that PRP was more effective, with a recurrence rate of 46.7% as compared to 23% for the steroid group at 6 months [
]. Compared with the local steroid treatment group and the ultrasound therapy, massage therapy, stretch, and physical therapy groups, the short-term treatment results were superior in the local steroid injection therapy group; however, the long-term results were superior in the physical therapy group [
Factors that exacerbated the treatment outcomes of conservative therapy included occupational accidents, injections, radial tunnel syndrome, surgery, long-term follow-up of ≥12 months, dominant hand morbidity, and pre-treatment pain [
Prognostic factors in lateral epicondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice.
6.22 BQ 5-2 Does recurrence occur after conservative therapy?
There are some recurrences in patients who have received any form of conservative therapy.
A comparison of 3 groups who received local steroid injection, peripheral blood whole blood administration, and extracorporeal shock wave treatment showed that the steroid treatment group had significantly improved short-term pain, resistance lower dorsiflexion test result, and grip strength; however, all the patients in the local steroid injection group experienced recurrence at 1 year [
]. A comparison of 4 groups who received local steroid injection therapy with or without splint and saline injection with or without splint revealed significantly more symptom relapse at 24 weeks in the group that receiving steroid injection alone than in the group who received saline and sprint [
Vahdatpour B. A randomized clinical trial on comparison of corticosteroid injection with or without splinting versus saline injection with or without splinting in patients with lateral epicondylitis.
J Res Med Sci.2014 Sep; 19 (PMID: 25535493; PMCID: PMC4268187): 813-818
]. In all the groups, no-treatment with follow-up, injections, and treatments with physical therapy had recurrent factors with strong pain before treatment [
]. The short-term effectiveness of local steroid injection therapy was more than that of placebo; however, the recurrence rate of steroid injection after 1 year (steroid: placebo, 54%: 12%) was higher than that with the placebo [
]. Ultrasonography (US) and color-Doppler (CD) examination of the extensor origin was performed at the time of enrollment and at the 2-year follow-up after intratendinous injection treatment with polidocanol and/or a local anesthetic. The study showed improvement in 17 of the 20 cases and recurrence in 3 cases [
A comparison of 15 patients who were given PRP and steroid injections showed that 46.7% of the patients in the steroid group and 23% in the PRP group experienced recurrence at 6 months [
]. Botulinum toxin therapy reduced pain at 3 and 12 months, and the grip strength decreased significantly at 3 months; however, the pain reduced to the pre-injection level at 12 months [
]. The factors of recurrence after conservative therapy were occupational accidents, injections, radial tunnel syndrome, surgery, and long-term treatment for at least 12 months [
] reported no significant difference between arthroscopic and percutaneous approaches in surgical intervention, showing a 90% satisfaction rate without recurrence in both the groups. In another study on 109 patients (24, percutaneous; 44, arthroscopic; 41, open procedures), recurrences were observed in 2 patients (4.9%) of arthroscopic resection and 4 cases (10.5%) of open resection. Reoperations were performed after subcutaneous incisions in 3 patients who were evaluated as “fair.” One case of arthroscopic surgery and 2 cases of open incision that were evaluated as “fair” had chronic regional pain syndrome (CRPS) [
Following an elongation of the extensor carpi radialis brevis (ECRB) tendon, there was no recurrence in all 14 patients and 7 of 8 patients; however, 1 of 8 elbows and 2 of 17 patients [
] for whom the Garden method was used to extend the ECRB tendon attachment site exhibited poor results and required reoperation. In open surgery, 3 of the 77 patients underwent reoperation for recurrence [
Lateral epicondylitis treatment by extensor carpi radialis fasciotomy and radial nerve decompression: is outcome influenced by the occupational disease compensation aspect?.
]. Additional surgeries were performed in 2 of the 20 patients after a fasciotomy at the lateral epicondyle and in 1 of 8 elbows after an elongation of the ECRB tendon for re-recurrences. Local curettage was performed for 7 patients, and there was no recurrence after an average follow-up duration of 29.3 months. There were no additional treatments for patients who were followed up for >2 years after arthroscopic debridement [
Conflicts of interest (2015–2017) were confirmed via self-reporting by all the members of the Lateral Epicondylitis Guideline Committee. No company was directly involved in the guideline recommendations and the systematic review team. The Executive Director and members declared that no company was directly involved in the recommended text for the clinical questions. To minimize bias and conflict of interest in the text, all the members voted on the recommended decisions, excluding the persons in charge of the text in question. The authors focused on the consensus of the members during guideline development. Funds required to prepare the guidelines were provided by the JOA. No support was received from any other organization or company.
Acknowledgement
We appreciate Masahiro Yoshida, MD, PhD for a great advice of this guidelines. We would like to express our deep gratitude to Fuminori Kanaya, MD, PhD for his contribution as an advisor to the committee. We would like to thank systematic review team for preparation of structured abstract, and NAI Inc. (www.nai.co.jp) for English language editing. We also thanks to Ms. Misako Kaji, and Ms. Mariko Henmi, International Medical Information Center, for their clerical support. Funds required to prepare the guideline were provided by the JOA, no support was received from any other organization or company.
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Richly innervated soft tissues covering the superficial aspect of the extensor origin in patients with chronic painful tennis elbow - implication for treatment?.
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