For Practitioners, Papers

Management of lateral elbow tendinopathy

(Coombes, Bisset, & Vicenzino, 2015)

Aims: To collate evidence and expert opinion on the pathophysiology, clinical presentation, and differential diagnosis of LET. Factors that might provide prognostic value or direction for physical rehabilitation are canvassed. Clinical recommendations for physical rehabilitation are provided, including the prescription of exercise and adjunctive physical therapy and pharmacotherapy.

Methods: Not mentioned. Authors’ literature analysis

Results: Frequent pathology among 35- 54 years old people, 1-3% of general population, with increased risk if smokers, tennis player, or manual workers. Self-limiting pathology 83% to 90% of people without treatment improve, even though not fully recover after 1 year. 1/3 of patients may still experience symptoms after 1 year even with treatment. Large proportion of recurrence. 5% de not have benefits of conservative treatment and undergo surgery with variable outcomes.

Multimodal pathology (tendon continuum model + neuro-motor & nociceptive changes).

Examination: Symptom reproduction with loading of tendon (palpation, resisted contraction, stretching). Rule-out other causes. Check elbow, shoulder, neck, thoracic spine. PRTEE & Pain-free grip test & PSFS to measure function.

Imagery can rule out not diagnose. Lack of association between severity of imaging and symptoms. Prognostic factors: location on continuum tendon model, initial severity and functional impairment, central sensitization, associated with shoulder / neck pain, associated neuromuscular impairments, psychosocial / work factors. Treatments: oral NSAIDS in acute phase, injections not recommended (delay in recovery), antidepressant or antiepileptic drugs if central sensitization, PRP no evidence of effectiveness, prolotherapy and nitric oxide patches if associated with load may help if limited outcomes at 6 months. Manual therapy: short term benefits if adjunct to exercises. No data on type, intensity, frequency, or duration of exercise. Currently it is recommended to gradually increase load with focus on wrist extensors. Heterogeneity in presentations => tailored dosage according to severity, stages, and functional demand. Education to reassure, inform, and advice.

Low risk: Education, advice, self-medication = wait & see, + physio after 6-12 week if no improvement.

Moderate risk: 8 to 12 weeks of physiotherapy recommended.

High risk (PRTEE >54): Central sensitization: pain management then physio.

Imagery if not responding to physiotherapy, if not other diagnostic found then try patches or prolotherapy.

Limitations: Guidelines (not a study, methodology unknown)

Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 938–949. https://doi.org/10.2519/jospt.2015.5841

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