Putting Physiotherapy First: What Can We Do For Lateral Epicondylalgia

By Steve Young BHSc PT, BA, DPT; Sean Overin BHK, MPT, DPT; Curtis Tait BSc, MPT, DPT

Lateral Epicondylalgia (LE) is a common condition typically affecting middle aged adults. Although once believed to be an overuse injury with an inflammatory component, more recent evidence suggests a continuum of changes in the local tissue termed angiofibroblastic hyperplasia, which suggests the following: 1) increased cell numbers and ground substance; 2) vascular hyperplasia or neovascularisation; 3) increased concentration of neurochemicals and 4) disorganised and immature collagen1. Furthermore, LE changes the motor system, decreasing pain-free grip (PFG) and alters the pain system resulting in neurogenic inflammation and/or central sensitization. This new knowledge prompted the renaming of the condition from lateral epicondylitis to lateral epicondylalgia.

Cortisone injections (CSI) were once a commonly used treatment for LE, but two recent clinical trials suggest that physical therapy may provide superior outcomes for the condition. In 2006, Bisset et al. compared three groups: 1) CSI, 2) physiotherapy based treatment that included mobilizations with movement (MWM) and exercise and 3) a wait and see group2. Although those patients treated with CSI demonstrated a significant improvement at six and 12-week follow-up, they demonstrated the worst outcomes at one year. The physiotherapy group demonstrated superior outcomes than the wait and see group at six and 12-weeks, but the differences were no longer significant at one year follow-up. A closer look at the data suggests that most patients in both the physiotherapy and wait and see group had fully recovered at one year, suggesting that LE may be a self-limiting condition but that physiotherapy treatment can speed recovery.

A more recent trial appears to support these findings. Coombes and colleagues produced a high quality, four arm trial comparing physiotherapy with CSI, physiotherapy with placebo injection, CSI alone, and placebo CSI3. Similar to the Bisset trial, the physiotherapy treatment included the use of a MWM technique (A lateral glide at the elbow joint) along with an exercise program. Again, a significant improvement was noted in those patients receiving cortisone over the first few weeks, but at one year follow-up 55% of CSI patients had a recurrence compared with only 5% of those receiving physiotherapy. At one year, all groups demonstrated a greater than 80% recovery rate with the physiotherapy group demonstrating a 100% rate of recovery. Noteworthy, at four weeks, 39% of the physiotherapy group with placebo injection demonstrated recovery compared to 0% of the placebo injection group, again suggesting that physiotherapy has a role in speeding recovery. There is also a developing body of literature to support the use of manual therapy to the cervicothoracic region in conjunction with standard treatment for LE. Cleland et al. found that those patients treated for LE with both local and cervical spine treatment demonstrated faster recovery 4. In a pilot randomized trial, Cleland demonstrated improved outcomes with those patients receiving manual therapy to the cervical region along with concurrent elbow treatment when compared to a group receiving only elbow treatment5. Fernández-Carnero et al. demonstrated that a single cervical manipulation caused an immediate decrease in pain pressure thresholds (PPT) and increase in pain free grip (PFG) in ten patients presenting with LE6. Vicenzino conducted a randomized controlled trial performing a lateral cervical glide combined with a neurodynamic technique compared to a sham technique and no intervention7. He found a significant immediate improvement in PPT, PFG and retesting of neurodynamics in only the lateral glide group. It should be noted that while many of the trials looking at the influence of cervical-based treatment are small or have short follow-up durations, the findings are promising.

There is also some evidence to support the use of distal interventions in the form of wrist mobilizations8. As there is suggestions that hyperalgesia and altered motor control occur secondary to LE, perhaps manual therapy can be used as a “Primer” to allow greater pain free loading of the musculotendinous system and improved motor patterning prior to exercise based interventions9 . A recent systematic review of eccentric exercises for LE found that there is limited research investigating if eccentric or concentric loading was superior for LE, but the available research concluded that eccentric loading programs as part of a multimodal treatment program consistently decreases pain and improves function10. Clinical Bottom Line: CSI for the treatment of LE appears to increase the chance of symptom recurrence long-term. Regional manual therapy directed at the cervico-thoracic spine and upper extremity in conjunction with an exercise program may produce optimal results when treating LE.

References:

1) Coombes BK, Bisset L, Vicenzino B. A new integrative model of lateral epicondylalgia. Br J Sports Med. 2009;43:252–258.

2) Bisset Leanne, Beller Elaine, Jull Gwendolen, Brooks Peter, Darnell Ross, Vicenzino Bill et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial BMJ 2006; 333:939

3) Coombes, Brooke K., et al. "Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial." Jama 309.5 (2013): 461-469.

4) Cleland J, Julie M. Whitman, Julie M. Fritz, Effectiveness of Manual Physical Therapy to the Cervical Spine in the Management of Lateral Epicondylalgia: A Retrospective Analysis J Orthop Sports Phys Ther 2004;34:713-724.

5) Cleland J, Flynn T, Palmer J. Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: A pilot clinical trial. J Manual Manipulative Ther 005;13:143–151

6) Josué Fernández-Carnero, Cesar Fernández-de-las-Peñas, Joshua A. ClelandImmediate Hypoalgesic and Motor Effects After a Single Cervical Spine Manipulation in Subjects With Lateral EpicondylalgiaJournal of Manipulative and Physiological Therapeutics, Volume 31, Issue 9, November–December 2008, Pages 675–681

7) Vicenzino, Bill, David Collins, and Anthony Wright. "The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia." Pain 68.1 (1996): 69-74.

8) Struijs, Peter AA, et al. "Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study." Physical Therapy 83.7 (2003): 608-616.

9) Vicenzino, Bill. “Tendinopathy: Evidence-Informed Physical Therapy Clinical Reasoning.”J Orthop Sports Phys Ther 2015;45(11):816-818.

10) Cullinane FL, Boocock MG, Trevelyan FC. “Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review.” Clin Rehabil. 2014 Jan;28(1):3-19