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Rapid response to:

Clinical Review Extracts from Concise Clinical Evidence

Tennis elbow

BMJ 2003; 327 doi: (Published 07 August 2003) Cite this as: BMJ 2003;327:329

Rapid Response:

Physiotherapy and Tennis Elbow/Lateral Epicondylitis. Letter

Tennis Elbow (TE) or Lateral Epicondylitis (LE) is one of the most
frequent lesions of the arm. Even though the above two terms are not the
appropriate to describe this condition, these two will be used in this
letter. The signs and symptoms of LE are clear and the diagnosis of this
condition is rather easy. However, this disorder challenges the clinician
daily, as is an injury that is difficult to treat, prone to recurrent
bouts and may last for several weeks or months, with the average duration
of a typical episode of TE is reported to be between 6 months and 2

The primary choice of treatment for TE is the conservative treatment.
A plethora of conservative interventions, medical and physiotherapeutic,
has been recommended for the management of this condition. However, we are
wondering if the available conservative medical treatments, the
corticosteroid injections and the nonsteroidal anti-inflammatory drugs
(NSAIDs), are effective approaches reducing patients’ pain and improving
patients’ function in LE condition which is the role of physiotherapy in
this disorder?

Systematic reviews of the literature have shown that no conclusive
reports could be made on the effectiveness of injections2 or this kind of
treatment had a positive short-term effect; however due to the lack of
high quality studies it is not possible to draw definite conclusions3.
Furthermore, a systematic review found that there was some support for the
use of NSAIDs to relieve lateral elbow pain at least in the short term;
there was, however, insufficient evidence to recommend or discourage the
use of NSAIDs4.

Most importantly, we must acknowledge, at least till contrary data
appear, that these two kinds of treatments do not provide significant long
-term benefit in tendinopathy such as LE5-7. Moreover, tendon ruptures,
skin atrophy and deleterious effects in the tendinous structure have been
reported in literature from injections of corticosteroids even if they are
applied correctly8-13 making this modality dangerous for patients and the
use of NSAIDs can cause gastrointestinal problems impeding the healing
process though are given in the right dosage12-15. Thus, the need for more
effective and less hazardous conservative treatments exists. One of these
conservative treatments is physiotherapy.

However, which physiotherapeutic intervention is effective in this
condition is still unknown. Two recently systematic reviews, one by Smidt
et al. (2003)16, which examined the effectiveness of physiotherapy in the
management LE, and one by Trudel et al. (2004)17, which determined the
effectiveness of conservative treatments, which were all physiotherapeutic
interventions in the management of LE, concluded that more research to
investigate the effectiveness of physiotherapy in the management of LE is

It is generally accepted that the effectiveness of physical therapy
modalities in the treatment of musculoskeletal disorder is dependant on
the range of parameters applied18,19. These two systematic reviews were
not carried out a dose response analysis, as Bjordal et al. (2001)19 did
about the effectiveness of laser in tendinopathy. The reason for this is
that is difficult to test for such a dose response, due to poor reporting
of parameters and a dearth of clinical studies comparing the effectiveness
of different physical therapy modalities parameters (Gam et al., 1993)20.
Therefore, the need for well-designed RCTs to investigate the
effectiveness of physiotherapy exists.

Finally, we recommend as treatment approach in patients with LE,
based on personal experience and in literature about the management of
common tendinopathies such as patellar and Achilles21-25, an exercise
programme consisting of slow progressive eccentric exercises of wrist
extensors in combination with static stretching exercises of the extensor
carpi radialis brevis. However, a high quality RCT to investigate the
effectiveness of this treatment approach in patients with LE is required.


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Competing interests:
None declared

Competing interests: No competing interests

07 September 2004
Dimitrios I Stasinopoulos
Physiotherapist /M.Sc, PGCRM, Cert Clin ed Cert Orth Med (Cyriax)PhD student
Mark Johnson
Centre of Rheumatology and Rehabilitation Athens Greece 11141 Orfanidou 16 School of Health and Hum